P–732 Maternal over-the-counter analgesics use during pregnancy and adverse perinatal outcomes: cohort study of 151,141 singleton pregnancies

Study question

Is in utero exposure to five over-the-counter (non-prescription) analgesics (paracetamol, ibuprofen, aspirin, diclofenac, naproxen) associated with offspring health outcomes?

Summary answer

Consumption of over-the-counter analgesics during pregnancy, either as single compounds or in combinations, is significantly associated with a variety of adverse offspring health outcomes.

What is known already

A high percentage of pregnant women use over-the-counter analgesics during pregnancy globally. Some of these compounds such as paracetamol are considered safe to use, while contraindications exist for others, such as NSAIDs use beyond gestational week 30. Current evidence regarding the safety of use during pregnancy in humans is largely conflicting. Results from many published human studies on the topic suffer from limitations including use of small cohorts, short study time or failure to adjust for important confounders. These may explain conflicting results that cause significant concern regarding evidence-based prenatal guidance on use during pregnancy.

Study design, size, duration

Retrospective cohort study using the Aberdeen Maternity and Neonatal Databank. Data from 151,141 singleton pregnancies over 30 years (between 1985 and 2015) were used. Consumption of paracetamol, ibuprofen, aspirin, diclofenac and naproxen during pregnancy was recorded in medical notes of each woman. In our analysis, the control group was pregnancies where no analgesic was consumed, and the exposure groups included pregnancies with over-the-counter analgesic consumption either in combinations or as single compound use.

Participants/materials, setting, methods

Maternal baseline characteristics were compared using χ2 tests for categorical variables and Mann-Whitney for continuous variables (significance at < 0.05). Premature delivery, stillbirth, neonatal death, baby weight, neonatal unit admission, APGAR score at 1 and 5 minutes, neural tube defects, amniotic band defects, gastroschisis, and, in males only, hypospadias and cryptorchidism, were the outcomes assessed. Crude (cORs) and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated using logistic regression to control for confounders.

Main results and the role of chance

The overall prevalence of over-the-counter analgesics use during pregnancy was 29.1%, increasing over the 30-year study period, to over 60% of women in the last seven years of the study. 83.7% of those women reported first trimester use when specifically asked at their first antenatal clinic visit. Pregnancies exposed to at least one of the five analgesics were independently associated with increased risks for premature delivery <37 weeks (aOR=1.50, 95%CI 1.43–1.58), stillbirth (aOR=1.33, 95%CI 1.15–1.54), neonatal death (aOR=1.56, 95%CI 1.27–1.93), birthweight <2,500g (aOR=1.28, 95%CI 1.20–1.37), birthweight >4,000g (aOR=1.09, 95%CI 1.05–1.13), admission to neonatal unit (aOR=1.57, 95%CI 1.51–1.64), APGAR score <7 at 1 minute (aOR=1.18, 95%CI 1.13–1.23) and 5 minutes (aOR=1.48, 95%CI 1.35–1.62), neural tube defects (aOR=1.64, 95%CI 1.08–2.47) and hypospadias (aOR=1.27, 95%CI 1.05–1.54 males only). ). Associations of paracetamol alone with high birth weight, neural tube defects and hypospadias were not significant in the adjusted analysis. Diclofenac consumption was associated with significantly decreased odds of stillbirth (aOR=0.59, 95%CI 0.41–0.87).

Limitations, reasons for caution

Our data were based on medical notes; however, consumption is self-reported, and details on the timing, dosage, product type (single-ingredient vs combination) and administration type were not available in the database. Our study only considered neonatal health outcomes and longer-term follow-up of the offspring was not available at this time.

Wider implications of the findings: This is one of the largest and most comprehensive studies into analgesic use in pregnancy. The increased risks of adverse neonatal outcomes associated with non-prescribed, over-the-counter, analgesics use during pregnancy indicate that healthcare guidance for pregnant women regarding analgesic use should be re-assessed.

Trial registration number

N/A

Maternal gestational weight gain and offspring's risk of cardiovascular disease and mortality

OBJECTIVE

To examine the effect of maternal gestational weight gain (GWG) on adult offspring mortality, cardiovascular morbidity and cerebrovascular morbidity.

