Use of prescription and non-prescription drugs in pregnancy. The Baltimore-Washington Infant Study Group

Association of postpartum medication practices with early breastfeeding cessation among mothers with chronic conditions: A prospective cohort study

INTRODUCTION

Use of medications is a common concern for breastfeeding women, particularly when they are strongly needed or unavoidable to manage maternal chronic conditions. Yet the influence of medication usage patterns on breastfeeding duration in mothers with chronic conditions is unclear. The objective of this study was to examine whether postpartum medication practices were associated with shorter breastfeeding duration or earlier than planned breastfeeding cessation among mothers with chronic conditions.

MATERIAL AND METHODS

We analyzed 346 mothers with chronic conditions enrolled in a prospective, community-based pregnancy cohort study (Alberta, Canada) who initiated breastfeeding after birth. Data were collected through self-report questionnaires spanning late pregnancy to 6 months postpartum. Based on reported use of preexisting medications while breastfeeding, women were classified as continuing medications (reference group), discontinuing one or more medications, or those who did not use preexisting medications. Cox proportional hazards regression was used to analyze the association of medication practices and overall breastfeeding duration in weeks. Logistic regression was used to analyze the association of medication practices and earlier than planned breastfeeding cessation. Multivariable models adjusted for demographic and health-related factors.

RESULTS

Overall, 30.6% of women with chronic conditions stopped breastfeeding in the first 6 months, almost all of whom did so earlier than planned. In multivariable models, medication discontinuation was significantly associated with shorter breastfeeding duration (adjusted hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.03-2.70) and earlier than planned breastfeeding cessation (adjusted odds ratio [OR] 1.85, 95% CI 1.01-3.42), whereas medication non-use was not associated with differences in breastfeeding outcomes.

CONCLUSIONS

Women with chronic conditions who discontinued preexisting medications while breastfeeding had significantly shorter breastfeeding duration and were less likely to meet their breastfeeding goals in the first 6 months postpartum compared to women who continued preexisting medications.

The use, perceptions and knowledge of safety of over-the-counter medications during pregnancy in a Canadian population

BACKGROUND

The prevalence of prenatal over-the-counter medication use in Canadian women is unknown.

METHODS

A cross-sectional study of prenatal over-the-counter medication use and safety knowledge was conducted among pregnant and post-partum women attending an academic hospital obstetrics clinic.

RESULTS

Seventy-two women participated; 90.3% were Caucasian, 69.4% had a college/university degree, and 61.1% lived in an urban area. Of the 72 women, 87.5% used over-the-counter medications prenatally, first (55.6%), second (65.3%), and third (47.2%) trimesters, with prenatal acetaminophen use most common (72.2%). Women who used over-the-counter medications 1-0onths before conception were more likely to use over-the-counter medications during pregnancy, and 18% of women initiated over-the-counter medications in pregnancy. Women self-reported a medium level of over-the-counter medication safety knowledge (73.6%) and responded that not all over-the-counter medications are safe during pregnancy (95.8%).

CONCLUSION

Despite limited safety profiles of some over-the-counter medications, pre-conception and prenatal over-the-counter medication use was high. Further research on the risk of over-the-counter medications and combinations in pregnancy is needed to help women to make safe choices during pregnancy.

Maternal-Fetal Pharmacology of Drugs: A Review of Current Status of the Application of Physiologically Based Pharmacokinetic Models

Pregnancy and the postpartum period are associated with several physiological changes that can alter the pharmacokinetics (PK) and pharmacodynamics (PD) of drugs. For certain drugs, dosing changes may be required during pregnancy and postpartum to achieve drug exposures comparable to what is observed in non-pregnant subjects. There is very limited data on fetal exposure of drugs during pregnancy, and neonatal exposure through transfer of drugs via human milk during breastfeeding. Very few systematic clinical pharmacology studies have been conducted in pregnant and postpartum women due to ethical issues, concern for the fetus safety as well as potential legal ramifications. Over the past several years, there has been an increase in the application of modeling and simulation approaches such as population PK (PopPK) and physiologically based PK (PBPK) modeling to provide guidance on drug dosing in those special patient populations. Population PK models rely on measured PK data, whereas physiologically based PK models incorporate physiological, preclinical, and clinical data into the model to predict drug exposure during pregnancy. These modeling strategies offer a promising approach to identify the drugs with PK changes during pregnancy to guide dose optimization in pregnancy, when there is lack of clinical data. PBPK modeling is also utilized to predict the fetal exposure of drugs and drug transfer via human milk following maternal exposure. This review focuses on the current status of the application of PBPK modeling to predict maternal and fetal exposure of drugs and thereby guide drug therapy during pregnancy.

Association of Cord Plasma Biomarkers of In Utero Acetaminophen Exposure With Risk of Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder in Childhood

IMPORTANCE

Prior studies have raised concern about maternal acetaminophen use during pregnancy and increased risk of attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in their children; however, most studies have relied on maternal self-report.

OBJECTIVE

To examine the prospective associations between cord plasma acetaminophen metabolites and physician-diagnosed ADHD, ASD, both ADHD and ASD, and developmental disabilities (DDs) in childhood.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study analyzed 996 mother-infant dyads, a subset of the Boston Birth Cohort, who were enrolled at birth and followed up prospectively at the Boston Medical Center from October 1, 1998, to June 30, 2018.

EXPOSURES

Three cord acetaminophen metabolites (unchanged acetaminophen, acetaminophen glucuronide, and 3-[N-acetyl-l-cystein-S-yl]-acetaminophen) were measured in archived cord plasma samples collected at birth.

MAIN OUTCOMES AND MEASURES

Physician-diagnosed ADHD, ASD, and other DDs as documented in the child's medical records.

RESULTS

Of 996 participants (mean [SD] age, 9.8 [3.9] years; 548 [55.0%] male), the final sample included 257 children (25.8%) with ADHD only, 66 (6.6%) with ASD only, 42 (4.2%) with both ADHD and ASD, 304 (30.5%) with other DDs, and 327 (32.8%) who were neurotypical. Unchanged acetaminophen levels were detectable in all cord plasma samples. Compared with being in the first tertile, being in the second and third tertiles of cord acetaminophen burden was associated with higher odds of ADHD diagnosis (odds ratio [OR] for second tertile, 2.26; 95% CI, 1.40-3.69; OR for third tertile, 2.86; 95% CI, 1.77-4.67) and ASD diagnosis (OR for second tertile, 2.14; 95% CI, 0.93-5.13; OR for third tertile, 3.62; 95% CI, 1.62-8.60). Sensitivity analyses and subgroup analyses found consistent associations between acetaminophen buden and ADHD and acetaminophen burden and ASD across strata of potential confounders, including maternal indication, substance use, preterm birth, and child age and sex, for which point estimates for the ORs vary from 2.3 to 3.5 for ADHD and 1.6 to 4.1 for ASD.

CONCLUSIONS AND RELEVANCE

Cord biomarkers of fetal exposure to acetaminophen were associated with significantly increased risk of childhood ADHD and ASD in a dose-response fashion. Our findings support previous studies regarding the association between prenatal and perinatal acetaminophen exposure and childhood neurodevelopmental risk and warrant additional investigations.

