Pregnancy With POTS

Whether you are currently pregnant, trying to get pregnant, hoping to get pregnant, or just here to learn about POTS and pregnancy, you came to the right place. We will say that although the data and research specific to POTS and pregnancy is limited, there still is enough data at this point for us to be able to answer questions and hopefully provide some added support and awareness specific to what individuals in our community may experience. We will also say, however, that given the number of individuals in our community with co-occurring conditions, pregnancy considerations specific to those other conditions in combination with POTS will also need to be taken into consideration with your medical team.

Applicable Questions and Answers Listed Below:

Can I still have a healthy pregnancy with POTS?

Although a lot does need to be taken into consideration, including medications you may need to take, maternal age, and other co-occurring conditions you may have, individuals with POTS can still have healthy pregnancies! : ) Though there is a lot of variation within our community, and the severity of POTS can certainly vary alongside potential other co-occurring conditions, researchers and providers have continued to state that they believe individuals with POTS who would like to get pregnant can do so safely (Kanjwal et al., 2012; Morgan et al., 2022). Researchers have found that those with mild to moderate forms of POTS “have similar pregnancy outcomes to the general population” (Bhatia et al., 2018). We should note that despite this, it is important to discuss fall precautions with your team related to syncope, and those in our community with EDS and other co-occurring conditions should also be more closely monitored given the risk for more complications (Ruzieh et al., 2017).

Is there a POTS and pregnancy support group?

Yes! There is one that comes to mind specifically on Facebook. Though we can’t speak to the quality of the group and how helpful it may be for you, we can say that there are a few thousand individuals within the group who often ask questions and can offer added support/share their own personal experiences. We will say that this is not a place where you can get helpful medical advice, but rather added peer support. The group is called “P.O.T.S & Pregnancy/Families,” and they have around 4,000 members.

Do individuals with POTS really feel better when pregnant?

This varies quite considerably but some do, yes! Our answer to this is based on a few studies by Blitshteyn et al., Kanjwal et al., Morgan et al., and Bhatia et al. (2012; 2009; 2022; 2018). The increase in blood volume and fluid retention experienced during pregnancy can certainly be helpful for some individuals in our community as one potential explanation for those who experience improved symptoms (Bhatia et al., 2018)! This being said, all of the studies also note that some feel about the same, and others in our community can feel worse, so you aren’t alone if pregnancy was a more difficult time/experience for you, or if you didn’t experience any changes (Blitshteyn et al., 2012; Kanjwal et al., 2009; Bhatia et al., 2018; Morgan et al., 2022).

What is it like to be pregnant with POTS?

This is a great question! For starters, we will say that it can vary considerably and appears to be influenced by the POTS severity before getting pregnant (Bhatia et al., 2018; Powless et al., 2010; Morgan et al., 2022). Individuals experiencing symptom improvement, or the stability of symptoms throughout, were more likely to have mild symptoms prior to pregnancy, moderate symptoms prior to pregnancy, or did not require medication when conceiving (Morgan et al., 2022). Other co-occurring conditions may influence this as well, so it is important for providers to be mindful of this. Around 60% report feeling better during pregnancy, especially when on medication (though we found that this statistic can vary slightly depending on the study), 12-15% have stable symptoms throughout, and about 30-40% report feeling worse (Kanjwal et al., 2009; Glatter et al., 2005; Bhatia et al., 2018; Morgan et al., 2022). There is a higher chance for individuals in our community to experience hyperemesis gravidarum (a more severe form of nausea and vomiting that can occur during pregnancy with about a 59% incidence in our community), so this is important for your providers to be aware of (Blitshteyn et al., 2012). Providers aren’t fully sure why this is the case, but one potential theory or contributing factor to consider is that it is related to co-morbid migraines as there is an association between migraines and hyperemesis gravidarum in pregnancy (Blitshteyn et al., 2012; Heinrichs, 2002).

Can pregnancy cause POTS?

Unfortunately, yes, some find that they may have POTS symptoms that develop during pregnancy and resolve, while others may develop POTS after pregnancy. Although researchers aren’t fully sure why this occurs, immunological stressors are believed to trigger POTS (Fedorowski, 2019). If this is something you have experienced, we want to take time to acknowledge how difficult we understand it may be, both adapting to new changes as a parent, while also adapting to new changes that arise when navigating an illness like POTS. We hope that our other sections throughout the website offer additional support, and please don’t hesitate to reach out to our team if you need added support or have other questions we haven’t answered. If helpful, you can also visit our What Causes POTS section to learn more about various POTS triggers.

