The PCP is the first line of care for women planning or beginning a pregnancy, and their questions range from “Which vitamins do I need?” to “Should I get genetic testing?” Updating care basics for each stage, from preconception through breastfeeding, OB-GYN Robyn Lamar, MD, MPH, dispels the confusion commonly surrounding heredity, supplements, vaccinations, medications for chronic conditions, and the need for specialty care.
I always love talking about care for pregnant patients. My name is Robin Lamar. I'm one of the O. B. G. Y. N. Is that U. C. S. F. And I worked here as a generalist. So I do prenatal care but I asked to do that. It's a logic care and deliver babies and two surgeries. I've been at UCSF for 10 years but I've been in California for about 20 years now. I came out for college and went to Stanford um did med school at U. C. A. Staff, got a master's in Public health at Berkeley. So I feel like I've made my way around all the bay area schools and have stayed put. Um But happy to give this talk today. I feel like it can be difficult to do care for pregnant and lactating people and they have lots of regular primary care needs that come up along the way. So, I meant for this talk to address to some of the practical aspects here um end up deciding focusing on kind of preconception care was an important thing. Not that that's necessarily going to be the stated purpose of the visit. But if you've got someone who's there for an annual or a problem visit who's in that reproductive age and they share that they might be planning pregnancy. There's a couple of things that I think we're good to keep in mind and want to go through some of those today. Um And then during pregnancy itself I thought it would be helpful to talk about some of the chronic common chronic conditions that people have pre pregnancy obviously are still going to exist during their pregnancy and talk about optimizing care and medications and what you might do if someone sees you for a flair for one of these things. Um And then I was unfinished with breastfeeding which I hope will convince you it's not as scary as it sounds and that most things are fine by your breastfeeding. That's a very short part of that time. Um So for preconception I think if there's just one question you could ask people who are in that broad reproductive ranges, would you like to become pregnant in the next year because that will help you figure out you need to be talking with them about a whole host of things if possible. Um I think the really important things not to miss our some of these chronic conditions that require a lot of special care during pregnancy and during the postpartum phase. And ideally kind of here for this ideal part that what we want to see is good control before you start trying to get parts. And this is particularly true for things like diabetes and thyroid disease and autoimmune conditions where maybe the medications you're on could be toxic. Um Maybe the condition itself like high blood sugar can be toxic and if we're able to get things under good control before there's a pregnancy things will be much easier. Um These are also conditions that should prompt you to get an O. B. G. Way and involved. If the station doesn't have an O. B. Already. We love seeing these patients for preconception consultation. It really takes the pressure off that first trimester here if we've met them before and laid out a plan. Um And the third thing is just planning for medications if you've got someone with hypertension and they've been well managed on their ace inhibitor and now they share they're hoping to become pregnant in the next year. This might be the right time to transition over to one of the anti hypertensive that we know is safe for use during pregnancy. Um One other thing you might consider offering to people who say yeah I'm ready to start trying. I'm going to be going for. It would be to get them hooked up with genetic counseling and I bring this up because I think things have shifted since I was in medical school and the menu we're offering to people which is a little bit different. Um I think I was taught to kind of get a good family history and then really kind of delve into their ancestry and if they were astronauts see they got one menu and if they were french Canadian they got another and if they had mediterranean or asian ancestry. We screened for these things and there's now a shift towards offering the option of what's called a standard carrier testing that really has nothing to do with your ancestry and has offered the same to everybody with these extended carrier panels. Often they're testing for dozens or sometimes a few 100 different recessive conditions. Um And the way we're doing it at UCSF which you could certainly take advantage of is by having people do a video visit with one of the genetic counselors at the prenatal diagnosis center. So you just place the referral to the UCSF prenatal diagnosis center and type in preconception genetic counseling and they'll take care of the rest. Um They do a video visit, they take a family history. If there's anything weird that comes up, they'll delve into that. Otherwise if they want to do expanded carrier testing the nail kit to their house patients, swab the inside of their chief. It's just a saliva test, they send it back in and then the genetic counselor will call them back up to follow up on results into any genetic counseling that needs to come from there. So a nice option to go to know