Prenatal Exposure to Acetaminophen and Risk for Attention Deficit Hyperactivity Disorder and Autistic Spectrum Disorder: A Systematic Review, Meta-Analysis, and Meta-Regression Analysis of Cohort Studies

Acetaminophen is the analgesic and antipyretic most commonly used during pregnancy. Evidence of neurodisruptive properties is accumulating. Therefore, we sought to evaluate the risk for attention deficit hyperactivity disorder (ADHD) and autistic spectrum disorder (ASD) in the offspring of women exposed to acetaminophen during pregnancy. We searched MEDLINE, Embase, and Cochrane databases for relevant studies up to January 2017. Data were independently extracted and assessed by 2 researchers. Seven eligible retrospective cohorts included 132,738 mother-child pairs, with follow-up periods ranging from 3 to 11 years. The pooled risk ratio for ADHD was 1.34 (95% confidence interval (CI): 1.21, 1.47; I2 = 72%); for ASD, the risk ratio was 1.19 (95% CI: 1.14, 1.25; I2 = 14%), and for hyperactivity symptoms, it was 1.24 (95% CI: 1.04, 1.43; I2 = 93%). In meta-regression analysis, the association between exposure and ADHD increased with the child's age upon follow-up (β = 0.03, 95% CI: 0.00, 0.07) and with the mean duration of exposure (β = 0.00, 95% CI: 0.00, 0.01). The available data is of observational nature only. Studies differed widely in exposure and outcome assessment. Acetaminophen use during pregnancy is associated with an increased risk for ADHD, ASD, and hyperactivity symptoms. These findings are concerning; however, results should be interpreted with caution given that the available evidence consists of observational studies and is susceptible to several potential sources of bias.

Self-medication among pregnant women attending antenatal clinic at Makongoro health centre in Mwanza, Tanzania: a challenge to health systems

BACKGROUND

Self-medication is a universal challenge that requires attention because of the potential threat not only to the pregnant women but also to unborn child. Data on self-medication practice and predictors among pregnant women is lacking in Tanzania. Information on the effects of this practice to the pregnant woman and the foetus globally is also scanty.

METHODS

This was a cross sectional study which was conducted using face to face interview with 372 pregnant women at Makongoro health centre. Semi-structured questionnaires were used. Data were analysed using STATA 13 (Statistical Corporation, College Station, Texas, US).

RESULTS

A total of 372 pregnant women participated in the study. The prevalence of self-medication among pregnant women was 172 (46.24%). There was a significant statistical association between self-medication and occupation (P value =0.01), gestation age (P < 0.01) and education (P < 0.01). Age, marital status and gravidity were not associated with self-medication (P = 0.809, P = 0.243 and P = 0.922) respectively. When bivariate logistic regression was performed, occupation and education were the only determining factors for self-medication. Pregnant women who were unemployed, doing business and house wife were most likely to practice self-medication than employed pregnant women (P = 0.03; OR = 2.33; 95% CI, 1.06-5.31, P = 0.01; OR = 2.31; CI 1.21-4.41, P = <0.01, OR = 2.73, 95% CI 0.52-2.43) respectively. Pregnant women with no formal education, incomplete primary education, primary education and secondary education were most likely to practice self-medication than pregnant women with college or university education (P < 0.01, OR = 6.37 95% CI 2.37-19.03, P < 0.01, OR = 6.58, 95% CI 2.36-18.25, P < 0.01, OR = 3.78, 95% CI 1.89-7.56, P < 0.01, OR = 2.59 95% CI = 1.30-5.17). The leading illness/symptoms which led to self-medication among pregnant women attending clinic were malaria 56 (32.56%, morning sickness 44 (25.55%) and headache 33(19.19%). Drugs commonly used in self-medication among pregnant women were ant malarial 42 (24.42%), antiemetics 59 (34.30%) and analgesics 33 (19.19%).

CONCLUSION

Prevalence of self-medication among pregnant women is high in Tanzania. This is a threat to the safety of the developing foetus and the pregnant woman. Therefore there is a need of interventions to minimize the practice among pregnant women.

Prescription drug use during pregnancy in France: a study from the national health insurance permanent sample

PURPOSE

To provide an up-to-date account of drug prescription during pregnancy in France from 2011 to 2014 using the permanent sample of the French national computerized healthcare database and with a focus on recommended supplementations, fetotoxic drugs and teratogenic drugs.

METHODS

All pregnancies identified by the International Classification of Diseases, 10th Revision codes list in the hospitalization database, lasting more than 9 weeks of amenorrhea and whose delivery occurred between 01/01/2011 and 12/31/2014, were included. Drugs delivered between the trimester before and until the end of the pregnancy were included. Drug exposure prevalence was calculated for each year and according to pregnancy trimesters.

RESULTS

The study included 28,491 pregnancies with a median number of 9 [5-13] (median [IQ range]) drugs delivered. The most prescribed drug class was antianemia (in 72.5% of exposed). The prescription rate of recommended vitamins (B9 and D) increased over the study period (+10%). Influenza vaccination also increased but remained at a low rate (1%). Exposure to fetotoxic drugs decreased as pregnancy advanced. Exposure to the main teratogenic antiepileptics was stable over the study period. Low-income pregnant women had a higher average drug consumption except for recommended vitamins.

CONCLUSION

Pregnant French women are among the largest consumers of prescription medications worldwide. Overall, the dispensation trends observed in this study are in line with the recommendations of the French National College of Gynecologists and Obstetricians. Nevertheless, while being low, exposure to fetotoxic drugs, teratogenic drugs or those under safety alerts still occurred. Supplementations and vaccines in low-income pregnant women should also be increased.

Drug Use before and during Pregnancy in Japan: The Japan Environment and Children's Study

Purpose: To elucidate drug use before and during pregnancy in Japan. Methods: The Japan Environment and Children's Study (JECS) is an ongoing nationwide birth cohort study. We analyzed data from JECS involving cases where drugs were used for 12 months before pregnancy was diagnosed, between the time of diagnosis of pregnancy until week 12 of pregnancy, and after week 12 of pregnancy. Results: We analyzed data from 97,464 pregnant women. The percentages of pregnant women who had taken one or more drugs and supplements before diagnosis of pregnancy, between the time of diagnosis of pregnancy until week 12 of pregnancy, and after week 12 of pregnancy, were 78.4%, 57.1%, and 68.8% respectively. Excluding iron supplements, folic acid, and other vitamins and minerals, the percentages of women taking supplements were 75.3%, 36.0%, and 51.7% at each respective time point. The following drugs and supplements were frequently used for 12 months before pregnancy diagnosis: Commercially available antipyretics, analgesics, and/or medicine for treating common cold (34.7%), antipyretics, analgesics, and/or medicine for treating common colds, which were prescribed in hospitals (29.8%), antimicrobial drugs (14.0%), and anti-allergy drugs (12.5%). The following drugs and supplements were frequently used from the time of pregnancy diagnosis until week 12 of pregnancy, and after week 12 of pregnancy: folic acid (28.9% and 26.2%), antipyretics, analgesics and/or medicines for treating common cold, that were prescribed in hospitals (7.8% and 13.3%), Chinese herbal medicines (6.0% and 9.4%, and uterine relaxants (5.1% and 15.2%). Conclusions: The analysis of a nationwide cohort study showed that a high percentage of Japanese pregnant women were taking medicinal drugs. Further research is required to elucidate the relationship between drug use during pregnancy and birth defects in Japan.

Perception of pharmacists regarding over-the-counter medication: A survey

Objective:

To assess knowledge, attitude, and practice of the pharmacists toward dispensing the over-the-counter (OTC) medications using questionnaire.

Materials and Methods:

cross-sectional questionnaire-based study was conducted to assess the knowledge, attitude, and practice among pharmacists regarding OTC medications. Eighty out of hundred filled questionnaires were received from various pharmacists from medical shops in and around Kolar. Data were analyzed using descriptive statistics.

