Postmarketing surveillance for drug safety in pregnancy: The Organization of Teratology Information Services Project

Safe Expectations: Current State and Future Directions for Medication Safety in Pregnancy Research

Medication use in pregnancy is common, but information about the safety of most medications in pregnant women or their infants is limited. In the absence of data from randomized clinical trials to guide decisions made by regulators, clinicians, and patients, we often have to rely on well-designed observational studies to generate valid evidence about the benefits and risks of medications in pregnancy. Spontaneous reporting, primary case-control and cohort studies, pregnancy exposure registries, and electronic health data have been used extensively for studying medication safety in pregnancy. This article discusses these data sources, their strengths and limitations, and possible strategies and approaches to mitigating limitations when planning studies or interpreting findings from the literature. Strategies discussed include combining data sources across institutional or national borders, developing and using more sophisticated study designs, and taking advantage of existing analytic methods for more complex data structures, such as time-varying exposure or unmeasured confounding. Finally, we make recommendations for study designs that aid in better risk-related communication.

Ethical approval for multicenter cohort studies on drug exposure during pregnancy: A survey among members of the European Network of Teratology Information Services (ENTIS)

The European Network of Teratology Information Services (ENTIS) is in a privileged position to perform independent post-marketing surveillance of drugs in pregnancy. The aim of this survey was to describe the legal requirements and procedures involved in obtaining ethical approval for collaborative cohort studies. We sent a survey questionnaire to all 28 Teratology Information Services (TIS), of which 25 (89%) in 18 countries completed our questionnaire. For 15 TIS, specific research ethical approval was mandatory. The review process was estimated to last from 2 up to 16 weeks. Procedures for patients' information and consent were oral (12), written (5) or both (3). Five TIS had no requirement to inform patients and seek consent. Since data on drug exposure during pregnancy are scarce, ENTIS research efforts should be further encouraged, and procedures optimized so that legitimate ethical and legal requirements do not translate into deterrent administrative constraints and costs.

Counseling about medication-induced birth defects with clinical decision support in primary care

BACKGROUND

We evaluated how computerized clinical decision support (CDS) affects the counseling women receive when primary care physicians (PCPs) prescribe potential teratogens and how this counseling affects women's behavior.

METHODS

Between October 2008 and April 2010, all women aged 18-50 years visiting one of three community-based family practice clinics or an academic general internal medicine clinic were invited to complete a survey 5-30 days after their clinic visit. Women who received prescriptions were asked if they were counseled about teratogenic risks or contraception and if they used contraception at last intercourse.

RESULTS

Eight hundred one women completed surveys; 27% received a prescription for a potential teratogen. With or without CDS, women prescribed potential teratogens were more likely than women prescribed safer medications to report counseling about teratogenic risks. However, even with CDS 43% of women prescribed potential teratogens reported no counseling. In multivariable models, women were more likely to report counseling if they saw a female PCP (odds ratio: 1.97; 95% confidence interval: 1.26-3.09). Women were least likely to report counseling if they received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Women who were pregnant or trying to conceive were not more likely to report counseling. Nonetheless, women who received counseling about contraception or teratogenic risks were more likely to use contraception after being prescribed potential teratogens than women who received no counseling.

CONCLUSIONS

Physician counseling can reduce risk of medication-induced birth defects. However, efforts are needed to ensure that PCPs consistently inform women of teratogenic risks and provide access to highly effective contraception.

Funding for teratology information services: up, down, and all around

Funding for Teratology Information Services has been an ongoing struggle over the 25 years of its existence. Traditional and novel funding mechanisms have been explored with varying success. The importance of providing teratology risk assessment and counseling to all women of reproductive age is now an established health care objective. Sufficient and stable funding for these services is essential.