about. We recommend offering this to people who are both trying and already pregnant. You don't have to wait til you're pregnant to go through all this. Um Next thing that I'd love for everybody to come into my office already having done is had their covid shot and be up to date on all their immunizations. Um I think particularly the data has become really clear that Covid is a specific or particular problem for pregnant people. And we see higher morbidity higher mortality. And people who get covid when they're pregnant. So find a vaccine once they're already pregnant. Even better get them good vaccine coverage before they conceive. And I know y'all are at this already. Um There's no waiting time between getting your covid booster and getting pregnant. There is no link between covid vaccines and fertility. So the community very reassuring to people in this population. Um Other thing to bring up live vaccines. Sometimes we'll see patients where they tell me oh yeah I'm hoping to get pregnant. But I was told I have to wait three months or six months after my NMR. You really don't need to wait that long. Um C. D. C. Recommends just waiting one month to conceive after a live vaccine. Um And if they do get their mmr and then they conceived the next week. You can be really reassuring that even though we recommend waiting a month they're actually haven't been any reports of harm. This is just theoretic. So please get people their boosters even if they're not contraceptive. And I would go ahead and get them vaccinated the day you meet them in their office tell them if they're willing to hold off conceiving that cycle the best you get them protected. Especially if it's rebel a that you're vaccinating against um flu vaccine, we definitely recommend for all the pregnant people if they're already pregnant. State of California says it has to be the preservative free vaccine. No, like you be professional organization agrees with this, that's fine. Um if they're not pregnant yet, they can get any flu shot. Um Last Little Pearl, we always redo the cheetah vaccine during week 27 to 36 of pregnancy, even if they just got it the year before. So don't give people extra t tops. If they're already within their 10 years, they don't need an extra booster prior to pregnancy. We're gonna jab them again. Um So don't set them up for that extra sore arm. You can get when you get a couple of them in a row. Um for exercise really get people out there and moving. I know this is what you'll talk about probably all day long in primary care. Um But I still feel like there's some myths out there about pregnancy. Find to do high intensity find to do weight training. We want people to keep up with exercise before and during pregnancy, if they're wondering what they're going to have to stop. It's not a lot next to the diving is the one thing that we just say, please don't do. Um And I tell people from a practical perspective to avoid sports that are likely to wind up in an orthopedic surgery situation, like downhill skiing and that kind of thing. Um For diet, I do try to do some screening around diets. I feel like this. There's been more and more fat diets out there. There's some things you do want to intercept before they're pregnant. Um I've had a growing number of patients who are vegan and I've been surprised at how many people don't know that they need a B-12 supplement of therapy via. Um so I definitely screamed for veganism. I've also started testing a lot of my stricter vegetarians for B-12 levels. I find that my patients who follow a more traditional Indian vegetarian diet where they might not be eating eggs are often pretty low on the 12. So finding these people ahead of time to talk with them about supplementation if they haven't started yet is the way to go. Um another group I think about kind of shifting their diet pre pregnancy if possible, or people doing the keto diet or a super super low carb diet. Um we want to want you to avoid ketosis while you're pregnant when you're pregnant, you do need glucose in your bloodstream because glucose through the, from the maternal bloodstream through the placenta is what you need for fetal brain development. So these diets that are geared towards generating a lot of ketones are fine to do when you're not pregnant, but you don't want to be doing this for your pregnancy. So I will try to get my patients who are doing a Titone focused diet to find some sort of way to bridge over to a more sustainable diet that they can continue during pregnancy if possible. Other dietary piece that plug away at with all my patients of reproductive age is to please eat fish and seafood if they're willing. Um I've got a nice little hand out here that I refer people to all the time. I've got. The story is like a little handout for people, but it's from the FDA, it's just FDA dot gov slash fish advice. It's meant to be printed out and like put on your refrigerator and it goes through all the best choices for people who are pregnant or lactating or for small Children. Um as well as good choices in just a couple of things to avoid. So there's good data coming out like that. The real problem in America is not that people are getting too much mercury from their seafood. The real problem is that pregnant and lactating people just aren't eating fish or seafood and we want them to, so I tell my patients to try to eat the little fish is the ones that are gonna have less time to accumulate mercury. They're willing to do anchovies