Medication use in early pregnancy-prevalence and determinants of use in a prospective cohort of women

Prenatal and perinatal analgesic exposure and autism: an ecological link

BACKGROUND

Autism and Autism Spectrum Disorder (ASD) are complex neurodevelopmental disorders. Susceptibility is believed to be the interaction of genetic heritability and environmental factors. The synchronous rises in autism/ASD prevalence and paracetamol (acetaminophen) use, as well as biologic plausibility have led to the hypothesis that paracetamol exposure may increase autism/ASD risk.

METHODS

To explore the relationship of antenatal paracetamol exposure to ASD, population weighted average autism prevalence rates and paracetamol usage rates were compared. To explore the relationship of early neonatal paracetamol exposure to autism/ASD, population weighted average male autism prevalence rates for all available countries and U.S. states were compared to male circumcision rates - a procedure for which paracetamol has been widely prescribed since the mid-1990s. Prevalence studies were extracted from the U.S. Centers for Disease Control and Prevention Summary of Autism/ASD Prevalence Studies database. Maternal paracetamol usage and circumcision rates were identified by searches on Pub Med.

RESULTS

Using all available country-level data (n = 8) for the period 1984 to 2005, prenatal use of paracetamol was correlated with autism/ASD prevalence (r = 0.80). For studies including boys born after 1995, there was a strong correlation between country-level (n = 9) autism/ASD prevalence in males and a country's circumcision rate (r = 0.98). A very similar pattern was seen among U.S. states and when comparing the 3 main racial/ethnic groups in the U.S. The country-level correlation between autism/ASD prevalence in males and paracetamol was considerably weaker before 1995 when the drug became widely used during circumcision.

CONCLUSIONS

This ecological analysis identified country-level correlations between indicators of prenatal and perinatal paracetamol exposure and autism/ASD. State level correlation was also identified for the indicator of perinatal paracetamol exposure and autism/ASD. Like all ecological analyses, these data cannot provide strong evidence of causality. However, biologic plausibility is provided by a growing body of experimental and clinical evidence linking paracetamol metabolism to pathways shown to be important in autism and related developmental abnormalities. Taken together, these ecological findings and mechanistic evidence suggest the need for formal study of the role of paracetamol in autism.

Asthma management in pregnancy

BACKGROUND

Asthma is common during pregnancy, however research is limited regarding the extent and timing of changes in asthma management associated with pregnancy.

OBJECTIVE

To determine the prevalence of asthma during pregnancy and identify changes in treatment and asthma exacerbation rates associated with pregnancy, while controlling for seasonal influences.

METHODS

Pregnant women with asthma were identified from the UK General Practice Research Database between 2000 and 2008. For each woman asthma medication prescribed during the study period was identified; for each product combination the British Thoracic Society medication-defined asthma treatment step was identified. Asthma exacerbations were identified during pregnancy and in the corresponding 12 months prior. Analyses of changes in asthma treatment and exacerbation rates during pregnancy relative to the corresponding period 12 months prior, to control for seasonality, were stratified by trimester and asthma treatment intensity level.

RESULTS

The prevalence of treated asthma in pregnancies resulting in a delivery was 8.3%. From 14,141 pregnancies, in 12,828 women with asthma, 68.4% received prescriptions for a short-acting β2-agonist and 41.2% for inhaled corticosteroids; 76.5% were managed with asthma treatment Step 1 or 2. Poor persistence to inhaled corticosteroids, defined as a gap of up to 60 days between prescriptions, was common. In 45.0% of pregnancies, an increase in average treatment step was observed whereas in 25.6% the treatment step decreased. Treatment intensity remained the same in 29.5% of pregnancies. Exacerbations occurred in 4.8% of pregnancies compared to 5.9% in the same season the year before (p<0.001).

CONCLUSION

Exacerbation rates during pregnancy were slightly lower than in the year before. However, treatment patterns and exacerbation rates in this study suggest asthma control during pregnancy is variable, and women may require close monitoring especially in those with evidence of poor control before pregnancy.

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.

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.

Fear of childbirth, mental health, and medication use during pregnancy

The aim of this work was to study the associations between medication use, fear of childbirth, and maternal mental health. Pregnant women (n = 1,984) were recruited through routine antenatal care at a Norwegian hospital from November 2008 through April 2010. Data were collected by three self-completed questionnaires at pregnancy week 17 and 32 and at 8 weeks postpartum. Fear of childbirth was measured by the Wijma Delivery Expectancy Questionnaire (W-DEQ). Symptoms of anxiety were measured by the Hopkins Symptom Checklist (SCL-25) and symptoms of depression by the Edinburgh Postnatal Depression Scale (EPDS). In total, 57.7 % of the women used medications during pregnancy. Analgesics were used by 55.8 % of the women and psychotropic medications by 1.8 %. In all, 7.8 % of the women reported fear of childbirth (W-DEQ >85), the prevalence of anxiety (SCL >18) was 11.8 % and the prevalence of depression (EPDS >13) was 8.1 %. Fear of childbirth was significantly associated with use of psychotropic drugs (OR 3.63; 95 % CI 1.39-9.43) but not with the use of analgesics or medications in general. The presence of symptoms of anxiety or depression increased the magnitude of this association. Fear of childbirth is associated with an increased use of psychotropic medication. This finding could not only be explained by an overlap between fear of childbirth and impaired mental health.

