Prescription drugs during pregnancy and lactation--a Finnish register-based study

The risk of postpartum hemorrhage with selective serotonin reuptake inhibitors and other antidepressants

OBJECTIVE

Limited evidence suggests that selective serotonin reuptake inhibitor (SSRI) antidepressants can hinder platelet aggregation and can increase the risk of hemorrhage. Because antenatal depression is common and is often treated with antidepressants, we sought to determine if exposure to SSRI antidepressants in late pregnancy is associated with an increased risk of postpartum hemorrhage compared with non-SSRI antidepressants.

METHOD

This was a population-based nested case-control study of women aged 16 to 45 years in Ontario, Canada, who received government-funded prescription coverage within 2 years before delivery. We identified case patients with postpartum hemorrhage and matched controls (1:10) without postpartum hemorrhage from the same cohort. Controls were matched to cases on age, mode of delivery, parity, and calendar time. We linked prescription claims data to hospital and physician records for the study period (January 1999 to March 2005). Exclusion criteria included drugs and medical conditions that predispose to hemorrhage, and receipt of multiple antidepressants in the 6 months preceding delivery. Antidepressant drug exposure was classified as SSRI or other agents within 90 days before delivery.

RESULTS

There were 2460 postpartum hemorrhage cases and 23,943 matched controls. The adjusted odds ratio for the association between postpartum hemorrhage and exposure to SSRIs within 90 days before index date was 1.30 (95% confidence interval, 0.98-1.72) as compared with 1.12 (95% confidence interval, 0.62-2.01) for non-SSRIs.

CONCLUSIONS

Selective serotonin reuptake inhibitors confer no disproportionate risk of postpartum hemorrhage at the time of delivery compared with non-SSRI antidepressants. This information may help guide decisions regarding pharmacotherapy for depression during pregnancy.

Prescribing of sulfasalazine, azathioprine and methotrexate round pregnancy--a descriptive study

PURPOSE

Continuation or discontinuation of drugs during pregnancy in chronic diseases is an issue of concern. Information on prescribing of disease modifying anti-rheumatic drugs (DMARDs) during pregnancy is scarce. In this study, we report prescribing patterns round pregnancy of sulfasalazine (SSZ), azathioprine (AZA), methotrexate (MTX) and co-medications among women to whom one of these DMARDs were prescribed before pregnancy.

METHODS

The pregnancy-interaction database (IADB.nl, 1994-2004), containing pharmacy dispensing data from Northern- Netherlands, was used. Women to whom SSZ (N = 13), AZA (N = 10) or MTX (N = 6) was prescribed before their first pregnancy were identified and described in detail.

RESULTS

AZA and SSZ are continued during pregnancy by 60% and 38% of the women, respectively, MTX was stopped before pregnancy. Among women receiving SSZ (N = 13) as their initial DMARD, anti-inflammatory and anti-rheumatic drugs (69%) and analgesics (45%) were the most commonly prescribed co-medications. Among women receiving AZA (N = 8) as their initial DMARD, corticosteroids for systemic use (100%) and intestinal anti-inflammatory agents (88%) were the most commonly prescribed co-medications. All women receiving intestinal anti-inflammatory drugs before pregnancy continued this during pregnancy, in contrast to other co-medications which were mainly discontinued.

CONCLUSIONS

Our study showed that DMARDs and co-medication are received before, during and after pregnancy, although no specific prescription patterns were found. Administrative databases, such as the pregnancy-IADB.nl, are useful in describing drug-prescribing patterns for better understanding of drug prescribing around pregnancy in daily practice. Based on these data, we conclude that prescribing of DMARDs and related co-medication is based on the individual patient.

Polypharmacy in pregnant women with major psychiatric illness: a pilot study

OBJECTIVE

There is increasing concern about the use of multiple medications in populations with psychiatric illnesses. One large study reported that 99% of pregnant women had received a prescription for at least one medication during pregnancy, with a mean of 13.6 medications per woman. The present descriptive study examined patterns of medication use across pregnancy in a low socioeconomic status population of women who had a psychiatric illness as a primary diagnosis.

METHOD

Data on 115 pregnant women were extracted from a Medicaid Database of 5,000 women who received prenatal and other medical care over a 2-year period (2002-2004). Subjects included women with bipolar disorder, schizoaffective disorder, and schizophrenia. Information on age, diagnoses, dates prescriptions were filled, and type, dose, and quantity of medications was recorded in the database.