and sardines. These are great sources of omega threes and they have some iron two same thing with shellfish, mussels, clams, um, cooked oysters. These are all safe things to eat through pregnancy and lactating that are low in mercury and really rich in nutrients. Um last thing, if I can only talk about one nutrient for pregnant people. I talked about fiber because I spend so much of my time dealing with hemorrhoids and I feel like if we can get everybody on a high fiber diet, it will just make everything better during pregnancy and postpartum. I think in the first two weeks postpartum our number one call is about hemorrhoids. So everyone needs more fiber. I have my rule of 30s, they tell people do 30 g of fiber a day, 30 minutes of exercise a day and you'll solve half the problems I see in my office. Um in terms of vitamins I am kind of a purist. I really don't think there's a lot of data behind a lot of these combination prenatal vitamins really the only micronutrient that's been extensively studied and has a lot of data to back it up is taking a full of gas and supplement before you conceive and for the first trimester of pregnancy and this is very specifically to prevent neural tube defects. Um There's a range of range of recommendations, somewhere between 408 100 micrograms a day is probably what you need. Um and you can get that just as it on its own. So if you've got someone is constipated and got a sensitive stomach, I just put them on plain old folic acid. There's like a deep cultural belief in the power of prenatal vitamins. So if they want to get this from a prenatal vitamins that's fine too. I do find in terms of micronutrients that people who are pregnant or postpartum run low on the number one is definitely iron. And I really don't think most prenatal vitamins will get to the iron you need because they put it in with like calcium and magnesium and phosphorus and all these other things that inhibit iron absorption. So my sense is that most people get G. I. Symptoms from their prenatal vitamins but they don't actually absorb the iron. So if you've got a patient who you think is iron deficient I would avoid a prenatal vitamins. I put them on folic acid in a separate iron supplement. Um I have become an evangelist for iron disk. Listen eight. I feel like I just have a lot more people who are able to tolerate it. Um and who actually have their iron levels rise while they're taking it compared to other formulations of ironed I've used. But any formulation will be helpful if the patient's willing to take it every day and tolerates it just don't use the enteric coated iron which you're unlikely to absorb. You'll feel gentle in your stomach but it won't get into your system. We talked a little bit about B. 12 for the vegetarians. Um And then vitamin D. In san Francisco I think to start long foggy summer set us up for it and a lot of people are quite vitamin D deficient. All right so shifting gears from preconception stuff to thinking about pregnancy I wanted to just touch on a couple of common conditions, things that people might see you for when they have a flare during pregnancy because as it will be, I definitely follow along with asthma, but I'm often not the one who's writing the refills for inhalers or managing flares that come up. So big one, especially this time of year when colds and flues are rampant and some people have flares after their your eyes is plasma. Um, definitely good data that you need good control during pregnancy, definitely oxygenation is something we want to do throughout the whole course of your pregnancy. And we really don't tend to change management for pregnant people. Pretty much all of the regular at 1000 of medications you're going to use during pregnancy are safe to use. And I don't recommend switching people's regiments for pregnancy. If they're on one of these standard things that got listed. So obviously albuterol spine, the long acting inhaled bronchodilators are fine. The inhaled cortical steroids I think are all fine. I know we've got a little bit more data for b just deny it and floating zone. But there's nothing to indicate that the other ones that just have a little less data are less safe. Um So personally, if I've got somebody who is well controlled on their current regiment. I don't tend to change them for pregnancy. I tend to keep them on whatever they're on. I do want people to follow their symptoms more carefully during pregnancy and I try to get all of my patients a peak flow meter. So this would be a great thing to intercept pre pregnancy. You get them in the habit of doing that peak flow meter each day. Because if you start to have trouble, you're going to want to bump up quickly in pregnancy. You're not going to want to wait for a dramatic flair um For allergy related stuff. I know y'all do this all the time. But all the stuff you normally use the spine. Um allergic rhinitis. Try to get people in the needs of steroids safe for pregnancy more effective than the anti histamines. Um The antihistamines are fine though. I feel like some of the fertility folks will tell people to stop into histamines if they're having trouble conceiving. There's some theoretic stuff around um Think fertilization of the embryo with anti histamines. But once you're actually pregnant it's totally fine. We just usually recommend avoiding decongestants during pregnancy. So use your Claritin. Just don't use your Claritin D um During pregnancy a lot of people would get more post