Teratogen update: pseudoephedrine

Risk of Major Congenital Malformations Associated with the Use of Japanese Traditional (Kampo) Medicine Containing Ephedra During the First Trimester of Pregnancy

BACKGROUND

Japanese traditional (Kampo) medicines containing ephedra may be used to treat colds during pregnancy. There are reports that ephedrine, a component of ephedra, has a risk of teratogenicity; however, the evidence remains equivocal.

OBJECTIVE

This study aimed to evaluate the risk of major congenital malformations (MCMs) associated with exposure to Kampo medicines containing ephedra during the first trimester of pregnancy using the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study (TMM BirThree Cohort Study).

METHODS

To 23,730 mother-infant pairs who participated in the TMM BirThree Cohort Study from July 2013 to March 2017, questionnaires in early and middle pregnancy were distributed approximately at weeks 12 and 26 of pregnancy, respectively. Infants' risk of MCMs in women who used Kampo medicines containing ephedra or acetaminophen during the first trimester was assessed, and the odds ratios (ORs) were estimated with unadjusted and adjusted analyses.

RESULTS

Among 20,879 women, acetaminophen and Kampo medicines containing ephedra were used in 665 (3.19%) and 376 (1.80%) women, respectively, in the first trimester. Among the infants born to the mothers who used acetaminophen or Kampo medicine containing ephedra during the first trimester, 11 (1.65%) and 8 (2.13%), respectively, had overall MCMs. OR of overall MCMs was higher in women who used Kampo medicines containing ephedra than in those who used acetaminophen in the first trimester (adjusted OR, 1.45; 95% confidence interval (CIs), 0.57-3.71); however, the difference was not statistically significant.

CONCLUSIONS

In this study, there was no statistically significant association between the use of Kampo medicines containing ephedra during the first trimester of pregnancy and the risk of MCMs. Although some point estimates of ORs exceeded 1.00, the absolute magnitude of any increased risks would be low.

Effects of pseudoephedrine on rat fetal bone development: evaluation by three different methods

Pseudoephedrine (PSE) is an agent that is contained in common cold medications. The agent, which is used to treat cold and cough, is the fourth most prescribed drug group in some countries. During pregnancy, expectant mothers use PSE for colds and other reasons. One out of every four expectant mothers use PSE alone or in combination with other medicines for various reasons. This study was aimed to investigate effects of PSE on long bones development in rat during fetal growth. Pregnant rats were divided into five groups: control and four experimental groups (25 mg/kg, 50 mg/kg, 100 mg/kg, 200 mg/kg PSE). Between 1 and 20 days of pregnancy, PSE was given to them by gavage. Weights and heights of fetuses isolated by cesarean on the 21st day were measured. Ossification of femur and humerus was examined by three different methods mentioned earlier. Depending on the dose increase, all morphometric data, ossification rate and bone length of the fetuses were decreased. Besides, it was determined that the amount of Calcium in the bone tissue decreased in the analyzes made with SEM-EDX Analysis. The data obtained from this study reveal that the use of PSE during pregnancy disrupts the existing balance in the bone and negatively affects ossification due to the dose increase. In conclusion, we present descriptive and novel data on the effects of PSE use during pregnancy on the bone development of rat fetal long bones.

Pseudoephedrine-Benefits and Risks

Pseudoephedrine (PSE) is a drug with a long history of medical use; it is helpful in treating symptoms of the common cold and flu, sinusitis, asthma, and bronchitis. Due to its central nervous system (CNS) stimulant properties and structural similarity to amphetamine, it is also used for non-medical purposes. The substance is taken as an appetite reducer, an agent which eliminates drowsiness and fatigue, to improve concentration and as a doping agent. Due to its easier availability, it is sometimes used as a substitute for amphetamine or methamphetamine. Pseudoephedrine is also a substrate (precursor) used in the production of these drugs. Time will tell whether legal restrictions on the sale of this drug will reduce the scale of the problem associated with its misuse.