RESULTS

Data were collected on 115 pregnancies; complete data throughout pregnancy were available for 75 women, while data on certain gestational months were available for the other 40 women. A majority of the 115 women were diagnosed with bipolar or schizoaffective disorder. Their mean age was 26 years. The mean number of medications taken during pregnancy was three (range 0-10; mode = 3); 26.8% of the pregnant women filled prescriptions for 6-10 medications during their pregnancy. No dose changes were made for the prescribed medications to accommodate changing metabolism across pregnancy. The most frequently prescribed medications for these psychiatrically ill women were from the opiate family.

CONCLUSIONS

Multiple medications are frequently prescribed to pregnant women with psychiatric disorders because of comorbid diagnoses. However, the effects of taking multiple psychotropic or other medications during pregnancy on pregnancy outcome and fetal development are unknown. Therefore, more research is needed concerning the effects on the developing fetus of taking multiple medications with central nervous system effects during pregnancy.

The potential of the European network of congenital anomaly registers (EUROCAT) for drug safety surveillance: a descriptive study

BACKGROUND

European Surveillance of Congenital Anomalies (EUROCAT) is a network of population-based congenital anomaly registries in Europe surveying more than 1 million births per year, or 25% of the births in the European Union. This paper describes the potential of the EUROCAT collaboration for pharmacoepidemiology and drug safety surveillance.

METHODS

The 34 full members and 6 associate members of the EUROCAT network were sent a questionnaire about their data sources on drug exposure and on drug coding. Available data on drug exposure during the first trimester available in the central EUROCAT database for the years 1996-2000 was summarised for 15 out of 25 responding full members.

RESULTS

Of the 40 registries, 29 returned questionnaires (25 full and 4 associate members). Four of these registries do not collect data on maternal drug use. Of the full members, 15 registries use the EUROCAT drug code, 4 use the international ATC drug code, 3 registries use another coding system and 7 use a combination of these coding systems. Obstetric records are the most frequently used sources of drug information for the registries, followed by interviews with the mother. Only one registry uses pharmacy data. Percentages of cases with drug exposure (excluding vitamins/minerals) varied from 4.4% to 26.0% among different registries. The categories of drugs recorded varied widely between registries.

CONCLUSIONS

Practices vary widely between registries regarding recording drug exposure information. EUROCAT has the potential to be an effective collaborative framework to contribute to post-marketing drug surveillance in relation to teratogenic effects, but work is needed to implement ATC drug coding more widely, and to diversify the sources of information used to determine drug exposure in each registry.

Drug prescription patterns before, during and after pregnancy for chronic, occasional and pregnancy-related drugs in the Netherlands

OBJECTIVE

To compare the prescription of drugs in women over a period from 2 years before until 3 months after pregnancy, regarding the type of drugs used and the fetal risk.

DESIGN

A cohort study based on pharmacy records of women giving birth to a child between 1994 and 2003.

SETTING

The study was performed with data from the InterAction database, containing prescription-drug-dispensing data from community pharmacies.

POPULATION

The study population included 5412 women for whom complete pharmacy records were available.

METHODS

Drugs were classified into three categories: (1) drugs for chronic conditions, (2) drugs for occasional use and (3) drugs for pregnancy-related symptoms and also classified according to the Australian classification system.

MAIN OUTCOME MEASURES

The prescription rate was calculated as the number of women per 100 women who received one or more prescriptions for a given drug within a specified time period.

RESULTS

About 79.1% of the women received at least one prescription during pregnancy. The prescription rate for most drugs for chronic diseases and for occasional use decreased during pregnancy, whereas, as expected, the prescription rate for pregnancy-related drugs increased. During the first trimester of pregnancy, 1.7% of all drugs prescribed for chronic conditions and 2.3% of the occasional drugs were classified as harmful.

CONCLUSIONS

The increase in prescription rate during pregnancy is caused by an increase in prescription rate of drugs for pregnancy-related symptoms. The prescription of harmful drugs is more commonly associated with drugs for occasional use rather than with drugs for chronic conditions. Therefore, a more cautious prescribing of drugs to healthy women in the fertile age is necessary.