Results:

A total of 74.6% responded to the questionnaire. Most of the dispensers (97.3%) at pharmacy were qualified with a D.Pharma/B.Pharma degree. Pharmacists with B.Pharma (80%) were able to define OTC. Majority of them had more than ten consumers taking OTC per week. Among the OTCs dispensed, common were analgesics (75%), antacids (48%), antihistaminics (40%), and others (35%). The choice of OTC brand was made by pharmacists (58.7%) and consumers (41.2%). Most of them (96.5%) asked the consumer's complaints before dispensing the drug, but only few (51%) counseled them regarding the instructions to administer medication. The brand of OTC was influenced by prescriptions of local doctor (60%), consumer's choice (31.2%), cost of the drug (16.7%), and medical representatives (5%). OTCs were safe to dispense, according to 90% of the pharmacists; however, among them, 50% expressed that the consumers should first consult doctor.

Conclusion:

Majority of the pharmacists were qualified to dispense medication, but only few knew about OTC drugs. Analgesics were most commonly used OTC. These drugs were safe to dispense, however, consulting doctor before taking medications was suggested by some of them.

Case-control analysis of maternal prenatal analgesic use and cardiovascular malformations: Baltimore-Washington Infant Study

OBJECTIVE

We sought to assess maternal prenatal use of analgesics and risk of cardiovascular malformations (CVM) in the offspring.

STUDY DESIGN

Data from the Baltimore-Washington Infant Study, a population-based case-control investigation of CVM, were used to examine selected isolated CVM diagnoses and maternal analgesic use during the periconceptional period (3 months before and after conception). We compared case and control infants on frequency of maternal use of analgesics and estimated adjusted odds ratios (adjORs) and 95% confidence intervals (CI) with logistic regression models for specific CVM phenotypes.

RESULTS

Frequency of periconceptional use of any analgesic was 52% among control mothers and 53% among case mothers. Analyses by CVM diagnoses identified an association of tetralogy of Fallot with maternal acetaminophen use (adjOR, 1.6; 95% CI, 1.1-2.3) and dextrotransposition of the great arteries with intact ventricular septum with maternal nonsteroidal antiinflammatory drug use (adjOR, 3.2; 95% CI, 1.2-8.7).

CONCLUSION

Analgesic use during the periconceptional period was not associated with CVM in the aggregate or with most phenotypes of CVM examined. Associations with 2 phenotypes of CVM may have occurred by chance. These findings warrant corroboration and further study, including further evaluation of the observed associations, the dose of analgesic taken, more specific timing of analgesic use, and indications for use.

Medication use in pregnancy: a cross-sectional, multinational web-based study

OBJECTIVES

Intercountry comparability between studies on medication use in pregnancy is difficult due to dissimilarities in study design and methodology. This study aimed to examine patterns and factors associated with medications use in pregnancy from a multinational perspective, with emphasis on type of medication utilised and indication for use.

DESIGN

Cross-sectional, web-based study performed within the period from 1 October 2011 to 29 February 2012. Uniform collection of drug utilisation data was performed via an anonymous online questionnaire.

SETTING

Multinational study in Europe (Western, Northern and Eastern), North and South America and Australia.

PARTICIPANTS

Pregnant women and new mothers with children less than 1 year of age.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of and factors associated with medication use for acute/short-term illnesses, chronic/long-term disorders and over-the-counter (OTC) medication use.

RESULTS

The study population included 9459 women, of which 81.2% reported use of at least one medication (prescribed or OTC) during pregnancy. Overall, OTC medication use occurred in 66.9% of the pregnancies, whereas 68.4% and 17% of women reported use of at least one medication for treatment of acute/short-term illnesses and chronic/long-term disorders, respectively. The extent of self-reported medicated illnesses and types of medication used by indication varied across regions, especially in relation to urinary tract infections, depression or OTC nasal sprays. Women with higher age or lower educational level, housewives or women with an unplanned pregnancy were those most often reporting use of medication for chronic/long-term disorders. Immigrant women in Western (adjusted OR (aOR): 0.55, 95% CI 0.34 to 0.87) and Northern Europe (aOR: 0.50, 95% CI 0.31 to 0.83) were less likely to report use of medication for chronic/long-term disorders during pregnancy than non-immigrants.

CONCLUSIONS

In this study, the majority of women in Europe, North America, South America and Australia used at least one medication during pregnancy. There was a substantial inter-region variability in the types of medication used.

Array comparative genomic hybridization as a clinical diagnostic tool in syndromic and nonsyndromic congenital heart disease

BACKGROUND

Congenital heart diseases (CHDs) are often associated with other congenital anomalies, dysmorphic features, and developmental delay, and only a few cases of chromosomal abnormalities are detected by conventional cytogenetic techniques. The microarray comparative genomic hybridization (CGH) analysis allows the identification of submicroscopic genomic rearrangements.

METHODS

During the past 3 y, 55 of 330 patients referred for array CGH had CHD of unknown etiology plus at least one additional indication of abnormal chromosomal phenotype. High-resolution 1 × 244 K or 4 × 180 K Agilent arrays were used in this study (average resolution 7-13 kb).

RESULTS

Copy-number variations were detected in 37 of 55 patients, and in 29 of 37 patients there were genes that have been associated with CHD. All 37 patients had at least one additional phenotypic abnormality: 30 of 37 had one or more other congenital anomalies, 23 of 37 had dysmorphic features, 16 of 37 had intellectual disability, 13 of 37 had abnormal magnetic resonance imaging, 10 of 37 had hypotonia, and 7 of 37 had seizures. In 9 of 55 patients, unexpected genomic rearrangements in relation to their phenotype were identified.

CONCLUSION

In patients with CHD and at least one additional indication of abnormal chromosomal phenotype, array CGH analysis could detect possible submicroscopic chromosomal abnormalities and provide proper genetic counseling.

Prevalence and predictors of over-the-counter medication use among pregnant women: a cross-sectional study in the Netherlands

Background

Over-the-counter-medication (OTC-medication) use during pregnancy can be potentially harmful for the fetus. To successfully counsel the patient it is important to know if the patient is at risk. In this study possible predictors for OTC-medication use were identified and a model was designed to predict OTC-medication use during pregnancy.

Methods

We performed a post-hoc analysis on data collected for a clustered clinical trial to study a screening strategy for Query fever. Pregnant women under supervision of a midwife were eligible for inclusion. These women filled out questionnaires during their pregnancy and post-partum. These questionnaires were used to determine the prevalence and to select possible predictors for OTC-medication use. These predictors were included in a prediction model using multivariate analysis. The discrimination and calibration of the model were assessed with Receiver Operating Characteristic analysis and the Hosmer and Lemeshow test.

Results

Of the 1348 women enrolling in the clustered clinical trial, we included 1246 women in this analysis. The prevalence of OTC-medication use was 12.5%. The predictors for OTC-medication use in our cohort were: nulliparity, use of prescription medication, the presence of a comorbidity, Body Mass Index between 26 and 30 kg/m² and General Practitioner visits. These predictors were used to design a prediction model for OTC-medication use. The area under the Receiver Operating Characteristic-curve of the prediction model was 0.667 (95% CI 0.620-0.714 P<0.001) and the predictive probabilities ranged from 6.6% to 57.4%. The Hosmer and Lemeshow goodness-of-fit test indicated good calibration of the model (P = 0.640).

Conclusion

It is possible to indicate women at risk for OTC-medication use during pregnancy, using five maternal characteristics that independently contribute to the prediction model. The predictors are easy to estimate and the model is easy to implement in daily practice.