nasal drip and we'll get a lot more Flynn and may or may not be their allergies. This condition called pregnancy rhinitis is really common and it tends to happen just as you get a little bit more upper airway and dina during pregnancy. So for that I encourage people just to do saline rinses each night. And that does tend to help more than anything else. Um For eczema. Sometimes this flares during pregnancy, it is safe to use the topical steroids, but just like for everyone else with eczema, we try to do the things first to prevent these flares. So getting people off of the all over their body soap and body wash to tell people wash your smelly parts, leave the rest of it alone and then using a good emollient, ideally twice a day, getting them to use a cream or if they're willing to use before Vaseline on their sensitive patches to try to minimize how much steroids they need to use this ideal. Um But I think it's really similar types of care outside of pregnancy. Um This is probably one of the most important, I think depression and psychiatric disorders can sometimes flare during pregnancy. So this is a group that I think does benefit from having a preconception council with an O. B. Who is comfortable doing site or with a psychiatrist who is comfortable doing obie. Um We do have some of these people that UCSF if you're struggling to find someone in your community who's comfortable managing pregnant patients. But I think increasingly the literature has come out that most of the psychiatric drugs were using are pretty safe during pregnancy, but the psychiatric conditions themselves are not, you know, it's really not safe to have untreated depression or untreated mania during pregnancy or postpartum and we've actually had a maternal death, that you see a stuff from bipolar disorder leading to suicide. So we're all I think quite sensitive to this right now. Um So I see from my patients with bipolar disorder, there's someone who needs to have a psychiatrist that's following them closely, who's comfortable following them during pregnancy. If they're psychiatrist is telling them things like we need to take you off all your meds for pregnancy, you need to find somebody else because there's definitely things that can use during pregnancy. Most of the antipsychotics are going to be fine to just continue. Um Sometimes we'll even use lithium for people who have serious manic episodes and don't do well on other things, because while there might be a small increase in the risk of birth defects, the absolute risk is really low. So the one exception is the all pro eight, that's the one we'll always try to stop before pregnancy. Um For depression anxiety here, I think more and more people are getting comfortable with continuing SSR is and SnR is from people who benefit from them during pregnancy, especially with the idea being that many people are going to flare postpartum and you want to have someone who's doing well during pregnancy, not kind of like just barely scraping by with their depression and then just headed for a total collapse postpartum. Um So it's a someone told you have to say I'm pregnant, I'm on my s s r I I would not encourage them to stop without doing a consultation with and will be your psychiatrist to really talk it through in their individual circumstance. And some people will be in off during pregnancy particularly if they've been stable for a long time. They've never had a hospitalization or suicide attempt. But many others will opt to continue through pregnancy to try to avoid the complications. Um A PhD is another group that seems to grow year by year in my practice. It's still harder than I would like to get good data about amphetamine use during pregnancy because so much of the literature is a mixed bag where they're studying people using recreational amphetamines as opposed to prescription but they don't seem to be true photogenic. The main concern is if they could cause growth restriction in the third trimester. So our party line is then to try to get people on the lowest dose that meets their needs. Some of my patients will just use their Adderall on days when they're at work or just on really critical days that work. Some people will lower their dose. Um I encourage people to increase their caffeine consumption a little bit sometimes that can help with alertness. So having like two cups of coffee first thing in the morning. Can sometimes make a difference for these folks. Um And again another good group to have a preconception consult um insomnia is the last big thing we see it does tend to flare during pregnancy. Does tend to flare postpartum. And while people are weaning. Um So I try to get as many of my patients as possible to go through cognitive behavioral therapy for insomnia. I've seen it make a big difference for people during pregnancy and postpartum. Many of the medications we use are safe for insomnia, they're just not going to be as effective as this. Alright, diabetes, I feel like is one of the scariest chronic conditions because um glucose itself is actually a really potent to religion if people get pregnant and have a really high hemoglobin A one C there's a very high chance of serious malformations. So we take hyperglycemia in the first trimester really seriously. Often by the time we get called and they're like eight weeks pregnant, the damage is done. So this is where primary care is so helpful for making sure these folks are on good contraception until they're ready. You can see