Risks associated with selective serotonin reuptake inhibitors in pregnancy

OBJECTIVE

To study the effects of selective serotonin reuptake inhibitors (SSRIs) on pregnancy outcome.

METHODS

We performed a population-based study of women exposed to SSRIs during pregnancy (n = 1782). Data were derived from a national project in Finland, established by 3 governmental organizations. In that project, the Drug Reimbursement Register, the Medical Birth Register, the Register of Congenital Malformations, and the Register of Induced Abortions have been linked. Comparisons were made between women with SSRI purchases to matched controls and between women with purchases in different trimesters. Only singleton pregnancies were included. Primary outcomes were major malformations, preterm birth, small for gestational age, low birth weight, and treatment in neonatal special or intensive care unit. Analyses were based on logistic models.

RESULTS

Major malformations were not more common in infants or fetuses of women with first trimester SSRI purchases (n = 1,398) when compared with controls with no drug purchases (P = .4). Of infants born to mothers with SSRI purchases in the 3rd trimester, 15.7% were treated in special or intensive care unit compared with 11.2% of infants exposed only during the 1st trimester (P = .009, adjusted odds ratio 1.6, 95% confidence interval 1.1-2.2). We found no increased risk of preterm birth (< 37 weeks), birth 32 weeks of gestation or less, small for gestational age, or low birth weight in women with purchases in each trimester or during the 2nd and 3rd trimesters when compared with women with only 1st trimester purchases.

CONCLUSION

Use of SSRIs during pregnancy is not independently associated with increased risk of adverse perinatal outcome other than need for treatment in neonatal special or intensive care unit.

Antibiotics in pregnancy: analysis of potential risks and determinants in a large German statutory sickness fund population

PURPOSE

Antibiotics are frequently prescribed drugs in pregnancy. The purpose of the study was to analyse the use, the potential risks and the determinants of systemic antibiotic prescriptions during pregnancy.

METHODS

A large, nation-wide acting German statutory sickness fund provided prescription data and personal data of 41,293 pregnant women. For this study, all prescriptions of systemic antibiotics (ATC: J01) dispensed to each woman during a 21-month period were analysed. We used the FDA risk classification system and enrolled a literature search to identify potentially harmful antibiotics. To investigate the impact of geographical and socio-economic determinants in antibiotic prescribing, a multivariate logistic regression model was performed.

RESULTS

Of the 41,293 women, 19.7% received at least one antibiotic drug during pregnancy. There was a shift to relatively safe and reduced antibiotic drug use during pregnancy. Prescribing of contraindicated antibactericals or potentially harmful drugs was seen in 521 women (1.3% of all women). In the logistic regression, being younger than 21 years (adjusted OR 2.14, 95%CI 1.80-2.53) or being welfare recipient (adjusted OR 1.57, CI 1.25-2.00) was strongly associated with higher antibiotic use. Significantly lower antibiotic use was seen in 5 of 16 German federal states (OR 0.74-0.83).

CONCLUSIONS

About 20% of pregnant women received antibiotics, and 1.3% received a harmful drug. To minimise the risks, detailed guidelines are needed for the antibiotic treatment during pregnancy.

Newer antidepressants in pregnancy and rates of major malformations: a meta-analysis of prospective comparative studies

BACKGROUND

A substantial number of women of childbearing age suffer from depression. Despite this, relatively little is known about the safety of antidepressant use during pregnancy.

PURPOSE

We conducted a meta-analysis of prospective comparative cohort studies to quantify the relationship between maternal exposure to the newer antidepressants and major malformations.

METHODS

We searched Medline, Embase and Reprotox from 1996 to the present for studies comparing outcomes in first trimester exposures to citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, reboxetine, venlafaxine, nefazodone, trazodone, mirtazapine and bupropion to those of non-exposed mothers. Data were combined using a random effects model; heterogeneity was tested with chi2, and publication bias with a funnel plot and the Begg-Mazumdar statistic.

RESULTS

Twenty-two studies were identified, 15 were rejected (4 reviews, 4 without comparison groups, 2 third trimester exposures, 2 retrospective database studies, 2 case reports and 1 duplicate); 7 studies (n = 1774) met inclusion criteria. Effects were not heterogeneous (chi2 = 2.04, p = 0.92); funnel plot and test (tau = -0.24, p = 0.45) indicated no publication bias. The summary relative risk was 1.01 (95%CI: 0.57-1.80).