Ethnic differences in drug utilization pattern during pregnancy: a cross-sectional study

OBJECTIVE

To investigate the differences in exposure to medications in a cohort of multi-ethnic pregnant women.

METHODS

Six hundred and forty-one pregnant women of Western, Arab/Turkish and "other origins" participated in this cross-sectional study using a questionnaire in a university hospital in Brussels, Belgium. Assessment of the drug safety was done using the food and drug administration (FDA) risk classification system. Data analysis was performed using SPSS (Chicago, IL).

RESULTS

In overall cohort, 83.8% used at least one preparation (including multivitamins) during pregnancy and 37.0% of women used at least one drug (excluding multivitamins). Significantly more Western women (43.7%) used one or more medications compared to Arab/Turkish women (28.7%; p = 0.000). This difference in exposure was most pronounced for over-the-counter (OTC) drugs for occasional and pregnancy-related complaints, and was observed for potentially unsafe drugs or drugs with unknown safety. None of the women reported use of FDA X category drugs.

CONCLUSIONS

The use of drugs known to be harmful was not observed, but a higher prevalence of exposure to potentially harmful drugs (FDA C/D) was found among Western women who also consumed more OTC drugs. This highlights the need for cautious prescribing for women in the fertile age in general and for continuous monitoring of medication use during pregnancy.

Predictors of the use of medications before and during pregnancy

BACKGROUND

Drug use in pregnancy is often reason of concern for mothers and their physicians. However, only few studies investigated predictors of drug use in pregnancy.

OBJECTIVES

To examine maternal characteristics as predictors of medication use in the 6 months before pregnancy and during the first 6 months of pregnancy. To examine whether prescription and over-the-counter (OTC) medication use in the 6 months before pregnancy had an impact on medication use in pregnancy.

SETTING

Six maternity care units and five community pharmacies.

METHOD

Data were collected using a specially designed self-reported questionnaire during the period March 2009-March 2010. Logistic regression was used to identify factors associated with medication use.

MAIN OUTCOME MEASURE

Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were used as association measures.

RESULTS

A total of 236 women were included in the analysis. After controlling for maternal characteristics, parity of more than one was associated with lower prescription medication use in pregnancy (aOR 0.46; 95% CI 0.22-0.93), higher household income with higher OTC medication use before pregnancy (aOR 3.13; 95% CI 1.22-8.00), and miscarriage with higher C and D Food and Drug Administration (FDA) risk category medication use in pregnancy (aOR 3.65; 95% CI 1.30-10.25). Prescription medication use before pregnancy was associated with higher prescription medication use in pregnancy (aOR 2.49; 95% CI 1.12-5.52), OTC medication use before pregnancy with higher OTC medication use in pregnancy (aOR 35.95; 95% CI 7.95-162.49), and C and D FDA risk category medication use before pregnancy with the same category medication use in pregnancy (aOR 3.54; 95% CI 1.23-10.17).

CONCLUSION

Different maternal characteristics were shown as predictors of medication use before and during pregnancy. However, medication use before pregnancy was shown as the most important predicting factor for the medication use in pregnancy.

Effect of endogenous steroid hormones on 17-alpha-hydroxyprogesterone caproate metabolism

OBJECTIVE

Plasma concentrations of 17-alpha-hydroxyprogesterone caproate (17-OHPC) vary substantially in pregnant patients who receive an identical dose. Endogenous steroid hormones may alter 17-OHPC metabolism, which contributes to this large variability.

STUDY DESIGN

Pooled human liver microsomes were incubated with 17-OHPC alone or in combination with progesterone, hydroxyprogesterone, estrone, estradiol, or estriol. High-performance liquid chromatography with ultraviolet detection was used to quantify 17-OHPC.

RESULTS

Under the conditions that were studied, 17-OHPC metabolism was inhibited by 37% by a combination of endogenous steroid hormones. Progesterone alone significantly inhibited 17-OHPC metabolism by 28% (P < .001).

CONCLUSION

17-OHPC metabolism is inhibited significantly by endogenous steroids and, in particular, progesterone. This effect may account for some of the large variation in plasma 17-OHPC concentrations that is seen in pregnant patients who receive a fixed dose of medication.

The effect of using the health smart card vs. CPOE reminder system on the prescribing practices of non-obstetric physicians during outpatient visits for pregnant women in Taiwan

INTRODUCTION

There is an evidence that pregnant women have been prescribed a significant number of improper medications that could lead to potential damage for a developing fetus due to discontinuity of care. The safety of pregnant women raises public concern and there is a need to identify ways to prevent potential adverse events to the pregnant woman. This study used a health smart card with a clinical reminder system to keep continuous records of general outpatient visits of pregnant women to protect them from potential adverse events caused by improper prescription.

METHOD

The health smart card, issued to all 23 million citizens in Taiwan, was used to work with a Computerized Physician Order Entry (CPOE) implemented at a 700-bed teaching medical center in Taipei to provide the outpatient information of pregnant women. FDA pregnancy risk classification was used to categorize the risk of pregnant women. The log file, combined with the physicians' and patients' profiles, were statistically examined using the Mantel-Haenszel technique to evaluate the impact of system in changing physician's prescription behavior.

RESULTS

A total of 441 patients ranged in age from 15 to 50 years with 1114 prescriptions involved in FDA pregnancy risk classification C, D, and X during the study period. 144 reminders (13.1%) were accepted by physicians for further assessment and 100 (69.4%) of them were modified. Non-obstetric physicians in non-emergency setting were more intended to accept reminders (27.8%, 4.9 folds than obstetricians). Reminders triggered on patients in second trimester (15.5%) were accepted by all physicians more than third trimester (OR 1.52, p<0.05).

CONCLUSION

A health smart card armed with CPOE reminder system and well-defined criteria had the potential to decrease harmful medication prescribed to pregnant patients. The results show better conformance for non-obstetric physicians (26%) and when physicians accepted the alerts they are more likely to went back and review their orders (69%). In sum, reminder criteria of FDA pregnancy risk classification C for obstetricians and reminder based on different trimesters is suggested to be refined to improve system acceptability and to decrease improper prescription.

Prescription drug use in pregnancy: a retrospective, population-based study in British Columbia, Canada (2001-2006)

BACKGROUND

Owing to the paucity of evidence available on the risks and benefits of drug use in pregnancy, the use of prescription medicines is a concern for both pregnant women and their health care providers.

OBJECTIVE

The aim of this study was to measure the frequency, timing, and type of medicines used before, during, and after pregnancy in a Canadian population.

METHODS

This retrospective cohort analysis used population-based health care data from all pregnancies ending in live births in hospitals in British Columbia from April 2001 to June 2006 (n = 163,082). Data from hospital records were linked to those in outpatient prescription-drug claims. Data from prescriptions filled from 6 months before pregnancy to 6 months postpartum were analyzed. Drugs were classified by therapeutic category and US Food and Drug Administration (FDA) pregnancy risk categories.

RESULTS

Prescriptions were filled in 63.5% of pregnancies. Evidence on safety is limited for many of the medicines most frequently filled in pregnancy, including codeine, salbutamol, and betamethasone. At least 1 prescription for a category D or X medicine was filled in 7.8% of pregnancies (5.5% category D; 2.5% category X). The most frequently filled prescriptions for category D drugs were benzodiazepines and antidepressants. The most frequently filled prescriptions for category X drugs were oral contraceptives and ovulation stimulants filled in the first trimester.