and ideally getting their hemoglobin a one C as normal as possible before conception. Um If somebody calls up and they are pregnant and they've got a high hemoglobin a one c. You can call labor and delivery for that if you need to because sometimes we'll actually admit these votes, we've got someone with like an A. One C. Of nine or 10 whose newly pregnant, we'll put them on an insulin drip will figure out their regiment in the house because we want to get that Lucas down as fast as we possibly can um for diabetics to conceive on Metformin, find to keep them on it until they see us. I feel like different obese and different Mfs have different opinions um whether to continue it during pregnancy or just fully convert over to insulin. You see stuff we tend to use more insulin, although occasionally have a patient who stays on that for men as well. Um but I think the main message is try to get to a place in the control as fast as you can loop. It will be if you've got someone with that hyper placing mia um hypertension. I feel like here the story is really that we've got a couple medications that are really well studied in pregnancy and work for pregnant votes Nifedipine metal on metal Dopa. When someone is trying to conceive, this would be the great time to get them off their ace inhibitor or their ARB and get them switched over to one of these. But don't panic if they conceive on one of these. I think the absolute risk of of problems pretty low. A lot of the concerns are actually more third trimester stuff. Um but switching them over to one of the better study medications during pregnancy to be helpful. We want people to have good blood pressure control through pregnancy though. Um Gi stuff is always a problem during pregnancy. Good is just going to get worse. Find these terms here and there. But I've had two patients now we've had kidney stones from taking so many tongues during pregnancy. So if people are just like eating times like candy all day is their heartburn so bad. It's time to up the ante. We usually go to H. Two blockers first and if that's not working, switch them over to a P. P. I. So if someone reaches out to all these are fine to use move up the line is needed. Um We talked about hemorrhoids and constipation and how I'm a fiber evangelist already. So I won't make you listen to that again. Um for people who call up nearly pregnant with bad nausea and vomiting are first time recommendation is to start vitamin B63 times a day, 10-25 mg. And if that's not enough they can add dot sila mean, which is just Eunice, I'm um take that every six hours tends to make you sleepy of course is starting at bedtime. Works best if they fail those two, you can usually get a preauthorization through to prescribe deploy aegis which is just a combined version of those two. That's slow release and it seems with the slow release it's a little less sedating and maybe a little more effective for some folks if that fails composing and Finnegan or the next plane agents, we tend to recommend um thyroid disease. If you've got someone of hypothyroidism obviously when you want tight control before pregnancy they'll likely help them get pregnant faster If they've got good control of their thyroid disease and it may lower their chance of miscarriage. Most people with Hashimoto's are not going to be able to melt the increase in thyroid hormone that's needed during pregnancy and it needs to go up by about 15%. So usually you're going to have to supply that increase with their supplement. So the old rule of families just to tell people whatever does here on add one or two pills a week and then recheck their levels four weeks later assuming you're starting at a normal point And we want tight control and pregnancy first trimester we try to keep the TSS less than 2.5. So if somebody is telling you about their thyroid disease before they get in to see us check their TSH it looks normal. Maybe empirically increase their dose just about 15%. That should hold them over until they're in for the first visit. So the flip side to this sort of postpartum. A lot of people get put on a thyroid supplement by the reproductive endocrinologist. You know they've got infertility. The cause isn't known they've got this like very subtle increase their TSH is like 3.1. The R. E. I. Office will put everyone on the supplement. So those are people during prenatal care I tend to encourage to go off the supplement postpartum and then follow up with y'all to see if in their non pregnant, non reproducing life. They actually need to supplement anymore or not. Hyperthyroidism I think is more complicated. I think these folks are folks are best served with having a maternal fetal medicine consult beforehand. There's a lot of debate about what the right approach is during the first trimester in terms of myth, a missile or PTU. So having them iron out that plan ahead of time to be helpful. Um Sorry, auto immune conditions. These are another group that probably needs an M. F. M. Referral ahead of time if they can because there's gonna be a couple of different issues going on preconception. One is how well controlled is their disease? Is this a safe time for them to get pregnant? You know, there's someone with lupus. Is that kidney disease? What is going to be the risk of pregnancy for this person? And then another issue is, is the medication they're on right now safe for preconception. Is it safe to remain on once they conceive? And there are a couple of medications in