Are my POTS medications safe for pregnancy?

Some medications taken by individuals in our community recommended to help manage POTS symptoms can be prescribed during pregnancy, but research is still limited, and we can’t speak to all medications or medications taken for other co-occurring conditions. Most of the first-line medications prescribed (like beta-blockers, fludrocortisone, and midodrine) are considered category C for pregnancy, where risks can’t be ruled out, but the benefits may outweigh potential risks. One example of a medication that is category B for pregnancy is pyridostigmine (Bhatia et al., 2018). Receiving IV Normal Saline infusions is another potential safe option to discuss with your team if your POTS symptoms are severe. The use of IV Normal Saline to increase blood volume, though not studied well in those who are pregnant with POTS, has been proven to help significantly both with improving quality of life and symptom reduction (Ruzieh et al., 2017). It appears that the use of 1 liter over a period of 1-2 hours each week can be helpful but should be titrated as tolerated as individualized care is important (Ruzieh et al., 2017). To learn more about these see our Managing Symptoms pharmacological treatments section.

It is important to note that Ivabradine is not considered a safe medication option as it is considered category D for pregnancy, and the safety of Octreotide is not fully clear (Bhatia et al., 2018). Although there are no controlled data in human pregnancy for Ivabradine, concerning evidence from animal studies leads to a need for those on the medication to be advised to use contraception. Because all of us are different and the way medications can impact us can vary considerably, discussing what medication options you have with your team can be helpful and important. The goal is to try to manage symptoms without medications, if possible, by weaning prior to a pregnancy, but it is always best to weigh the risks and benefits (Ruzieh et al., 2017). The increase in blood volume during pregnancy for about 2 liters can enable a reduction or elimination of helpful medications before the pregnancy, but this does need to be determined by your medical team given how much variability there can be.

When will I know if my POTS symptoms will get worse during pregnancy?

It is unfortunately very hard to say and difficult to predict! We wish we had a clear answer for you but the current research is limited. We will say that researchers have found that about 1/3 of individuals experience worsening symptoms only during the first trimester, 1/3 around 24 weeks continuing through the pregnancy, and 1/3 with these symptoms throughout (Kanjwal et al., 2012; Glatter et al., 2005). Other studies have reinforced symptom exacerbation during the first trimester with improvements for some during the second trimester, and more variability during the third trimester, believed to be related to increased cardiac output associated with increased blood volume later in pregnancy (Morgan et al., 2022).

How can I get symptom relief if my physical symptoms worsen during pregnancy?

If pre-existing symptoms worsen, researchers have found that the worsening symptoms are often specific to increased presyncope, syncope, and/or migraines (Corbett et al., 2006; Glatter et al., 2005, Kanjwal et al., 2012). Some found that increasing the doses of medications individuals were already on proved to be helpful; one cited example included increasing doses of beta-blockers (Powless et al., 2010). As mentioned above, there is also a higher chance for individuals in our community to experience hyperemesis gravidarum (a more severe form of nausea and vomiting which can occur during pregnancy with about a 59% incidence in our community), so this is important for your providers to be aware of as well (Blitshteyn et al., 2012). Some with more severe symptoms may require IV hydration (Bhatia et al., 2018). This may be something individuals in our community can discuss with their medical teams proactively. It is also important to consider the benefits associated with non-pharmacological interventions, with a number of options within our Managing Symptoms section for individuals with POTS, in collaboration with your care team to decide what interventions are best and most appropriate. Some of these specific to pregnancy may include the incorporation of light exercise, increased daily sodium chloride consumption (7 grams or more), the use of waist high compression garments, and a daily fluid intake of at least 2.5L, but recommendations will need to be tailored to meet your individual needs (Morgan et al., 2022).

Do I need to be followed by a high-risk team if I have POTS?

This is a difficult question to answer and will vary as a great deal needs to be taken into consideration. Maternal age, past medical history, current diagnoses, needed medications, fetal health, and how you are tolerating the pregnancy are all factors that can influence the need to be followed by a high-risk obstetrics team. Asking your providers ahead of time may be a good idea, and you can also consider scheduling a pre-conception appointment with a high-risk obstetrics practice to determine what their feelings are specific to your history (if this is something you feel would be helpful). Although this pre-conception appointment doesn’t take into consideration changes during pregnancy and the health of the baby which may be unforeseen and could change your need to be followed by them, it may still be helpful if you have a number of questions. You deserve to have those questions answered!

