Correspondence (reply): In Reply

We would like to emphasize once more that any drug treatment during pregnancy requires balancing risks and benefits; therapeutic alternatives need to be considered, as do the consequences of non-treatment. Fundamentally, the preferred option is to treat any illness in pregnant women without drugs. Even 60 years after thalidomide it cannot be stressed enough that any medication should be restricted to what is absolutely necessary.

It is generally a challenge to evaluate the importance of results from cell cultures or animal models for humans. So far, no substantial indications exist that the amphibian models mentioned by Dr. Conradi in the context of azole compounds can be generalized to the use of clotrimazole in humans. Clotrimazole and nystatin are among the local antimycotic drugs with the greatest amount of experience in pregnancy. Treating vaginal fungal infections to an insufficient degree or not at all could indirectly put the baby at risk. For ibuprofen, so far no clinical correlates exist to the experimental results on germ cell toxicity. With regard to treating depression, priority should be given to non-medication (psychotherapeutic) approaches, at least in mild symptoms. However, if medication is required or has already be given, comprehensive clinical experience especially regarding sertraline and citalopram has not evidenced any substantial embryotoxic or fetotoxic risk or relevant impairment of long-term development. On the other hand, it should be borne in mind that insufficiently treated symptoms in the mother may lead to behavioral disorders in the child.

We agree with Professor Kiesewetter that if heparin is not tolerated, other anticoagulants may be indicated, including fondaparinux. Intravenous administration of iron preparations should be limited to pronounced anemia because it may cause severe hypersensitivity reactions. Vitamin D supplementation will have to be decided on an individual basis. Metamizole is a reserve analgesic because of its side effect profile and lack of experience in pregnant women. In the first half of pregnancy, ibuprofen and paracetamol are equivalent. Embryotoxic or teratogenic effects associated with ibuprofen have been discussed on occasion. In summary, the existing data do not support such a risk.

If selective serotonin reuptake inhibitors (SSRIs) are used to term the risk of persistent pulmonary hypertension in the neonate seems slightly raised. According to what is known, amitriptyline is not associated with any embryotoxic risk in humans. The effectiveness of tryptophan preparations for depression has not been confirmed. Possible interactions militate against uncritical use.

It is correct that the most studied diuretics hydrochlorothiazide and furosemide/frusemide should be used with discretion, so as to prevent fetoplacental underperfusion. Diuretics are not among the antihypertensive medications of choice in pregnancy. However, teratogenic effects in humans have not been proved.

We’d like to add furthermore that influenza vaccination is among the vaccinations recommended for pregnant women (Table 3 in our article [1]).