Periconceptional folic acid and teratogenic drug use in women undergoing fertility treatments

OBJECTIVE

To evaluate periconception drug use in women undergoing fertility treatment and compare it to women with spontaneous pregnancies.

METHODS

Retrospective observational cohort study on reproductive-age women. Data on pregnancies, fertility treatments, prescription fillings and demographics were extracted from Clalit Health Services computerized systems. Two quality measures were evaluated: periconception folic acid prescription fillings and use of potentially hazardous drugs in early pregnancy.

RESULTS

There were 12,891 fertility treatment cycles in 4868 women; and 4968 women had spontaneous pregnancy. Periconceptional folic acid use was low and similar in both groups (31.3% of fertility cycles versus 29.9% of spontaneous pregnancies, p = 0.07). In the infertility group, 293 prescriptions for potentially hazardous drugs were filled within 45 days after the beginning of a fertility cycle (2.3% of cycles) compared to only 47 (0.9%) in women with spontaneous pregnancy (p < 0.001).

CONCLUSIONS

The periconception medical care of women who undergo fertility treatment is suboptimal and is not better than in women with spontaneous pregnancies. Folic acid use that can reduce the risk of congenital anomalies is underused; whereas the use of potentially hazardous drugs in early pregnancy is significant. More intensive and targeted counseling regarding drug use before pregnancy is urgently needed.

Psychosocial outcomes are related to asthma control and quality of life in pregnant women with asthma

BACKGROUND

Little is known about the psychosocial impact and perceived teratogenic (fetal harm due to medication) risks of asthma treatment (inhaled/oral corticosteroids and β-agonist) during pregnancy.

AIMS

To assess the perception of asthma control, quality of life (QoL), and perceived risks of therapy in pregnant women with asthma.

METHODS

Pregnant women with asthma (n = 125) were recruited between 12 and 20 weeks gestation. QoL (generic: Short Form-12 Health Survey v1, and asthma specific: Asthma Quality of Life Questionnaire-Marks (AQLQ-M)) and psychological variables were assessed using the Perceived Control of Asthma Questionnaire (PCAQ), the Brief Illness Perception Questionnaire, and the Six-Item Short-Form State Trait Anxiety Inventory (STAI-6). Women's perceptions of the teratogenic risks of asthma therapy were also assessed and analyzed for adherence to maintenance inhaled corticosteroids (ICSs), poor asthma control, and QoL.

RESULTS

Women reported good QoL (median AQLQ-M total score/maximum score = 0.88/10), moderate ability to deal with asthma symptoms (mean PCAQ score = 42.6/55), positive beliefs about their asthma and low anxiety (median STAI score = 26.7/80). Perceived teratogenic risks for asthma drugs were excessive and class dependent. Women perceived there was a 42% teratogenic risk for oral corticosteroid, a 12% risk for ICSs, and a 5% risk with short-acting β-agonist. Illness beliefs, emotional response to illness (p = .030), age ≥ 30 years (p = .046), and maintenance ICS use (p = .045) were significantly associated with uncontrolled asthma, while maintenance ICS use (p = .023), illness beliefs, consequences (p = .044), timeline (p = .016), and emotional response (p = .015) and anxiety (p ≤ .0001) were significantly associated with reduced QoL.

CONCLUSIONS

In pregnancy, women with asthma experience good QoL but overestimate teratogenic risks of asthma medication. Maintenance ICS use, illness beliefs, and anxiety are associated with impaired QoL and asthma control.

Effects of personality on use of medications, alcohol, and cigarettes during pregnancy

PURPOSE

The aim of the study was to examine the role of personality in a pregnant woman's consumption of medications, cigarettes, and alcohol.

METHODS

The study included 835 pregnant women in Norway who responded to an electronic questionnaire posted on websites for pregnant women. On the questionnaire, the women reported their use of medications, cigarettes, and alcohol during pregnancy. They also filled out a personality assessment questionnaire, the Big Five Inventory.