CONCLUSIONS

The majority of pregnant women in British Columbia filled at least 1 prescription, and ~1 in 13 filled a prescription for a drug categorized as D or X by the FDA. The prevalence of maternal prescription drug use emphasizes the need for postmarketing evaluation of the risk-benefit profiles of pharmaceuticals in pregnancy. Future research on prenatal drug use based on administrative databases should examine maternal treatment adherence and the determinants of maternal drug use, considering maternal health status, sociodemographics, and the characteristics and providers of prenatal care.

Drug utilization pattern in pregnant women in rural areas, India: cross-sectional observational study

AIM

The aim of this study was to evaluate the drug-utilization trend of pregnant women in rural areas of central India.

MATERIALS AND METHODS

This was a prospective, observational study using a questionnaire, face-to-face interview and a prescription audit.

RESULTS

The majority of the subjects were primigravida (51.4%), from the lower socioeconomic group (71.3%) and with poor formal education. Although the drugs prescribed for them per prescription (2.66) were within rational limits, there was scope for improvement in generic (21%) and essential drugs (18%), antibiotics (9.6%) and injections (10.97%).

CONCLUSIONS

Morbidity and mortality during the antenatal period occur due to different factors. Regular drug-utilization studies following the guidelines of the World Health Organization and information, education and communication factors related to drug use by pregnant women can be improved.

Prescription drug use during pregnancy in developed countries: a systematic review

PURPOSE

To review the literature describing patterns of outpatient prescription drug use during pregnancy by therapeutic category, potential for fetal harm, and overall.

METHODS

We conducted a systematic review of peer-reviewed literature published from 1989 to 2010. We included studies evaluating individual-level exposures to prescription medicines during pregnancy. We selected only studies conducted in developed (Organization of Economic Co-operation and Development) countries and published in English.

RESULTS

Published drug utilization studies reveal wide variation in estimates of overall prescription drug use in pregnancy (27-93% of pregnant women filling at least one prescription excluding vitamins and minerals). Among studies of similar design, estimates were lowest in Northern European countries (44-47%) and highest in France (93%) and Germany (85%). Measured rates of use of contraindicated medicines in pregnancy ranged from 0.9% (Denmark, 1991-1996) to 4.6% (USA, 1996-2000). The use of medicines with positive evidence of risk ranged from 2.0% (Italy, 2004) to 59.3% (France, 1996).

CONCLUSION

Avoidable inconsistencies in study design and reporting attenuate conclusions that can be drawn from the literature on antenatal drug utilization. Nevertheless, the body of published research shows that antenatal prescription drug use is common, with many studies finding that a majority of women use one or more prescription medicine during pregnancy. Similarly, studies consistently report the use of drugs recognized as having potential risks in pregnancy. Given this widespread use, it is particularly important to develop standards for calculating and reporting antenatal exposures to improve the value of future research in this area.

Medication use during pregnancy, with particular focus on prescription drugs: 1976-2008

OBJECTIVE

The objective of the study was to provide information on overall medication use throughout pregnancy, with particular focus on the first trimester and specific prescription medications.

STUDY DESIGN

The study design included the Slone Epidemiology Center Birth Defects Study, 1976-2008, and the National Birth Defects Prevention Study, 1997-2003, which together interviewed more than 30,000 women about their antenatal medication use.

RESULTS

Over the last 3 decades, first-trimester use of prescription medication increased by more than 60%, and the use of 4 or more medications more than tripled. By 2008, approximately 50% of women reported taking at least 1 medication. Use of some specific medications markedly decreased or increased. Prescription medication use increased with maternal age and education, was highest for non-Hispanic whites, and varied by state.

CONCLUSION

These data reflect the widespread and growing use of medications by pregnant women and reinforce the need to study their respective fetal risks and safety.

Effects of codeine on pregnancy outcome: results from a large population-based cohort study

Background

Guidelines on codeine safety during pregnancy rely on small studies with inconsistent results, and associations between codeine use during pregnancy and increased risk of congenital malformations remain unsubstantiated.

Objectives

Our objective was to analyze the effect of codeine on pregnancy outcome.

Methods

Pregnancy outcomes of 2,666 women who used codeine during pregnancy were compared with 65,316 women who used no opioids during pregnancy. Information on maternal sociodemographic and medical characteristics, potential confounders, and pregnancy outcome was obtained from The Norwegian Mother and Child Cohort Study [den norske Mor & barn-undersøkelsen (MoBa)] data set and the Medical Birth Registry of Norway (MBRN) data set. The data sets were linked via the maternal personal identification number. Associations between codeine therapy and pregnancy outcomes were identified using logistic regression analyses.

Results

No significant differences were found in the survival rate [adjusted odds ratio (OR) 0.9, 95% confidence interval (CI) 0.6–1.5] or the congenital malformation rate (adjusted OR 0.9, 95% CI 0.8–1.1) between codeine-exposed and unexposed infants. Codeine use anytime during pregnancy was associated with planned Cesarean delivery (adjusted OR 1.4, 95% CI 1.2–1.7; P < 0.0001). Third-trimester use was associated with acute Cesarean delivery (adjusted OR 1.5, 95% CI 1.3–1.8; P < 0.0001) and postpartum hemorrhage (adjusted OR 1.3, 95% CI 1.1–1.5; P < 0.0001). No significant associations with other adverse pregnancy outcomes were found.

Conclusions

No effects of maternal codeine intake during pregnancy were observed on infant survival or congenital malformation rate. Our findings are reassuring; however, the association with acute Cesarean delivery and postpartum hemorrhage may justify a certain level of caution when administering codeine toward the end of pregnancy.

Electronic supplementary material

The online version of this article (doi:10.1007/s00228-011-1069-5) contains supplementary material, which is available to authorized users.

Nationwide register-based surveillance system on drugs and pregnancy in Finland 1996-2006

PURPOSE

The aim of this population-based nationwide drugs and pregnancy surveillance system was to get basic information on the use of prescribed drugs during pregnancy and to achieve more detailed information on drug exposure-outcome associations with data obtained from the Finnish national health registers.

METHODS

The data are based on information on all pregnancies ending in births (n = 632,629) or termination of pregnancy (TOP) (n = 117,255) in Finland between 1996 and 2006. The data containing information on maternal background factors, chronic diseases and drug purchases during pregnancy, born children, induced abortions, perinatal health and major congenital malformations were obtained from the Finnish national health registers. Information from the different registers was merged through record linkages based on unique personal identification numbers. Statistical analyses were conducted between the exposed and unexposed for individual drugs or Anatomical Therapeutic Chemical (ATC) classification drug groups in multivariate logistic regression including potential confounding factors.

RESULTS

Nearly half of parturients and almost every third woman with TOP purchased drugs at least once 1 month prior to pregnancy and/or during pregnancy. The most frequent chronic diseases during pregnancy were asthma, hypothyroidism, epilepsy, rheumatoid arthritis and diabetes. Previously known causal connections between maternal chronic diseases and/or medication and perinatal health risks were already seen in the ATC-group-level analysis.

CONCLUSIONS

Comprehensive and detailed information for pharmacoepidemiological research on the effects of drug use during pregnancy in a cohort setting is possible with long-term and cumulative data collection.

Medication use for chronic health conditions by pregnant women attending an Australian maternity hospital

BACKGROUND

Most women use medications at some stage in their pregnancy. Medication nonadherence during pregnancy could be detrimental to both mother and fetus.

AIMS

To study the extent and nature of the use of prescribed medications during pregnancy and factors associated with medication nonadherence.

METHODS

All women≥18 years presenting for their 36th week antenatal visit at the pregnancy clinic of a maternity hospital were invited to complete an anonymous questionnaire that contained 61 items, including the Morisky scale. Factors associated with nonadherence were identified in univariate analysis; factors with P<0.1 were further analysed in a binary logistic regression model.