Recent trends in tablet subdivision and factors affecting subdivision in South Korea: A cross-sectional study

Tablet subdivision by physicians or patients frequently occurs in various clinical settings for multiple reasons, including dose adjustment, alleviation of swallowing difficulties, or cost savings. However, not all tablets are suitable for subdivision, and it might cause side effects. It is informative to know which medicines are regularly subdivided, which healthcare institutions prescribe subdivided medicines, and to whom the medicines are prescribed from the perspectives of quality of care and patient safety. In this study, we aimed to examine recent trends in tablet subdivision and to address factors associated with subdivision of tablets both at the patient and healthcare institution levels.The yearly claims data in 2016 retrieved from the National Patients Sample provided by the Health Insurance Review and Assessment (HIRA-NPS). This study used descriptive statistics to examine characteristics of medicines that were frequently prescribed in subdivided forms, and retrieved information regarding the medicines to assess the appropriateness for tablet splitting. Then, we selected five medicines, and performed a multivariate logistic regression analysis to estimate the effect of the variables of interest on tablet subdivision.We presented the top 25 medicines prescribed in subdivided forms in 2016, and confirmed these medicines could be relevantly halved according to their Summary of Product Characteristics. Of the 25 medicines, 14 (56%), 5 (20%), and 3 (12%) medicines belonged to the respiratory system (R), nervous system (N), and systemic hormonal preparations (H), according to the first category of Anatomical Therapeutic Chemical (ATC) classification system, respectively. Being female at the patient level and tertiary healthcare institutions and private owned institutions at the institution level were positively associated with subdivision of medicines.Subdivision of tablets frequently occurred for vulnerable populations with various reasons. Female and geriatric patients are prescribed split medicines for clinical reasons, while low-income patients are prescribed nonsplit medicines for cost savings. It would be better if medicines were not so small, and if they had dividing lines on their surfaces to enable successful splitting of the tablet and to protect the health of vulnerable patients. Furthermore, avoid splitting those pharmacotherapies with a narrow therapeutic range, and provide a pharmacist assistance and a splitting device for unavoidable splitting.

Recurrent miscarriage and fetal congenital malformations: Is there a neglected causal association?

OBJECTIVE

The aim of the present study is to investigate the correlation between pregnancies complicated by morphological or chromosomal fetal anomalies and an obstetric history of two or more pregnancy losses, analyzing the association with any maternal risk factor.

STUDY DESIGN

Retrospective analysis of women who had access to the Day Hospital Clinic of Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome from 2012 to 2018 for a pregnancy complicated by fetal malformation and/or abnormal karyotype, and who had an obstetric history of at least one pregnancy loss. Patients were divided into four groups depending on the number of miscarriages and the presence of a genetic anomaly: Group 0 included women with <2 miscarriages and fetal malformations, Group 1 included women with ≥2 miscarriages and fetal malformations, Group 2 included women with <2 abortion, fetal malformations and the presence of genetic anomalies; Group 3 included women with 2 ≥ abortions, fetal malformations and genetic anomalies. Statistical analysis was performed using the SAS v. 9.4 (SAS Institute Inc., Cary, NC, USA).

RESULTS

A total of 466 patients were included in the present analysis. Out of these, 379 patients belonged to Group 0; 40 patients entered in Group 1; Group 2 included 42 patients, and 5 patients were part of Group 3. Pregnancies complicated by fetal congenital malformations in patients with two or more pregnancy losses were significantly associated with maternal trombophilic disease and previous birth defects. Recurrent miscarriage and fetal structural anomalies were also significantly correlated with advanced maternal age.

CONCLUSIONS

An adequate periconceptional counseling regarding the risk of fetal congenital anomalies may be indicated in patients affected by thrombophilic disease, as well as in those of advanced maternal age and with a pregnancy history of fetal malformations. The screening for thrombophilia may be advisable in patients with an obstetric history of congenital birth defects.