RESULTS

Use of medications, alcohol, and cigarettes was significantly associated with different personality traits. Women with high scores for conscientiousness were less likely to use an over-the-counter medication such as paracetamol than other women (odds ratio (OR) 0.74; 95% confidence interval (CI) 0.55-0.99). Women who scored high for neuroticism were four- to sixfold more likely to use prescription medications such as sedatives/anxiolytics (OR 4.07; 95% CI 1.48-11.20) or antidepressants (OR 5.73, 95% CI 2.33-14.09). Women with high scores for openness to experience were more likely to use herbal remedies (OR 1.59; 95% CI 1.00-2.52). Women who continued consuming alcohol during pregnancy were more likely to score high on extraversion and low on conscientiousness than women who quit alcohol use. Scoring high on neuroticism increased the likelihood of quitting smoking during pregnancy.

CONCLUSIONS

This study shows that a woman's personality traits are associated with use of medications, cigarettes, and alcohol during pregnancy. This knowledge could be of clinical importance to health care personnel providing prenatal care.

Gestational medication use, birth conditions, and early postnatal exposures for childhood asthma

Our aim is to explore (1) whether gestational medication use, mode of delivery, and early postnatal exposure correlate with childhood asthma, (2) the dose responsiveness of such exposure, and (3) their links to early- and late-onset asthma. We conducted a matched case-control study based on the Taiwan Children Health Study, which was a nationwide survey that recruited 12-to-14-year-old school children in 14 communities. 579 mothers of the participants were interviewed by telephone. Exclusive breastfeeding protected children from asthma. Notably, childhood asthma was significantly associated with maternal medication use during pregnancy, vacuum use during vaginal delivery, recurrent respiratory tract infections, hospitalization, main caregiver cared for other children, and early daycare attendance. Exposure to these factors led to dose responsiveness in relationships to asthma. Most of the exposures revealed a greater impact on early-onset asthma, except for vacuum use and daycare attendance.

Drug exposure during the periconceptional period: a study of 1793 women

BACKGROUND

Many studies have described the prescribing of drugs to pregnant women, but only very few have data concerning the periconceptional period specifically.

AIM

The aim of the study was to evaluate the incidence of exposure to teratogenic drugs during early pregnancy and to determine whether a safer drug exists.

METHODS

In a French health insurances database, we analyzed drugs prescribed during the period starting 1 month before and ending 2 months after the beginning of pregnancy between 1 January 2006 and 31 December 2007. Based on the Summary of Product Characteristics (SPC), drugs we considered were those 'contraindicated', 'not recommended', 'to be avoided', and 'possible' for use during the first trimester of pregnancy. For drugs 'contraindicated', we established if there were alternatives with similar efficacy for the mother and lower risk for the fetus.

RESULTS

Over a period of 2.25 years, 8754 drugs were prescribed to 1793 women starting 1 month prior to and ending 2 months after conception. Among these drugs, 20 (0.2%) were 'contraindicated', 195 (2.2%) were 'not recommended', and 1209 (13.8%) were 'to be avoided' during the first trimester of pregnancy. Twenty (1.1%) women received at least one drug that was 'contraindicated' during the first trimester, 171 (9.5%) received a drug that was 'not recommended' and 768 (42.8%) received a drug that was 'to be avoided'. At least one possible alternative was available for all except one 'contraindicated' drug.

CONCLUSIONS

During the highest teratogenic risk period, 1.1% of women received a contraindicated drug, despite existence of a safer alternative drug. This may be partly accounted for by physicians not being aware of the pregnancy at the time the drug was administered and could be reduced by adding a section entitled 'women of child-bearing potential' to the SPC.

Use of prescribed drugs among primiparous women: an 11-year population-based study in Denmark

PURPOSE

To describe patterns of prescribed drug use over time among primiparous women in Denmark.

METHODS

Through the Danish Medical Birth Registry, we identified all primiparous women giving live birth or stillbirth at ≥ 22 gestational weeks in northern Denmark, from 1999 to 2009. From the Aarhus University Prescription Database we obtained information on the women's prescriptions for reimbursed drugs filled from 30 days before conception until delivery.

RESULTS

Among 85,710 primiparous women, 47,982 (56.0%) redeemed at least one prescription from 30 days before conception until delivery. Women aged 35 years and older had the highest overall prevalence of prescription drug use (61.1%). Age-standardized prevalence of drug use was 54.7% in 1999 and 61.2% in 2009, prevalence ratio (PR) of 1.13 (95% confidence interval 1.10; 1.16), adjusted for age and smoking.

CONCLUSION

Over the 11-year period from 1999 to 2009, we found a modest increase in overall use of drugs by primiparous women in Denmark. This increase was not, however, explained by an increasing proportion of older first-time mothers. We noted changes in patterns of use of anti-infective drugs and antidepressants.