METHODS

The Aberdeen Children of the Nineteen Fifties (ACONF) is a population-based cohort of adults born in Aberdeen, Scotland between 1950 and 1956. GWG of the mothers of cohort members was extracted from original birth records and linked to the data on offspring morbidity and mortality up to 2011 obtained from Scottish national records. HRs for cardiovascular events and mortality in offspring according to maternal weight gain in pregnancy were estimated adjusting for maternal and offspring confounders using a restricted cubic spline model.

RESULTS

After exclusions, 3781 members of the original ACONF cohort were analysed. Of these, 103 (2.7%) had died, 169 (4.5%) had suffered at least one cardiovascular event and 73 (1.9%) had had a hospital admission for cerebrovascular disease. Maternal weight gain of 1 kg/week or more was associated with increased risk of cerebrovascular event in the offspring (adjusted HR 2.70 (95% CI 1.19 to 6.12)). There was no association seen between GWG and offspring's all-cause mortality or cardiovascular event. Adult offspring characteristics (smoking, body mass index (BMI) and diabetes) were strongly associated with each outcome.

CONCLUSIONS

Maternal GWG above 0.9 kg/week may increase the risk of cerebrovascular disease in the adult offspring, but not all-cause mortality or cardiovascular disease. Health and lifestyle factors such as smoking, BMI and diabetes in the adult offspring had a stronger influence than maternal and birth characteristics on their mortality and morbidity.

Time from first presentation in primary care to treatment of symptomatic colorectal cancer: effect on disease stage and survival

Background:

British 5-year survival from colorectal cancer (CRC) is below the European average, but the reasons are unclear. This study explored if longer provider delays (time from presentation to treatment) were associated with more advanced stage disease at diagnosis and poorer survival.

Methods:

Data on 958 people with CRC were linked with the Scottish Cancer Registry, the Scottish Death Registry and the acute hospital discharge (SMR01) dataset. Time from first presentation in primary care to first treatment, disease stage at diagnosis and survival time from date of first presentation in primary care were determined. Logistic regression and Cox survival analyses, both with a restricted cubic spline, were used to model stage and survival, respectively, following sequential adjustment of patient and tumour factors.

Results:

On univariate analysis, those with <4 weeks from first presentation in primary care to treatment had more advanced disease at diagnosis and the poorest prognosis. Treatment delays between 4 and 34 weeks were associated with earlier stage (with the lowest odds ratio occurring at 20 weeks) and better survival (with the lowest hazard ratio occurring at 16 weeks). Provider delays beyond 34 weeks were associated with more advanced disease at diagnosis, but not increased mortality. Following adjustment for patient, tumour factors, emergency admissions and symptoms and signs, no significant relationship between provider delay and stage at diagnosis or survival from CRC was found.

Conclusions:

Although allowing for a nonlinear relationship and important confounders, moderately long provider delays did not impact adversely on cancer outcomes. Delays are undesirable because they cause anxiety; this may be fuelled by government targets and health campaigns stressing the importance of very prompt cancer diagnosis. Our findings should reassure patients. They suggest that a health service's primary emphasis should be on quality and outcomes rather than on time to treatment.

Prevalence and year-on-year trends in childhood thinness in a whole population study

BACKGROUND

The burden of childhood thinness in the UK is poorly understood. The aim of this study was to describe the prevalence and year-on-year trends of childhood thinness in a population born between 1970 and 2006 in North East Scotland.

METHODS

Measurements were routinely collected by school nurses as part of school medical entry. Trends in International Obesity Task Force thinness grades 1, that is, body mass index (BMI) corresponding to adult BMI <18.5 kg/m(2) but ≥ 17 kg/m(2) or grade ≥ 2, that is, corresponding to adult BMI <17 kg/m(2) were analysed over time by sex and socioeconomic deprivation quintile.