Do individuals with POTS experience more miscarriages?

We are not sure, unfortunately. Some data did appear to suggest that individuals with POTS may experience more miscarriages on average, as there was an approximate 41% rate of miscarriage; this being said, they felt it was too premature to conclude or make any statements one way or the other based on their small sample size (Blitshteyn et al., 2012). They felt that a larger study needed to be done before drawing any conclusions or assuming that there is a causal relationship between POTS and incidence of miscarriages (Blitshteyn et al., 2012).

Do I need to have a C-section?

Not necessarily, no, but this decision should be made based on a number of factors including various obstetric considerations (Kanjwal et al., 2009). In Kanjwal’s study specifically, 81% of patients had vaginal deliveries and 19% had C-sections with no delivery complications (Kanjwal et al., 2009). Although a great deal of the literature does support vaginal delivery as being preferred and safe for many with POTS, it appears to be recommended to focus on obstetric/surgical considerations when determining what is best for each individual patient, given the lack of large clinical studies available and reliance on smaller studies and case reports (Morgan et al., 2022).

What will my labor and delivery be like with POTS?

Added fear around labor and delivery is completely understandable for women who are pregnant, especially given the added uncertainty and unpredictability. We will do our best here to offer added comfort and helpful information! We always hope that labor and delivery is in line with your expectations and desired birth plan, so we first want to speak to this and make room for what may be coming up for you as you proactively prepare. Added compassion and empathy is so important as you prepare to give birth to your beautiful bundle (or bundles) of joy! Although we can’t fairly predict what your labor and delivery will be like with POTS, there is some research available that we hope helps you and your medical team create a safe labor and birthing plan you feel confident in. It appears to be very important to manage pain effectively, where considering the benefits of early epidural anesthetic management may be helpful, with adequate IV hydration beforehand given the potential for drops in blood pressure (hypotension) associated with its administration (Morgan et al., 2022). In the event that a vasoconstrictor is needed, researchers do mention the potential use of phenylephrine, as it may “help prevent reactive tachycardia caused by peripheral vasodilation, which may lead to hypotension,” which is an important consideration for your providers to be aware of in the event that it is needed (Morgan et al., 2022). Although some researchers do appear to caution against home births for individuals with POTS given the potential for vital sign variability, and caution against natural births given how pain can influence autonomic nervous system functioning, it is important to note that data available is quite limited, as we don’t have access to large clinical studies (Morgan et al., 2022). Ultimately, you know your body best, and we recommend having these important discussions with your medical team as you weigh all of your potential options.

What will my postpartum period be like with POTS?

The postpartum period for all new parents can be quite challenging and isn’t talked about enough. There are social, cultural, environmental, and personal experiences that can influence how an individual responds, adapts to, and copes with these significant changes (Nelson, 2003). Although there are so many beautiful aspects to growing your family, the added demands, hormonal changes, sleep disturbances, breastfeeding (if this is something you decide), physical changes your body may be going through, and relational changes within your family may all be difficult and require you to have sufficient support, especially given how each of these both individually and combined may increase the risk for POTS flare-ups. It is ok to ask for help, as we all need help sometimes, and your health and well-being are extremely important! : ) As a society we often focus on the new, beautiful babies (as we should), but often don’t do enough to support new parents, even without POTS, who may be navigating these changes and experiencing postpartum depression. Adding POTS into the mix may understandably require you to have more resources and support available, so we do recommend talking to your team about creating a plan to ensure you have as many resources available to you as possible, just in case! When specifically looking at individuals with POTS, a small study found that around 50% of individuals felt their POTS symptoms were either better than before pregnancy or the same, and at one year post-delivery, the same was true (Blitshteyn et al., 2012). This demonstrates that similar to other answers, where how individuals in our community do during pregnancy varies, the same is true within the postpartum period. It seems to be difficult to predict who will improve, remain the same, or have worsening symptoms. This is an important discussion to have with your loved ones and your medical team so that you have the opportunity to review all potential options and can plan ahead as well as possible. The fewer surprises often the better, unless they are pleasant surprises - nothing wrong with pleasant surprises! : )

Does POTS increase my risk for postpartum depression and mental health difficulties?