The CTIS Womb to Classroom Screening Program for the detection of agents with adverse effects on neuropsychological development

Over the last several decades, federal agencies engaged in the screening of environmental or pharmaceutical agents have recognized the need to conduct research in animal models to identify agents that have classic teratogenic effects as well as effects on neural and behavioral development. Many questions typically addressed in rodent models can be further addressed using real-world, everyday human exposures. Although some postmarketing surveillance programs have been put in place to examine the influences on birth characteristics, it is now urgent that programs be launched to examine the long-term risks associated with exposure to the many medications, drugs, and environmental chemicals for which data are currently unavailable and unexplored. The California Teratogen Information Service (CTIS), established in 1983, and its corresponding Clinical Research Program represent the oldest national program directed at identifying pregnancy risk factors and exposures associated with adverse pregnancy outcome, including behavioral dysfunction. In recognition of the rising rates of developmental disorders involving compromised mental ability, in 2007, CTIS committed to the development of a more comprehensive screening program designed to detect relationships between adverse prenatal exposures and compromised human neurobehavioral development. The "CTIS Womb to Classroom Screening Program for the Detection of Agents with Adverse Effects on Neuropsychological Development" is the first program designed to identify agents not yet known to be of concern.

Antidepressants in pregnancy: a review of commonly prescribed medications

Perinatal depression is an increasingly common comorbidity of pregnancy and is associated with adverse birth outcomes. Newer classes of antidepressants have been developed with a variety of mechanisms and improved side effect profiles. There is increasing use of these medications in reproductive-aged women. Medical providers have to balance the need to prevent relapse of maternal depressive symptoms with the need to minimize fetal exposure to medications. We review the literature on 10 of the most commonly used antidepressant medications: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine, duloxetine, bupropion, and mirtazapine. The pharmacokinetic properties of the medications are detailed, as well as practical considerations for their use in pregnant and lactating women. Guidance on counseling and management of pregnancies complicated by perinatal depression is discussed.

TARGET AUDIENCE

Obstetricians & Gynecologists and Family Physicians.

LEARNING OBJECTIVES

After completing this CME activity, physicians should be better able to differentiate the current classes of medications utilized commonly for perinatal depression, evaluate the reported adverse effects of antidepressant medications on the patient and developing fetus and choose the appropriate antidepressant medications for a depressed patient who is breast-feeding.

Agreement between self-report and prescription data in medical records for pregnant women

BACKGROUND Clinical teratology studies often rely on patient reports of medication use in pregnancy with or without other sources of information. Electronic medical records (EMRs), administrative databases, pharmacy dispensing records, drug registries, and patients' self-reports are all widely used sources of information to assess potential teratogenic effect of medications. The objective of this study was to assess comparability of self-reported and prescription medication data in EMRs for the most common therapeutic classes. METHODS The study population included 404 pregnant women prospectively recruited from five prenatal care clinics affiliated with the University of New Mexico. Self-reported information on prescription medications taken since the last menstrual period (LMP) was obtained by semistructured interviews in either English or Spanish. For validation purposes, EMRs were reviewed to abstract information on medications prescribed between the LMP and the date of the interview. Agreement was estimated by calculating a kappa (κ) coefficient, sensitivity, and specificity. RESULTS In this sample of socially-disadvantaged (i.e., 67.9% high school education or less, 48.5% no health insurance), predominantly Latina (80.4%) pregnant women, antibiotics and antidiabetic agents were the most prevalent therapeutic classes. The agreement between the two sources substantially varied by therapeutic class, with the highest level of agreement seen among antidiabetic and thyroid medications (κ ≥0.8) and the lowest among opioid analgesics (κ = 0.35). CONCLUSIONS Results indicate a high concordance between self-report and prescription data for therapeutic classes used chronically, while poor agreement was observed for medications used intermittently, on an 'as needed" basis, or in short courses.

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.

The role of teratology information services in screening for teratogenic exposures: challenges and opportunities

Teratology Information Services (TIS) located throughout the world have long played a key role in screening for potential new human teratogens. Using a basic prospective cohort study design, TIS recruit pregnant women from among callers to the Services who have had an exposure of interest and at the same time identify an unexposed comparison group from the same pool of callers. Women in both groups are followed to pregnancy outcome and a range of adverse outcomes including major congenital anomalies, birth size, pregnancy loss, and preterm delivery are evaluated, while controlling for potential confounding. Particularly for rare exposures or newly marketed medications, TIS may be uniquely suited to gathering this information in a timely and efficient fashion. The primary limitation of these studies is the unknown representativeness of the volunteer sample, and the typical small to moderate sample sizes. Methods to increase the proportion of exposed pregnancies that are recruited should be developed. However, small sample size TIS studies, especially when considering new or rare exposures, often fulfill the important function of providing some reassurance to women who have already had the exposure of interest by ruling out major risks for teratogenicity, that is, on the order of thalidomide. Collaborations across TIS nationally and internationally help to address the sample size challenges. A formal collaboration between the TIS cohort study model with a case-control study design is also underway and will provide complementary strengths.

