Pregnant women who have contact with lead can pass the lead to the developing fetus and breastfed infant. Children exposed to lead before and/or after birth are at increased risk for delays in development and growth. Lead exposure may result from contact with lead in the environment, including lead-based paint, dirt, cosmetics, hobby products, occupational exposures, and other sources. Lead exposure generally occurs when contaminants with lead are inhaled or ingested. Lead exposure from water sources is less common but occasionally occurs in the United States.

Risk assessment

Risk assessments can be used to determine if pregnant women might have been exposed to lead and if a blood test is needed. Risk assessments can provide anticipatory guidance to prevent lead exposure from home renovations, occupational exposures, crafts, herbal products, or other avoidable sources.

Remove exposure

The priority for treatment is removing the source of lead exposure.

Centers for Disease Control and Prevention.
Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women.
Center for Disease Control and Prevention; (2010) https://www.cdc.gov/nceh/lead/publications/leadandpregnancy2010.pdf. Accessed on 3/24/2023.

Committee on Obstetric Practice.
Committee opinion No. 533: Lead screening during pregnancy and lactation.
Obstet Gynecol. 2012;120(2 Pt 1):416-20. PubMed abstract / Full Text

• Gestational hypertension
• Hypertension
• Preeclampsia
• Lead colic or abdominal pain
• Peripheral neuropathy
• Spontaneous abortion
• Preterm delivery
• Low birth weight, head circumference, and length
• Delirium
• Stupor
• Coma
• Seizures or tremors
• Death

While prenatal lead exposure does not increase the risk of structural birth defects, it increases the risk of other poor outcomes. Signs and symptoms in infants and young children may include:

• Constipation
• Anorexia
• Vomiting
• Inattentiveness, distractibility, impulsivity
• Anemia
• Learning problems
• Decreased growth
• Neurodevelopmental delays
• Intellectual disability (see the Portal’s module on Intellectual Disability & Global Developmental Delay for more information)
• Attention deficit hyperactivity disorder [Daneshparvar: 2016] (see the Portal’s module on Attention-Deficit/Hyperactivity Disorder (ADHD) for more information)

Risk Factors

Risk assessments are an important step in screening for lead exposure. Symptoms will not usually present until very high blood lead levels are reached. The prenatal history, at the first prenatal visit, should include a health risk assessment to determine possible exposure to lead from various sources, including (but not limited to): [Committee: 2012] [Centers: 2010]

• Residence (leaded gasoline, environmental sources, contaminated water, etc.)
• Occupation (police officers, artists, construction workers, etc. See Jobs That May Have Lead Exposure (CDC) for more examples.) [Centers: 2010]
• Pica
• Imported cosmetics, foods, alternative health care products
• Hobbies and housewares (stained glass, lead-glazed pottery, shooting/reloading)
• Home remodeling in older homes
• Previous lead exposure
• Living with others with elevated lead levels

A complete list can be found in the Guidelines for the Identification and Management of Lead Exposure in Pregnant Women (CDC) ( 3.7 MB) (Table 4-1) and Lead Screening During Pregnancy and Lactation (ACOG) (Box 1).

Screening

Testing

Among women ages 15-44, approximately 1% have blood lead levels (BLL) of 5 μg/dL or greater. [Centers: 2010]

Worse outcomes, including hypertension, seizures, and death, are correlated with increased blood lead levels (BLLs).

Blood Lead Follow-Up Testing During Pregnancy

Calcium Supplementation

Fetal and Child Treatment & Management

Recommendations for Initiating Breastfeeding

• Measurement of levels of lead in breast milk is not recommended.
• Mothers with BLLs <40 μg/dL should breastfeed.
• Mothers with confirmed BLLs ≥40 μg/dL should begin breastfeeding when their blood lead levels drop below 40 μg/dL. Until then, they should pump and discard their breast milk. Repeat blood lead levels every 1-2 weeks after removal of the exposure source.

Common treatment interventions, including removal from the source of the exposure and nutritional interventions, are attempted before medications are considered due to the risks of using the medications.

Oral chelation may improve blood lead levels and reduce symptoms of acute lead intoxication but may have limited usefulness in reducing other existing symptoms such as neurodevelopmental delays. [Kosnett: 2007] Chelation is generally not recommended during pregnancy since it releases lead from the bone, increases blood lead levels, and increases fetal exposure, except in cases where the life of the mother is at risk. [Centers: 2010]

Chelation is considered when blood lead levels are greater than 45 μg/dL when the individual has been removed from the lead exposure, and based on the individual situation of the exposed mother. An expert in lead poisoning should be consulted for chelation. Chelation medications bind to and release lead and other essential minerals from bone and other tissues. The blood lead level may drop immediately after chelation treatment but usually increases about two weeks after treatment. [Centers: 2010] [Family: 2022] Blood lead levels may remain high for years even after chelation therapy, particularly if there has been longstanding exposure, and chelation may not affect long-term neurodevelopmental outcomes in children. [Cantor: 2018] In pregnant women, the loss of other minerals from the therapy may increase the risks of complications for the fetus. [Centers: 2010]

Recommendations for chelation therapy:

• Chelation therapy should be considered for pregnant women with confirmed blood lead levels ≥45 μg/dL on a case-by-case basis, in consultation with an expert in lead poisoning. In most cases, chelation will not be performed unless the pregnant woman has a blood lead level >70 μg/dL.
• Pregnant women with confirmed BLLs ≥45 μg/dL should be considered as having high-risk pregnancies and should be managed in consultation with an expert in high-risk pregnancy.
• Pregnant women with life-threatening lead encephalopathy should be chelated regardless of trimester.
• Insufficient data exist regarding the advisability of chelation for pregnant women with BLLs <45 μg/dL.
• Before considering chelation therapy for a pregnant woman (or infant), blood lead levels should be repeated and confirmed using an additional venous blood lead sample collected within 24 hours.
• Chelation therapy must occur in a lead-safe environment; therefore, prior to initiating chelation therapy, the patient should be removed from further lead exposure.

Limited case reports are available that describe the use of chelating agents in pregnancy. For a list of chelating agents, see Childhood Lead Exposure.

The CDC recommends case management services for pregnant women with blood lead levels >15 μ/dl”. [Centers: 2010] The medical home can provide care coordination including anticipatory guidance; care planning; identification of resources and specialists; appointment coordination; collection and coordination of testing and treatment results; and other care coordination activities.

After blood lead levels are identified, local health department, occupational health, and other experts will perform important roles depending upon the source of the lead exposure. OSHA-acceptable exposure levels that trigger action are higher than CDC levels, with a medical evaluation required at 40 μ/dL and removal from the exposure required at 50 μ/dL. The physician examining the pregnant or breastfeeding woman may, however, recommend stronger actions at lower levels based upon the clinical presentation or other situational information. [Centers: 2010] Those actions would include identification of the source of lead, removal from further exposure, and blood testing frequency based on the BLL.

After blood lead levels are identified, an expert in lead poisoning should be consulted for chelation. [Centers: 2010] See the section above, Medications Used to Treat Lead Exposure, for details on chelation.

Z77.011, Contact with and (suspected) exposure to lead
R78.71, Abnormal lead level in blood
Z13.88, Encounter for screening for disorder due to exposure to contaminants
See ICD-10 related to lead exposure (icd10data.com) for further coding details.