this class that we always recommend avoiding methotrexate being the most common. So if you've got someone another try to say you'd like to become pregnant, they do need to see an N. F. M. And come up with an individualized plan for what the regiment is going to be preconception or pre conception and during pregnancy. Mhm. Um For pregnancy medications, there is not a great resource. It is really frustrating the FDA is phasing out the old five category system which I'm happy about because they felt like you've over simplified things. That wasn't all that informative. I think the best website out there is this one called Mother to Baby dot org will show a couple of slides from it. A couple of things in primary care if people are having team during pregnancy. acetaminophen is our first flying which you'll probably know. Um we're using lidocaine patches more and more for musculoskeletal pain so that's fine to use to. Um And then in terms of antibiotics, almost all of the really first line stuff. penicillin, cephalosporins, splenda metro notice all those are all okay to use. So a lot of the common things that people call it for find infrastructure, usual antibiotics, one plug um We love to be able to use penicillin during pregnancy because they're so well studied. They're so effective for so many of the things they treat but it's pretty common allergen to report. Um the data from our allergy group is that more than 90% of people who report a penicillin allergy don't actually have a penicillin allergy anymore. Either they outgrew it or you know they were told they had it as a child and maybe it was just a viral exam, thumb and not actually a drug rash. So we recommend all of our pregnant patients who reported penicillin allergy to undergo penicillin testing and we can do this through the allergy group at UCSF. So you just refer people to the allergy group in type and penicillin testing, preconception patient or penicillin testing patient. Now pregnant, I've been sending patients for the last two years and Probably like 20 or 30 people. And so far I've had zero people who are actually allergic. So it's been very gratifying to clean up people's allergy lists. Um This is what the mother to baby website looks like. I use this all the time both for myself and um to print out these fact sheets for patients. So if you go to the front page like on exposures, they've got these things they call fact sheets that basically provides a very well organized summary for whatever medication you're looking up. So this is the one on East inhibitors. This is what your patient would see. It goes on a long ways from there but it does summarize some of the data for its use during pregnancy and provide some practical advice about whether to continue it or not. Um This type is just a little hodgepodge of things that come up all the time. Your patients calling in with tooth pain or possible dental abscess or they got gum bleeding, please send them to the dentist. They can definitely get dental work done when they're pregnant. We have this like standard funny letter that prints out that tells the dentist please treat this patient. Yes give them local anesthesia. Yes give them antibiotics. Safety is nitrous oxide etcetera. But there is data that people who have untreated periodontal disease are more likely to have preterm birth and pregnancy loss. So we want our patients to get good dental care. Another thing that gets called we get called about all the time of someone like a broken leg and they won't want to get an X ray. Please get imaging during pregnancy when you need it. Um Ultrasound and MRI without contrast are always safe. There's no radiation. There's no concerns to those technologies. An X ray is super super safe. Um chest head limb wherever you're looking that's not like right over the pelvis. The fetal dose is really hard to calculate its less than 0.1 mg. Dads. We think just being in utero for nine months you get exposed to about one mg. Just for um just for reference we do try to avoid cts of the abdomen and pelvis. Even a ct of the chest till they rule out pe is actually quite safe during pregnancy. Um But I have done cts of the abdomen pelvis when we're really pushed during pregnancy. So I feel like if you're in some sort of critical situation where patients absolutely need imaging. You can do it. But from the primary care perspective for that like broken ankle that like possible fracture of their hand that possible pneumonia, pleased to get them the next day if they need it. Um Last one is a little funny, but I've got to write so many letters over the years explaining why my patient's cholesterol levels are sky high cholesterol naturally rises during pregnancy. I think it's probably because you need to push all those liquids through the placenta to grow another body on the other side. So everyone has high cholesterol while they're pregnant. It comes up either because my patients are getting it checked for life insurance, which a lot of people decide to do while they're pregnant or they're doing it for some sort of like employee program or if you show that you've got low cholesterol, you get like some sort of special benefit. Um So please don't let them check their cholesterol while they're pregnant. Don't offer to order it for people while they're pregnant. It'll just come back high and sometimes it can cause problems for them. Mhm. All right, this is my breast feeding pep talk. Um I feel like breastfeeding as a mother of three. It