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.

The effectiveness of Teratology Information Services (TIS)

BACKGROUND

Women and their health care providers have few reliable sources of information regarding the safety of exposures in pregnancy and lactation. Evidence-based information on these topics is provided by Teratology Information Services (TIS). Access to TIS, however, is limited in many regions, and many services have difficulty maintaining ongoing funding. The objective of this review is to highlight published reports of the effectiveness of TIS in improving maternal and neonatal health.

METHODS

A search of the Pub Med and Econ Lit databases was performed with no date restriction, using the search terms teratology, information, counseling, pregnancy, effectiveness, birth defects.

RESULTS

Information disseminated from TIS has been shown to prevent congenital malformations, unnecessary pregnancy terminations, and occupational risks. TIS support optimal nutritional supplementation in pregnancy and optimal drug therapy in pregnancy and breast-feeding. In addition, they correct misperceptions of risk and facilitate knowledge transfer and translation. TIS have the potential to provide health care cost savings.

CONCLUSIONS

TIS are vital services in supporting optimal maternal and neonatal health. A formal economic evaluation of TIS is required in order to inform resource allocation decision-making and continued funding of these services.

Linking teratogen information service and birth defects registry databases to improve knowledge of birth defect status

BACKGROUND

Although teratogen information services (TISs) obtain maternal exposure information from their callers, such services often do not know if the pregnancies were affected by a birth defect. This study attempted to improve the completeness of this information for Texas Teratogen Information Service (TTIS) callers by linking their records with the Texas Birth Defects Registry (TBDR) and Texas birth certificates (TBCs).

METHODS

A total of 344 expectant mothers called TTIS with expected dates of delivery between 1 January 2000 and 31 December 2001. These pregnancies were linked with TBDR and TBC data. The percentages of pregnancies with known birth defect information both before and after the linkage were compared.

RESULTS

The TTIS originally collected birth defect status information for 101 of the 344 callers (29.4%) and 0.6% of all 344 callers or 2.0% of callers with birth defect status information had a pregnancy affected by a birth defect. Linking TTIS records with TBDR and TBC data helped to raise the percentage of callers with birth defect status information from 29.4% to 71.5%. Among those callers, the percentage known to have birth defects increased from 2.0% to 4.1%. The sensitivity of TTIS follow-up calls in identifying birth defects was 50%, and the specificity was 100%.

CONCLUSIONS

Linking TTIS caller records with TBDR and TBC data significantly increased both the percentage of pregnancies with birth defect status information and the percentage of pregnancies identified as affected by birth defects. Such linkage may be a good approach by which TISs can increase the completeness of their birth defect status information.

Prevalence of periconceptional folic acid use and perceived barriers to the postgestation continuance of supplemental folic acid: Survey results from a Teratogen Information Service

BACKGROUND

Fewer than 40% of U.S. women are taking folic acid supplements periconceptionally at a time when the risk of neural tube defects (NTDs) can be reduced by supplementation. A better understanding of the vitamin-taking habits of childbearing-age women and effective methods for improving periconceptional supplement use are needed.

METHODS

A telephone survey conducted through the California Teratogen Information Service (TIS) between August 2003 and January 2004 assessed the prevalence and characteristics of pregnant callers who did not use folic acid supplements in the periconceptional period, and explored attitudes toward advice to continue vitamin use following pregnancy in order to be protected in a future pregnancy.

RESULTS

A total of 327 pregnant women who called the TIS for information agreed to participate in the survey. More than half (53.2%) were not taking folic acid-containing supplements in the periconceptional period. Predictors of lack of use included a higher prepregnancy body mass index, younger maternal age, non-white race/ethnicity, lower education level, and unplanned pregnancy. One-quarter of the women said they would be willing to continue taking vitamins after the pregnancy if advised to do so by a physician. The remainder identified obstacles to following that advice--notably, not planning to become pregnant again and the belief that enough folate is derived from diet alone.