RESULTS

The participants (n=819) had a mean age of 30.8±5.3 years. Most participants were born in Australia, lived with a partner, had university education, were nulliparous, carried one fetus and were nonsmokers. Of these participants, 322 (39.3%) reported a chronic health condition during pregnancy, the most common being asthma (104; 12.7%). Two hundred and seventeen (26.5%) were using prescribed medications, which included anti-anaemics (68; 8.3%), medicines for chronic airway conditions (64; 7.8%), vitamins and minerals (59; 7.2%) and anti-diabetics (43; 5.2%). Nonadherence was reported by 107 (59.1%) participants, mainly because of forgetting (79; 43.6%). Factors associated with nonadherence were having asthma (OR 0.26 (95% CI 0.095-0.72), P=0.009) and using nonprescription dietary minerals (0.30 (0.10-0.87), P=0.027).

CONCLUSIONS

Adherence to prescribed medicines during pregnancy is alarmingly low. Health professionals should be more proactive in promoting adherence and assisting women avoid potential fetal harm because of nonadherence.

The use during pregnancy of prescription, over-the-counter, and alternative medications among Hispanic women

BACKGROUND

Despite lack of scientific evidence about the safety of complementary and alternative medicines, the reported use of such remedies during pregnancies has increased. This study was undertaken to investigate the use of herbs, vitamins, and over-the-counter and prescription medications among pregnant Hispanic women and reasons for use, and to assess physician-patient level of communication about women's use.

METHODS

A total of 485 Hispanic women were surveyed by means of a self-administered questionnaire immediately postpartum in a public hospital in Houston, Texas. The primary outcome was use of alternative therapies during the prenatal period.

RESULTS

During their pregnancies, 19 percent of the participants took herbs and 47 percent took vitamin supplements, other than prenatal vitamins. The most common reason for using herbs and vitamins was to improve the woman's general health and energy level (59%); a few women (12%) had used them for specific pregnancy-related problems. Overall, 77 percent took prenatal vitamins and 21 percent supplemented with folic acid. The rates of use of over-the-counter and prescription medications were 23 and 29 percent, respectively. The use of prescription medication was two-and-a-half times higher among women with history of medical problems (adjusted OR = 2.59, 95% CI = 1.59-4.25, p = 0.0001). No other factor studied was independently associated with supplement or medication use. One in five women (20%) believed that herbs and vitamins were safer to use than prescription medication or were better at treating medical problems than prescription medicine, and one-third had not disclosed information about supplement use to their physicians.

CONCLUSIONS

Use of herbal remedies does not appear to be a replacement for conventional medicine among most pregnant Hispanic women. Patient education about the risks of alternative therapies may lead to a reduction in intake of alternative medicines and greater disclosure to medical practitioners among this ethnic group.

Assessment of drug use among pregnant women in Addis Ababa, Ethiopia

PURPOSE

To assess the drug use among antenatal care (ANC) attendant pregnant women in Addis Ababa.

METHODS

Institution-based cross sectional study was conducted reviewing the antenatal care follow up cards and interviewing pregnant women using semi-structured questionnaire.

RESULTS

A total of 1268 women were included in the study; of which 71.3% of them were prescribed at least one drug during pregnancy. Twelve point four per cent of the pregnant women who reported illness in the 2 weeks prior to the date of the interview, self-medicated themselves with either over the counter or prescription drugs or traditional herbs. The majority of the drugs prescribed were iron and vitamins followed by anti-infectives. Nearly 4% of the pregnant women were prescribed with drugs from category D or X of the US-FDA risk classification.

CONCLUSION

A considerable proportion of pregnant women were exposed to drugs, including those with potential harm to the fetus. Furthermore, pregnant women self-medicated themselves with modern medications or traditional herbs. Health care providers should thus weigh the therapeutic benefits of the drug to the mother against its potential risk to the developing fetus before prescribing. In addition it is essential to routinely inquire about the woman's self-medication practice and provide the appropriate advice to the pregnant women.

Use of antihistamine medications during early pregnancy and isolated major malformations

BACKGROUND

Antihistamines are commonly used during pregnancy. There is little evidence that they have teratogenic effects, but there are knowledge gaps with respect to newer products, as well as the relationship between specific antihistamines and specific birth defects.

METHODS

Using the National Birth Defects Prevention Study (1997-2003), the authors examined associations between maternal use of 14 antihistamines during early pregnancy and 26 isolated major birth defects. A Bayesian analysis incorporating prior knowledge about the relationships between antihistamines, birth defects, and measured covariates was conducted.

RESULTS

Of the 364 associations investigated, 24 had 95% posterior intervals excluding 1.0. All 24 associations were positive; 23 associations were of weak to moderate magnitude (posterior OR < 3.0) and one was strong (OR > 6.0) but very imprecise. Of the 24 associations, 20 were with noncardiac defects. Eight associations involved the antihistamine diphenhydramine.

CONCLUSIONS

The results of this study generally were consistent with no association between birth defects and antihistamine use during early pregnancy. Several of the findings might warrant further investigation, although the observed elevated associations should be interpreted in the context of the number of associations investigated and the analysis of retrospective, self-reported data.

Shared gene expression profiles in developing heart valves and osteoblast progenitor cells

The atrioventricular (AV) valves of the heart develop from undifferentiated mesenchymal endocardial cushions, which later mature into stratified valves with diversified extracellular matrix (ECM). Because the mature valves express genes associated with osteogenesis and exhibit disease-associated calcification, we hypothesized the existence of shared regulatory pathways active in developing AV valves and in bone progenitor cells. To define gene regulatory programs of valvulogenesis relative to osteoblast progenitors, we undertook Affymetrix gene expression profiling analysis of murine embryonic day (E)12.5 AV endocardial cushions compared with E17.5 AV valves (mitral and tricuspid) and with preosteoblast MC3T3-E1 (subclone4) cells. Overall, MC3T3 cells were significantly more similar to E17.5 valves than to E12.5 cushions, supporting the hypothesis that valve maturation involves the expression of many genes also expressed in osteoblasts. Several transcription factors characteristic of mesenchymal and osteoblast precursor cells, including Twist1, are predominant in E12.5 cushion. Valve maturation is characterized by differential regulation of matrix metalloproteinases and their inhibitors as well as complex collagen gene expression. Among the most highly enriched genes during valvulogenesis were members of the small leucine-rich proteoglycan (SLRP) family including Asporin, a known negative regulator of osteoblast differentiation and mineralization. Together, these data support shared gene expression profiles of the developing valves and osteoblast bone precursor cells in normal valve development and homeostasis with potential functions in calcific valve disease.

Risk management and monitoring methods for the future mother, embryo, fetus, and post-natal consequences

Data required to asses the risk of a new drug regarding the normal course of pregnancy as well as embryo, fetal and neonate development, are often missing when a new product is launched. In such a situation, a risk management plan is to be developed by the industrial and validated by regulatory authorities. This risk management plan is to take into account the data benefits on the drug and its potential therapeutic use by women as being of childbearing age. The obtaining of post licence human data is to be built on many players, both private and public, involved in the data collection and evaluation. The setting up of such a network would allow them to join together and optimize their action by standardizing the data collected and their follow up. This should help to generate or rapidly respond to an alert, to conduct collaborative pharmacovigilance pharmacology studies.

Associations between socio-economic factors and the use of prescription medication during pregnancy: a population-based study among 19,874 Danish women

OBJECTIVE

To examine the association between socio-economic factors and use of prescription medication during pregnancy in a population of Danish women.