Etiology and Pathogenesis of Hemifacial Microsomia

Hemifacial microsomia (HFM) is a common congenital malformation of the craniofacial region. There are 3 possible pathogenic models of HFM—vascular abnormality and hemorrhage in the craniofacial region, damage to Meckel’s cartilage, and the abnormal development of cranial neural crest cells—and the most plausible hypothesis is the vascular abnormality and hemorrhage model. These 3 models are interrelated, and none of them is completely concordant with all the variable manifestations of HFM. External environmental factors (e.g., thalidomide, triazene, retinoic acid, and vasoactive medications), maternal intrinsic factors (e.g., maternal diabetes), and genetic factors (e.g., the recently reported mutations in OTX2, PLCD3, and MYT1) may lead to HFM through ≥1 of these pathogenic processes. Whole genome sequencing to identify additional pathogenic variants, biological functional studies to understand the exact molecular mechanisms, and additional animal model and clinical studies with large stratified samples to elucidate the pathogenesis of HFM will be necessary. Small-molecule drugs, as well as CRISPR/CAS9-based genetic interventions, for the prevention and treatment of HFM may also be a future research hotspot.

Asthma Outcomes and Management During Pregnancy

Asthma during pregnancy poses a common, increasingly prevalent threat to the health of women and their children. The present article reviews recent insights gained from the epidemiology of asthma during pregnancy, demonstrating the many short- and long-term risks to mother and fetus incurred by poorly controlled maternal asthma. We further discuss emerging evidence that active management of asthma during pregnancy can positively influence and perhaps completely mitigate these poor outcomes. Recent high-quality trials examining best methods for asthma treatment are reviewed and synthesized to offer an evidence-based pathway for comprehensive treatment of asthma in the outpatient setting. Safe and effective medications, as well as nonpharmacologic interventions, for asthma during pregnancy are discussed, and treatment options for related conditions of pregnancy, including depression, rhinitis, and gastroesophageal reflux, are presented. Throughout, we emphasize that an effective treatment strategy relies on a detailed patient evaluation, patient education, objective measurement of asthma control, and frequent and supportive follow-up. The cardiovascular and respiratory physiology of pregnancy is reviewed, as well as its implications for the management of patients with asthma, including patients requiring intubation and mechanical ventilation. For the situation when outpatient asthma management has failed, an approach to the critically ill pregnant patient with status asthmaticus is detailed. Multidisciplinary teams that include pulmonary specialists, obstetricians, primary care providers, nurses, pharmacists, and asthma educators improve the care of pregnant women with asthma.

Over-the-counter medications: Risk and safety in pregnancy

Over-the-counter (OTC) medications are among the most commonly used products in pregnancy. Similar to prescription medications, for many products there is a lack of adequate data on safety of use in pregnancy. Assumptions of safety for these products based on long experience and OTC status, in the absence of data, may be ill founded. Examples of four OTC products used to treat common conditions in pregnancy are described. Potential links to adverse short- and long-term infant outcomes for these products are reviewed, and the strengths and limitations of data to support these. Research to detect or rule out these risks is essential.

A descriptive study to provide evidence of the teratogenic and cellular effects of sibutramine and ephedrine on cardiac- and liver-tissue of chick embryos

Exposure to drugs during pregnancy is a major concern, as some teratogenic compounds can influence normal foetal development. Although the use of drugs during pregnancy should generally be avoided, exposure of the developing foetus to teratogens may occur unknowingly since these compounds may be hidden in products that are being marketed as "all natural." The aim of the current study was to investigate the possible teratogenic and cellular effects of sibutramine-a serotonin-norepinephrine reuptake inhibitor used in the treatment of obesity-on the heart and liver tissue of chick embryos. Ephedrine was used as a positive control. The chick embryo model was chosen because it has been used in studying developmental and experimental biology and teratology with great success. The embryos were exposed to three different concentrations of sibutramine and ephedrine respectively. The results obtained revealed that both compounds exhibited embryotoxicity when compared to the control groups. Liver and heart tissue of the exposed embryos was severely affected by these compounds in a dose-related manner. Morphology similar to that of muscle dystrophy was observed in the heart, where the muscle tissue was infiltrated by adipose and connective tissue. Severe liver steatosis was also noted. A more in-depth investigation into the molecular pathways involved might provide more information on the exact mechanism of toxicity of these products influencing embryonic development.