RESULTS

Data were obtained for 194 391 children, 52% boys, mean age 5.6 years (SD 0.8). The prevalence of thinness grade 1 was 6.5% (95% CI 5.9% to 7.2%) and 4.8% (4.2% to 5.5%) for those born in 1970 and 2006, respectively, but between these years was variable with the fluctuations being greater for boys than girls. The prevalence of thinness grade ≥ 2 fell for those born between 1974 and 1985 from 6.1% (5.5% to 6.8%) to 1.3%, (1.0% to 1.6%) and remained relatively stable thereafter in boys and girls. Thinness grade ≥ 2 was initially less prevalent in more affluent communities, but for those born in 1990 and afterwards, prevalence was equal across deprivation quintiles. In contrast, there was no interaction between deprivation quintile and year of birth for thinness grade 1.

CONCLUSIONS

Thinness has become less common in this population. While thinness was initially more prevalent among deprived communities, this association is no longer apparent.

Pregnancy outcomes of women with and without a history of anorexia nervosa

BACKGROUND

When women have a history of anorexia nervosa (AN), the advice given about becoming pregnant, and about the management of pregnancies, has usually been cautious. This study compared the pregnancy outcomes of women with and without a history of AN.

METHOD

Women with a confirmed diagnosis of AN who had presented to psychiatric services in North East Scotland from 1965 to 2007 were identified. Those women with a pregnancy recorded in the Aberdeen Maternal and Neonatal Databank (AMND) were each matched by age, parity and year of delivery of their first baby with five women with no history of AN. Maternal and foetal outcomes were compared between these two groups of women. Comparisons were also made between the mothers with a history of AN and all other women in the AMND.

RESULTS

A total of 134 women with a history of AN delivered 230 babies and the 670 matched women delivered 1144 babies. Mothers with AN delivered lighter babies but this difference did not persist after adjusting for maternal body mass index (BMI) in early pregnancy. Standardized birthweight (SBW) scores suggested that the AN mothers were more likely to produce babies with intrauterine growth restriction (IUGR) [relative risk (RR) 1.54, 95% confidence interval (CI) 1.11-2.13]. AN mothers were more likely to experience antepartum haemorrhage (RR 1.70, 95% CI 1.09-2.65).

CONCLUSIONS

Mothers with a history of AN are at increased risk of adverse pregnancy outcomes. The magnitude of these risks is relatively small and should be appraised holistically by psychiatric and obstetric services.

Patient satisfaction with GP-led melanoma follow-up: a randomised controlled trial

BACKGROUND

There are no universally accepted guidelines for the follow-up of individuals with cutaneous melanoma. Furthermore, to date, there have been no randomised controlled trials of different models of melanoma follow-up care. This randomised controlled trial was conducted to evaluate the effects of GP-led melanoma follow-up on patient satisfaction, follow-up guideline compliance, anxiety and depression, as well as health status.

METHODS

A randomised controlled trial of GP-led follow-up of cutaneous melanoma was conducted over a period of 1 year with assessment by self-completed questionnaires and review of general practice-held medical records at baseline and 12 months later. It took place in 35 general practices in North-east Scotland. Subjects were 142 individuals (51.4% women 48.6% men; mean (s.d.) age 59.2 (15.2) years previously treated for cutaneous melanoma and free of recurrent disease. The intervention consisted of protocol-driven melanoma reviews in primary care, conducted by trained GPs and supported by centralised recall, rapid access pathway to secondary care and a patient information booklet. The main outcome measure was patient satisfaction measured by questionnaire. Secondary outcomes were adherence to guidelines, health status measured by Short Form-36 and the Hospital Anxiety and Depression Scale.

RESULTS

There were significant improvements in 5 out of 15 aspects of patient satisfaction during the study year in those receiving GP-led melanoma follow-up (all P<or=0.01). The intervention group was significantly more satisfied with 7 out of 15 aspects of care at follow-up after adjustment for potential confounders. There was significantly greater adherence to guidelines in the intervention group during the study year. There was no significant difference in health status or anxiety and depression between intervention and control groups at either baseline or outcome.

CONCLUSIONS

GP-led follow-up is feasible, engenders greater satisfaction in those patients who receive it, permits closer adherence to guidelines and does not result in adverse effects on health status or anxiety and depression when compared with traditional hospital-based follow-up for melanoma.