METHODS

This was a population-based cohort study. Using record linkage from public administrative registries, we described the use of prescription medication during pregnancy and the financial and educational resources for each pregnant woman in the cohort.

RESULTS

The analyses included all 19,874 primiparous women delivering singletons in North Jutland county, Denmark, in 1991-1998. We identified 24,243 prescriptions filled by the women during their pregnancies. The highest overall prescription medication use was among women with basic schooling (OR 1.3; 95% CI 1.2-1.4), and lowest among women with the highest education (OR: 0.8; 95% CI 0.7-0.9) compared with women who had vocational education. Stratified analysis of therapeutic subgroups revealed that socio-economic factors were associated with the use of anti-infective and anti-asthmatic medications during pregnancy.

CONCLUSION

Maternal educational level, and to a lesser degree household income, paternal educational level and cohabitation status, was associated with the use of prescription medication during pregnancy. However, the analyses did not take into account important clinical variables such as maternal illness, and the results could be affected by differential misclassification of exposure information, by confounding or chance.

National patterns of medication use during pregnancy

PURPOSE

To describe patterns of medication use during pregnancy in ambulatory care settings according to the U.S. Food and Drug Administration (FDA) pregnancy risk classification.

METHODS

A cross-sectional study of two national ambulatory care surveys, sampling all office visits made by pregnant women in 1999 and 2000, was conducted. Using the FDA pregnancy risk classification, patterns of medication use and predictive factors for FDA pregnancy risk D or X (D/X) medications were evaluated.

RESULTS

In 1999 and 2000, about half of all pregnant visits had one or more medications. Among the total visits, FDA Class A was the majority (private = 65.7%; hospital = 79.5%; p < 0.05) followed by Class C (private = 26.5%; hospital = 36.4%; p < 0.05). Class D/X medications accounted for 6.4% and 2.9% of visits in private and hospital, respectively (p < 0.05). Medications with unknown pregnancy categories were predominant in the private setting (12.0% and 3.9%; p < 0.05). Age, insurance type, region, physician specialty, and number of medications were associated with a category D/X prescription. Among hospital visits, those from the West region and with private insurance were more likely to receive category D/X prescriptions. Number of medications was strongly associated with high-risk drugs in both settings.

CONCLUSIONS

This study shows considerable medication use among pregnant women. The prevalence of visits with FDA pregnancy category D/X drugs was moderate, but still indicates exposure to high-risk medications.

Correlates of prescription drug use during pregnancy

PURPOSE

To evaluate the extent of prescription drug use and the use of category D or X drugs during pregnancy and examine the maternal characteristics associated with use.

METHODS

Medical record and survey data from an observational cohort of pregnant women from 2001 to 2003 (n=1626) were analyzed to examine the use of prescription drugs and the use of category D or X drugs.

RESULTS

A majority of these pregnant women were prescribed a prescription drug (56%), and 4% of women were prescribed a category D or X drug. The most common classes of medications prescribed were antibiotics (62%), analgesics (18%), asthma medications (18%), and antiemetics (17%). After adjustment for sociodemographic and clinical characteristics, African American women were more likely to use a prescription drug than white women. Lower levels of educational attainment were also associated with greater use of prescription drugs compared with women who had graduated from college. Women with a chronic health condition, gestational diabetes, a prenatal hospitalization, a history of infertility, or symptoms of acid reflux were also more likely to use a prescription drug than women without these conditions. Nulliparous women and women who were married or living with a partner were less likely to use category D or X drugs during pregnancy than women without these characteristics. Women with a history of infertility and those with a chronic health condition were more likely to use a category D or X drugs during pregnancy than those without these conditions.

CONCLUSIONS

The common use of prescription drugs during pregnancy supports the importance of expanding the evidence about the risks and benefits of prescription drug use during pregnancy and suggests the need for systems to safeguard prescribing practices for women of reproductive age.

Use of over-the-counter medications during pregnancy

OBJECTIVE

The most common medications used in pregnancy are nonprescription or over-the-counter medications, although there has been little research on their risks or safety. We describe the patterns of over-the-counter medication use among pregnant women.

STUDY DESIGN

Data were collected in 2 case-control studies of birth defects: the Slone Epidemiology Center Birth Defects Study (BDS) and the National Birth Defects Prevention Study (NBDPS).

RESULTS

Among 7563 mothers of malformed and nonmalformed offspring in the Slone Epidemiology Center Birth Defects Study and 2970 mothers of nonmalformed offspring in the National Birth Defects Prevention Study, acetaminophen, ibuprofen, and pseudoephedrine were used by at least 65%, 18%, and 15%, respectively. Among women in the Slone Epidemiology Center Birth Defects Study, the use in pregnancy of aspirin and chlorpheniramine decreased from 1976 to 2004 and of ibuprofen, pseudoephedrine, diphenhydramine, dextromethorphan, and guaifenesin increased. Among women in the National Birth Defects Prevention Study, the use of acetaminophen, pseudoephedrine, diphenhydramine, and guaifenesin was higher during pregnancy than before pregnancy.

CONCLUSION

Findings show that over-the-counter medications are used by most pregnant women. Studies that examine specific over-the-counter medications in relation to specific birth defects are necessary to better inform pregnant women about risks and safety.

Drug intake behaviour of immigrants during pregnancy

OBJECTIVE

To assess differences between native Spanish and immigrant pregnant women in behaviour relating to the use of medications during pregnancy.

STUDY DESIGN

This cross-sectional study was carried out at the department of obstetrics and gynaecology of an acute-care teaching hospital in the city of Barcelona, Spain. A total of 1103 women who gave birth at the hospital during a 1-year period were enrolled in the study. Each woman was interviewed by a gynaecologist during her stay in hospital after delivery, with special reference to drug use during the pregnancy. Drug exposure was assigned to trimesters, and drugs were divided into therapeutic groups, while the women taking part were divided up by nationality, educational level, parity and age. Data were analysed using bivariate, multivariate, and cluster analyses.

RESULTS

Slightly over half (55.7%) of the women were native to Spain and 44.3% were immigrants of other nationalities. About a quarter, or 25.4%, of pregnant patients had not taken any drugs during their pregnancies. The most frequent drugs taken by the others were vitamins, which were used mostly by Spanish women, followed by analgesics, which were mostly taken by non-Spanish western women. The largest group who had taken folic acid was made up of non-Spanish western women, while the Asiatic patients had taken this in the smallest proportion of cases.

CONCLUSIONS

Spanish patients and immigrants from other western countries showed a similar behaviour in terms of drug intake during pregnancy, which was different from the behavioural patterns seen in pregnant patients from developing countries.

Metamizol (dipyrone, optalgin) in pregnancy, is it safe? A prospective comparative study

AIM

To assess the teratogenic effect of metamizol when used during the first trimester of pregnancy.

METHODS

One hundred and eight women who used metamizol during the first trimester of pregnancy were recruited from 4 teratogen information centers in Israel (3) and in Italy (1). The study group was paired for age, smoking habits and alcohol consumption with a comparative group exposed to acetaminophen.

RESULTS

Maternal demographics and history, birth weight, gestational age at delivery, rate of live births, spontaneous abortions and fetal distress were comparable in both groups. The rate of major malformations in the metamizol group (3%) did not differ significantly from the rate in the comparative group (2%) (P = 0.57, relative risk = 1.55, 95% confidence interval 0.26-9.05).

CONCLUSIONS

Our data may suggest that exposure to metamizol during the first trimester of pregnancy is probably not associated with a significantly increased risk for malformations or spontaneous abortions.