Although we can’t definitively say yes, an analysis of what factors contribute towards postpartum depression and other mental health difficulties for new mothers, does suggest individuals in our community may be at higher risk. Overall, approximately 1 in 7 women develop postpartum depression, which is already quite significant and striking (Mughal et al., 2022). The postpartum period alone, separate from POTS or other chronic illnesses, is known to be quite difficult for new parents, especially if they don’t have enough familial support. Researchers have continued to look at risk factors that contribute towards the development of postpartum depression and other mental health challenges, and have found that women with sleep disturbances during pregnancy, women with more severe nausea and vomiting during pregnancy, and women with chronic physical conditions, are all at an increased risk (Maghami et al., 2021; Muchanga et al., 2020; Brown et al., 2019). We are understandably concerned by these findings given the prevalence of sleep disturbances in our community, increased risk for hyperemesis gravidarum for individuals with POTS, and known elevated risk for women with chronic conditions as a whole. Given the added difficulties that new mothers in our community may navigate, we highly recommend frequent mental health screenings and the incorporation of appropriate and proactive mental health support. We would recommend this for all new mothers both during pregnancy and postpartum, but strongly encourage this added support for new moms with POTS and other co-occurring conditions. It is imperative for providers to be aware of these risks and ensure everyone has access to the added mental health support they may need.

Are my POTS medications safe for breastfeeding?

Studies supporting the use of POTS medications during breastfeeding are much more limited, but we will update this section as more becomes evidence becomes available. First, there are no breastfeeding studies on fludrocortisone specifically, but the American Academy of Pediatrics does classify this class of medications (glucocorticoids) as being compatible with breastfeeding at this time (“Transfer of drugs…,” 2001). Second, when considering another first-line medication, midodrine, unfortunately there is no significant breastfeeding data at this time. Lastly, one beta-blocker that is often used, propranolol, has been classified by the American Academy of Pediatrics as being compatible with breastfeeding (“Transfer of drugs…,” 2001). We understand how challenging it can be to navigate the uncertainty when hoping to breastfeed and requiring some of these medications to manage your POTS symptoms. We recommend speaking with your team to make the most informed decision, considering the evidence that is currently available and what is best for both you and your baby.

Will I have more difficulty breastfeeding with POTS?

This is not a guarantee, but it is a possibility and something that is important to be both aware of and mindful of. Given that the total water intake (TWI) recommendations increase for individuals both during pregnancy and when breastfeeding, it stands to reason that appropriate hydration is important (Bardosono et al., 2017). Given the increased risk for potential flare-ups during the postpartum period, especially given the known link between inadequate sleep, stress, hormone fluctuations, and POTS flare-ups separate from pregnancy and postpartum considerations, it may be more challenging for breastfeeding mothers with POTS to maintain their hydration status (Morgan et al., 2022). We recommend tailoring your breastfeeding journey to meet both your physical and mental health needs, as do other researchers, which may require the consideration of alternatives to breastfeeding if you are really struggling (Morgan et al., 2022). It may be helpful to meet with a lactation specialist to express concerns that you have ahead of time, though we can’t encourage you enough to do what is best for your physical and emotional well-being. If supplementing with formula, relying on formula, or pumping is best for you and your baby’s caloric needs, we encourage you to individualize your approach with the support of your care team. It can be very emotionally challenging to navigate breastfeeding difficulties, and is important to remember that a fed baby is ultimately what is best, regardless of what that looks like for you and your family. The hope is that you can feed your baby in the way you are most comfortable with, and without added difficulties, alongside the support and compassion from those around you, regardless of what you decide is best!

As with all of the content on our website, it is designed for you. If you have other questions that you would like for us to be able to answer, although we can’t provide medical advice, we are always happy to immerse ourselves in the research and provide you with as much helpful information that you can share with your medical teams to discuss as is possible. So please don’t hesitate to reach out and let us know! You can do this by sending us a message on Instagram (link can be found at the top right portion of our webpage), or by sending us a message here.

Sources:

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Blitshteyn, S., Poya, H., & Bett, G. C. (2012). Pregnancy in postural tachycardia syndrome: Clinical course and maternal and fetal outcomes. The Journal of Maternal-Fetal & Neonatal Medicine, 25(9), 1631–1634. https://doi.org/10.3109/14767058.2011.648671

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Brown, H. K., Wilton, A. S., Ray, J. G., Dennis, C.-L., Guttmann, A., & Vigod, S. N. (2019). Chronic physical conditions and risk for perinatal mental illness: A population-based retrospective cohort study. PLOS Medicine, 16(8). https://doi.org/10.1371/journal.pmed.1002864

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Pregnancy With POTS

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Awareness for POTSies was founded in 2021. This website was developed with love and a great deal of time and commitment to our community. When sharing any content we developed, we ask that you cite our organization and resources appropriately.