Medical problems in pregnancy

Medical problems in pregnancy

Editor – We were disappointed that the letter by Stoian and MacDonald (Clinical Medicine, December 2017) in response to our article¹ makes some incorrect statements about medications in pregnancy.

Low-dose aspirin has extensive safety data in pregnancy, including the third trimester. A recent multi centre double-blind placebo-controlled trial found that aspirin 150 mg daily taken until 36 weeks gestation did not have any adverse effects on the foetus or neonate.² Given that the suggested dose for migraine prophylaxis is only 75 mg, we can confidently regard it as safe. The British National Formulary (BNF) may advise caution, but this is based on the much higher anti-inflammatory dose of aspirin. The authors of the letter should note that the mechanism and effects of low-dose aspirin are rather different than that of high-dose aspirin.

With regard to propranolol, there have historically been concerns about the effects of in utero exposure to β-blockers on foetal growth. However, this was observed in hypertensive mothers, so it is difficult to clearly distinguish the role of the drug versus maternal disease. Furthermore, the association was seen when using significantly higher doses than those suggested for migraine prophylaxis. Low-dose propranolol is now well recognised as an acceptable second-line option for migraine prophylaxis in pregnancy.^3–6

In the treatment of acute migraine attacks, we agree that the use of opiates should be avoided, and this is stated in the original article. Finally, we agree that fundoscopy can be useful in the clinical assessment of any patient presenting with headache. The loss of spontaneous venous pulsation is a subtle sign of raised intracranial pressure. However, we would emphasise that normal fundoscopy does not exclude serious intracranial pathology.