Medication use in pregnancy in relation to the risk of isolated clubfoot in offspring

Clubfoot, a common major structural malformation, develops early in gestation. Epidemiologic studies have identified higher risks among boys, first-born children, and babies with a family history of clubfoot, but studies of risks associated with maternal exposures are lacking. We conducted the first large-scale, population-based, case-control study of clubfoot with detailed information on maternal medication use in pregnancy. Study subjects were ascertained from birth defect registries in Massachusetts, New York, and North Carolina during 2007-2011. Cases were 646 mothers of children with clubfoot without other major structural malformations (i.e., isolated clubfoot); controls were mothers of 2,037 children born without major malformations. Mothers were interviewed within 12 months of delivery about medication use, including product, timing, and frequency. Odds ratios were estimated for exposure to 27 medications in pregnancy months 2-4 after adjustment for study site, infant sex, first-born status, body mass index (weight (kg)/height (m)(2)), and smoking. Odds ratios were less than 1.20 for 14 of the medications; of the remainder, most odds ratios were only slightly elevated (range, 1.21-1.66), with wide confidence intervals. The use of antiviral drugs was more common in clubfoot cases than in controls (odds ratio = 4.22, 95% confidence interval: 1.52, 11.73). Most of these results are new findings and require confirmation in other studies.

[Medication therapy during pregnancy]

Approximately 85% of pregnant women receive at least one medical prescription during their gestation. One percent of major congenital malformations of the fetus are attributed to embryotoxic medication. Because ENT surgeons and pregnant women are often uncertain about proper medication, treatment of specific ENT problems is often provided by the obstetrician. Based on the current knowledge, PubMed research, and recommendations of the Red List (Rote Liste) of the German Pharmaceutical Industry and the FDA, medical treatment of ENT-specific diseases is discussed.

Nitrosatable drug exposure during the first trimester of pregnancy and selected congenital malformations

BACKGROUND

Nitrosatable drugs can react with nitrite in the stomach to form N-nitroso compounds, and results from animal studies suggest that N-nitroso compounds are teratogens. With data from the National Birth Defects Prevention Study, the relation between prenatal exposure to nitrosatable drugs and limb deficiencies, oral cleft, and heart malformations in offspring was examined.

METHODS

Maternal reports of drugs taken during the first trimester of pregnancy were classified with respect to nitrosatability for mothers of 741 babies with limb deficiencies, 2774 with oral cleft malformations, 8091 with congenital heart malformations, and 6807 without major congenital malformations. Nitrite intake was estimated from maternal responses to a food frequency questionnaire.

RESULTS

Isolated transverse limb deficiencies and atrioventricular septal defects were associated with secondary amine drug exposures (adjusted odds ratios [aORs], 1.51; 95% confidence limit [CI], 1.11-2.06 and aOR, 1.97; 95% CI, 1.19-3.26, respectively). Tertiary amines were associated with hypoplastic left heart syndrome (aOR, 1.50; 95% CI, 1.10-2.04) and single ventricle (aOR, 1.61; 95% CI, 1.06-2.45). These two malformations were also significantly associated with amide drugs. For several malformations, the strongest associations with nitrosatable drug use occurred among mothers with the highest estimated dietary nitrite intake, especially for secondary amines and atrioventricular septal defects (highest tertile of nitrite, aOR, 3.30; 95% CI, 1.44-7.58).