CONCLUSIONS

As a group, the newer antidepressants are not associated with an increased risk of major malformations above the baseline of 1-3% in the population.

Drug prescription in pregnancy: analysis of a large statutory sickness fund population

OBJECTIVE

To examine the prescription of drugs in Germany prior to, during and after pregnancy.

METHODS

For the first time, prescription data of a large cohort of pregnant women, from a German statutory sickness fund, were available for scientific analysis. For each woman who gave birth between June 2000 and May 2001 reimbursed prescriptions for two periods (90 days each) before pregnancy, three during and two after delivery were considered. The drugs were classified according to the ATC code.

RESULTS

Of the 41,293 women, 96.4% received at least one drug during pregnancy. A median of 7 drugs per women was prescribed. Excluding vitamins, minerals, iodide and iron, 85.2% received at least one drug and the median was 3. Magnesium, which was seldom prescribed outside of pregnancy, was by far the most frequently prescribed substance (20% of all prescriptions, 61% of the women). Iron (54% of the women) and iodide (31%) were also prescribed often. The prescription rates of gynaecological antiinfectives (maximum in third trimester: 23% of the women), antacids (max. in third trim.: 11%), as well as antiemetics and antinauseants (max. in first trim.: 8%) during pregnancy considerably increased. A decrease was seen for analgesics, antiinflammatory and antirheumatic drugs, muscle relaxants, ophtalmologicals and anti-acne preparations, for example. Potential teratogenic drugs were prescribed to 1.3% of the women.

CONCLUSION

This analysis of a large nation-wide cohort of pregnant women showed that during pregnancy drugs were prescribed to most women, even when vitamins, minerals, iodide and iron were omitted. Magnesium and iron seemed to have been over-prescribed. On the other hand, the official recommendation for iodide substitution, to prevent thyroid diseases in mother and child, was insufficiently implemented. In our opinion, regular analysis of prescription data can identify potential harmful therapies and focal points where guidelines are needed and can check their implementation.

Prescription of Hazardous Drugs During Pregnancy

BACKGROUND

Prescribing drugs to pregnant women requires the balancing of benefits and risks. Only a small proportion of drugs are known to be harmful to the fetus, but for the vast majority of drugs little evidence of fetal safety exists.

AIM

To determine the prescription pattern of potentially and clearly harmful prescription drugs during pregnancy with reference to drug safety categorisation, and to define the drug groups primarily responsible for multiple drug use during pregnancy.

STUDY DESIGN

A retrospective, register-based cohort study.

METHODS

Linkage of three nationwide registers in Finland. Data collection included prescription drugs purchased during the preconception period and each trimester in the pregnant cohort, and the corresponding time periods in the non-pregnant controls. The pregnancy safety categorisation was determined for each drug (Anatomic Therapeutic Chemical [ATC] code) by using the Swedish classification of approved medicinal products (Farmaceutiska Specialiteter i Sverige [FASS]) and if not available, the corresponding Australian (Australian Drug Evaluation Committee [ADEC]) or US categorisation (FDA). GROUPS STUDIED: Women applying for maternity support (maternal grants) during the year 1999 (n = 43 470) plus non-pregnant control women matched by age and hospital district (n = 43 470).

RESULTS

In the pregnant cohort, 20.4% of women purchased at least one drug classified as potentially harmful during pregnancy, and 3.4% purchased at least one drug classified as clearly harmful. A significant decline occurred in the number of pregnant women purchasing potentially and clearly harmful drugs during the first trimester when compared with the preconception period, and the decline continued from the first to the second trimester. In the pregnant cohort, 107 (0.2%) women purchased at least ten different drugs during pregnancy. The drugs most commonly purchased in this group were topical corticosteroids and nasal preparations.

CONCLUSION

The use of hazardous prescription drugs declines during pregnancy but prescriptions of known teratogens and the relatively frequent practice of polypharmacy in epilepsy place emphasis on the need for careful pre-pregnancy counselling. However, drug safety classifications give a very crude estimation of risk and should only be used as general guidelines when planning treatment. Risk assessment must always be made on an individual basis, and pregnant women with illnesses requiring treatment must be treated adequately.