CONCLUSIONS

More than half of the callers to the TIS were not compliant with recommendations regarding periconceptional folic acid supplementation. This represents an opportunity for TIS specialists and physicians to intervene in a current pregnancy to encourage maintenance of supplement use in the subsequent interpregnancy interval.

Prescription of teratogenic medications in United States ambulatory practices

PURPOSE

The purpose of this study was to identify the potentially teratogenic medications most frequently prescribed to women of childbearing age and the specialty of physicians who provide ambulatory care to women who use such medications. In addition, we evaluated rates of contraceptive counseling to explore awareness of the risks associated with teratogenic medication use.

SUBJECTS AND METHODS

The prescription of teratogenic medications and provision of contraceptive counseling on 12,681 visits made by nonpregnant women, 14 to 44 years of age, to 1880 physicians in US ambulatory practice (National Ambulatory Medical Care Survey) between 1998 and 2000 was analyzed.

RESULTS

Use of a potentially teratogenic, class D or X, medication by a woman of childbearing age is documented on 1 of every 13 visits made to US ambulatory practices. These include anxiolytics (4.1 million annual prescriptions), anticonvulsant medications (1.4 million annual prescriptions), antibiotics like doxycycline (1.4 million annual prescriptions), and statins (0.8 million annual prescriptions). Isotretinoin accounts for less than 5% of potentially teratogenic prescriptions (0.5 million annual prescriptions). Internists and family/general practitioners provide ambulatory care to 45% of women prescribed potentially teratogenic medications, psychiatrists provide ambulatory care to 20% of women prescribed potentially teratogenic medications, and dermatologists provide ambulatory care to 20% of women prescribed potentially teratogenic medications. Contraceptive counseling was provided on less than 20% of visits that documented use of a potential teratogen by a woman of childbearing age. Women using low-risk (class A or B) drugs received contraceptive counseling as frequently as women using potential teratogens (P = .24).

CONCLUSION

Potentially teratogenic medications are prescribed to millions of women of childbearing age each year. Physician awareness of the teratogenic risk associated with class D or X medications seems low.

The contribution of new findings and ideas to the old principles of teratology

Although the last generally accepted concept of principles of teratology was issued more than 30 years ago, the cause of less than 50% of all congenital anomalies is known and no substantial change in their incidence has been observed worldwide. In the meantime, powerful techniques of molecular biology as well as many sophisticated preventive measures have been introduced with marginal effects on the overall birth defects numbers. In this paper, we follow the history of basic concepts of teratology starting with Isidore Geoffroy Saint-Hilaire and Dareste, followed in the 20th century by James Wilson. Since that time no bright and completely new idea, which would deserve the name principle, has emerged. The advanced molecular studies support the long-existing principles and disclose the great variability of individuals and their responses to adverse exposures. In this way, the future of teratology counseling may be seen in a deep analysis of any individual case.

Medication use during pregnancy and lactation: an urgent call for public health action

Questions about medication use during pregnancy and lactation are a concern for women and healthcare providers. Unfortunately, there is little experience with the use of most medications in human pregnancy and lactation at the time they are marketed. Even when information is available, it may not be readily accessible to women and healthcare providers. Nevertheless, medication use by pregnant and breastfeeding women may be beneficial, and even essential, to ensure the health of both mother and child. In addition, almost half of pregnancies in the United States each year are unintended, and medication exposures may occur in the early weeks of gestation before a pregnancy is recognized. For these reasons, it is critical that up-to-date information about the effects of medication use during pregnancy and lactation and the management of maternal conditions be available to women and healthcare providers. A comprehensive, coordinated public health approach that builds on and expands existing activities is needed to generate information about medication use, make that information readily available, and translate it into safe and effective healthcare. Critical components of this system include a central source of up-to-date information, further development and coordination of monitoring and research activities, the availability of counseling services throughout the country, development of standard communication messages, and a panel of experts to provide oversight. This will require collaborative support from government agencies, nonprofit organizations, academic and public health professionals, and healthcare providers to ensure safe and beneficial use of medications during pregnancy and lactation.