is really hard to do, especially if you're a working person. Um And people have put so many restrictions on women who are breastfeeding that are really probably not necessary. So, most medicines are going to be safe. Any breastfeed. All vaccines are safe safe except maybe yellow fever and I don't think anybody's vaccinating for smallpox right now. Anesthesia is actually safe when we're breastfeeding and I'll go through that um drinking lightly is safe to or even moderately. The american Academy of Pediatrics recommends that if you drink two drinks, wait two hours to go ahead and breastfeed or pump again, um you don't need to pump and dump. What happens when you drink alcohol is of course your blood alcohol content raises. And the alcohol will freely enter the milk while it's in the bloodstream and then it'll freely exit the milk back into the bloodstream as your body metabolizes the alcohol. So it's not like the milk is a reservoir for the alcohol and it's like tainted afterwards. It really just reflects your blood alcohol content. Um So basically if someone drinks, you know, like one drink and they are an hour or two later and they're not feeling buzzed that alcohol has left their milk and it's safe to go ahead and breastfeed or pump again. My O. B. Give me the pearl of basically starting to nurse and then starting the beer. So by the time you're blood alcohol content was rising, your baby was done nursing and there was the longest stretch of time between the next session. Other things for breastfeeding people, caffeine in moderation is fine, probably 300 mg or less. And there's none of the food restrictions like there are during pregnancy, all that stuff about like, you know, soft cheeses and deli needs not to eat. That's all about the placenta. There's no placenta when you're breastfeeding. So please go ahead and enjoy some very eat your turkey sandwich. It's all fine. Um As opposed to pregnancy, there is a great great database for medications during lactation. I love it. I use it every day. It's called locked med. I can never remember the link to get there. But if you go to google and you type in like net this will pop back up when you get to this page. Don't do what I always do and type it in here. Type the drug you want to do in this little search box here where it's searching in this lack net book. It will pop up a reference that looks like this. So here's the one for Ibuprofen. They update these all the time. They're usually super up to date in this first part here that says summary will usually provide everything you need to know. Um So it tells you how much is in the breast milk whether it's considered safe, how long it stays in the breast milk if that's an issue. And sometimes it will say other drugs preferred. And then very helpfully it'll tell you what the other drug is for stuff where there's not a lot of data and there's not a consensus about whether it's safe or not. It'll actually summarize everything we know from both human and animal studies and the lines below it. So it's very complete, very thorough. I've never found anything where I get more information somewhere else or if I like go to pub net I find new things. This is always really comprehensive. So tad lacks net. This will help you out of time for your lactating patients when you're about to write a new prescription. Um If you are a reference by person um thomas, Hales medications and mother's milk is sort of the gold standard reference book and dr Hales group at texas tech maintain this great website called the infant risk center. Just infant risk dot com. That has lots of information about medication and environmental exposures during lactation and does have the ability to like chat with experts or email or call for advice if you're feeling stuck. This is a great group to turn to if you need a quick second opinion. Um In terms of vaccinations, like I said anything except for smallpox and yellow fever. Um For covid you do not need to pump and dump. I feel like people are still being told that there's no reason to pump and dump after the covid vaccine. The M. RNA does not go to your breast milk. Um So please continue nursing pumping whatever you're doing through your vaccine. Um anesthesia, what to do. This is like the one guideline from another group other than a cod rather than the objectives group that I referenced all the time. I've emailed this to countless surgeons anesthesiologists over the years because there's so much misunderstanding about what's safe to do in terms of anesthesia and breastfeeding. And I think the statement is very concise and it's really reassuring. Yeah. So in their key recommendations which are summarized here, they do acknowledge that all of the anesthetics go to the breast milk but they go in really, really small concentrations and they don't tend to accumulate there. They get out of the system really fast. So the usual recommendation is that it's safe to assume breastfeeding as soon as as soon as you're awake and coordinated enough and cogent enough to be able to coordinate what you need to do to pump her future baby. So if someone's really drowsy and not with it, not the time to pump, not the time to breastfeed, wait until she feels alert. Well is with it and at that point it's safe. She does not need to pump and dump after surgery unless she got like radiate radioactive type stuff. Um And that's all I got for my short summary. I hope we left plenty of time for questions because I'm happy to fill them