Evaluation of gestational age and admission date assumptions used to determine prenatal drug exposure from administrative data

OBJECTIVE

Our aim was to evaluate the 270-day gestational age and delivery date assumptions used in an administrative dataset study assessing prenatal drug exposure compared to information contained in a birth registry.

STUDY DESIGN AND SETTING

Kaiser Permanente Colorado (KPCO), a member of the Health Maintenance Organization (HMO) Research Network Center for Education and Research in Therapeutics (CERTs), previously participated in a CERTs study that used claims data to assess prenatal drug exposure. In the current study, gestational age and deliveries information from the CERTs study dataset, the Prescribing Safely during Pregnancy Dataset (PSDPD), was compared to information in the KPCO Birth Registry. Sensitivity and positive predictive value (PPV) of the claims data for deliveries were assessed. The effect of gestational age and delivery date assumptions on classification of prenatal drug exposure was evaluated.

RESULTS

The mean gestational age in the Birth Registry was 273 (median = 275) days. Sensitivity of claims data at identifying deliveries was 97.6%, PPV was 98.2%. Of deliveries identified in only one dataset, 45% were related to the gestational age assumption and 36% were due to claims data issues. The effect on estimates of prevalence of prescribing during pregnancy was an absolute change of 1% or less for all drug exposure categories. For Category X, drug exposures during the first trimester, the relative change in prescribing prevalence was 13.7% (p = 0.014).

CONCLUSION

Administrative databases can be useful for assessing prenatal drug exposure, but gestational age assumptions can result in a small proportion of misclassification.

Fatores associados ao uso de medicamentos durante a gestação em seis cidades brasileiras

O objetivo deste estudo foi comparar o uso de medicamentos durante a gravidez, segundo variáveis sócio-demográficas, em gestantes que fizeram o pré-natal em serviços do SUS em seis grandes cidades brasileiras. Utilizando-se um questionário estruturado, foram entrevistadas 5.564 gestantes que se apresentaram para consulta em serviço de pré-natal do SUS, participantes do Estudo Brasileiro de Diabetes Gestacional, entre 1991 e 1995. O uso de qualquer medicamento mostrou uma associação positiva com o aumento da escolaridade, da idade e com o fato de ter companheiro, e uma associação negativa com maior número de filhos. O uso de medicamentos multivitamínicos e medicamentos que atuam sobre o aparelho digestivo mostrou aumento da associação com maior escolaridade e idade e uma associação negativa com o aumento do número de filhos. O uso de medicamentos antianêmicos mostrou uma associação negativa com o aumento da escolaridade e com o aumento da idade. O uso de multivitamínicos e medicamentos que atuam sobre o aparelho digestivo mostrou uma associação com variáveis que caracterizam gestantes de melhor nível sócio-econômico, sugerindo que o uso de medicamentos é uma expressão de cuidado com a gestação.

Prescription drug use in pregnancy

OBJECTIVE

The purpose of this study was to provide information on the prevalence of the use of prescription drugs among pregnant women in the United States.

STUDY DESIGN

A retrospective study was conducted with the use of the automated databases of 8 health maintenance organizations that are involved in the Health Maintenance Research Network Center for Education and Research on Therapeutics. Women who delivered of an infant in a hospital from January 1, 1996, through December 31, 2000, were identified. Prescription drug use according to therapeutic class and the United States Food and Drug Administration risk classification system was evaluated, with the assumption of a gestational duration of 270 days, with three 90-day trimesters of pregnancy, and with a 90-day period before pregnancy. Nonprescription drug use was not assessed.

RESULTS

During the period 1996 through 2000, 152,531 deliveries were identified that met the criteria for study. For 98,182 deliveries (64%), a drug other than a vitamin or mineral supplement was prescribed in the 270 days before delivery: 3595 women (2.4%) received a drug from category A; 76,292 women (50.0%) received a drug from category B; 57,604 women (37.8%) received a drug from category C; 7333 women (4.8%) received a drug from category D, and 6976 women (4.6%) received a drug from category X of the United States Food and Drug Administration risk classification system. Overall, 5157 women (3.4%) received a category D drug, and 1653 women (1.1%) received a category X drug after the initial prenatal care visit.

CONCLUSION

Our finding that almost one half of all pregnant women received prescription drugs from categories C, D, or X of the United States Food and Drug Administration risk classification system highlights the importance of the need to understand the effects of these medications on the developing fetus and on the pregnant woman.

Medication use during pregnancy: data from the Avon Longitudinal Study of Parents and Children

OBJECTIVE

To present data on the self-reported use of all types of medicinal products collected during pregnancy in a large cohort in southwest England.

METHODS

Pregnant women with a delivery date during 1991-1992 and forming part of the prospective, population-based Avon Longitudinal Study of Parents and Children (ALSPAC) were sent up to four self-completion postal questionnaires during pregnancy. Text data collected from the questions on drug usage were coded using an ALSPAC drug dictionary based on the World Health Organization Drug Dictionary.

RESULTS

At least one antenatal self-completion questionnaire was completed for 14,119 pregnancies, and 11,545 women completed all four. The data included prescription, over-the-counter, herbal and homeopathic products as well as iron, vitamins and other supplements. Only 7.6% did not report use of any medicinal product throughout their entire pregnancy. The remaining 92.4% used at least one product at some stage. After exclusion of iron, folate, vitamins, supplements, herbal and homeopathic products and skin emollients, 83% of those completing all questionnaires had used conventional therapeutic drugs. Analgesics were reported by approximately one-third of women at each stage during pregnancy, and paracetamol was the most frequently reported substance. Iron preparations were reported by 33% of the full cohort, at some stage, and folate by 21.9%. Use of anti-anaemic products increased during pregnancy with the greatest incidence at 32 weeks. Other vitamins and supplements were taken by 17.4% at some stage. Use of vitamins decreased throughout pregnancy from 9.6% in early pregnancy to 5% at 32 weeks. Antacids were reported by 23% at 32 weeks. The reported incidence of antibiotic use decreased slightly during pregnancy from 8% early on to 5.8% at 32 weeks; amoxicillin was the most frequently reported antibacterial.

CONCLUSION

Use of medicinal products was high during pregnancy in the ALSPAC cohort. This finding is consistent with data from recent publications.

Prescription of drugs to pregnant women in France: the HIMAGE study

The HIMAGE study, conducted in partnership with the principal Public Health Insurance Funds of the Loire region, analysed medicinal prescriptions during pregnancy on the basis of a representative sample of 911 pregnant women resident in this region of France. Altogether 93.5% received at least one prescription, with a mean of 10.9 different drugs per woman. The prescriptions were predominantly for drugs of the following Anatomical Therapeutic Chemical (ATC) classes: "alimentary tract and metabolism" (78%); "genito-urinary system and sex hormones" (62%); "nervous system" (62%); and "blood and blood-forming organs" (57%). Iron supplements, paracetamol, folic acid, magnesium, progesterone, oxaceprol, phloroglucinol, amoxicillin, domperidone and diosmine were the most frequently prescribed drugs. In total, 4.6% of the women were exposed to drugs involving a risk during pregnancy: principally nonsteroidal anti-inflammatory drugs (NSAIDs) prescribed from the sixth month onwards. This study revealed a high frequency of prescription of drugs to pregnant women, largely motivated by non-rational and to some extent culture-specific considerations, and it also highlighted the prescription of drugs known to involve risk during pregnancy. These results provide a basis for advising clinicians on the rational and safe use of drugs during pregnancy.