CONCLUSION

Prenatal exposure to nitrosatable drugs may be associated with several congenital malformations, especially with higher nitrite intake. The possible interaction between nitrosatable drugs and dietary nitrite on risk of congenital malformations warrants further attention.

Over-the-counter medications and pregnancy: an integrative review

Many over-the-counter medications are available to help alleviate common discomforts experienced during pregnancy. Although many appear to be safe, healthcare providers must familiarize themselves with these medications.

A prospective cohort study of pregnancy outcomes of women inadvertently exposed to methylephedrine in the 1st trimester of pregnancy

No information is currently available on the safety of methylephedrine, a component of various cold medications available in South Korea. With previous approval by an Institutional Review Board, 349 women inadvertently exposed to methylephedrine during the 1st trimester of pregnancy and an age- and gravidity-matched control group, were enrolled in a prospective cohort study. Study outcomes, for example gestational age at birth, birth weight and major and minor malformations were evaluated in 282 cases and 280 controls. Exposure to methylephedrine was at a gestational age of 4.0 weeks (median), at doses ranging from 52.5 to 1,575 mg/day, for a median duration of 3 (range: 1-30) days. No differences were observed between cases and controls in any of the pregnancy outcomes studied. There were 4/265 (1.5%) babies born with major malformations in the case group and 4/260 (1.5%) in the control group. In conclusion, inadvertent exposure to methylephedrine as a component of over-the counter oral cold remedies in early pregnancy was not associated with an increased rate of adverse pregnancy outcomes. Co-exposure with acetaminophen, cigarette smoking or alcohol did not appear to modify the outcomes.

Gastroschisis: an update

Gastroschisis (GS) continues to increase in frequency, with several studies now reported an incidence of between 4 and 5 per 10,000 live births. The main risk factor would seem to be young maternal age, and it is in this group that the greatest increase has occurred. Whilst various geographical regions confer a higher risk, the impact of several other putative risk factors, including smoking and illicit drug use, may be less important than when first identified in early epidemiological studies. Over 90% of cases of GS will now be diagnosed on antenatal ultrasound, but its value in determining the need for early delivery remains unclear. There would appear no clear evidence for either routine early delivery or elective caesarean section for infants with antenatally diagnosed GS. Delivery at a centre with paediatric surgical facilities reduces the risk of subsequent morbidity and should represent the standard of care. The relative roles of primary closure, staged closure and ward reduction, with or without general anaesthesia, appear less clear with considerable variation between centres in both the use of these techniques and subsequent surgical outcomes. Survival rates continue to improve, with rates well in excess of 90% now routine. The limited long-term developmental data available would suggest that normal or near-normal outcomes may be expected although there remains a need for further studies.

Fruit and vegetable intake and risk of upper respiratory tract infection in pregnant women

OBJECTIVE

The present study evaluated the association between fruit and vegetable intake and the incidence of upper respiratory tract infection (URTI) during pregnancy.

DESIGN

In a cohort of 1034 North American women, each subject was asked retrospectively about their fruit and vegetable intake during the six months before the pregnancy and their occurrences of URTI during the first half of pregnancy. Multivariable-adjusted hazard ratios (HR) were calculated with Cox proportional hazards models.

RESULTS

The adjusted HR of URTI for women in the highest quartile (median 8.54 servings/d) v. the lowest quartile (median 1.91 servings/d) of total fruit and vegetable intake was 0.74 (95 % CI 0.53, 1.05) for the 5-month follow-up period and 0.61 (95 % CI 0.39, 0.97) for the 3-month follow-up period, respectively. A dose-related reduction of URTI risk according to quartile of intake was found in the 3-month (P for trend = 0.03) but not the 5-month follow-up. No association was found between either fruit or vegetable intake alone in relation to the 5-month or the 3-month risk of URTI.

CONCLUSIONS

Women who consume more fruits and vegetables have a moderate reduction in risk of URTI during pregnancy, and this benefit appears to be derived from both fruits and vegetables instead of either alone.

Demographic and environmental risk factors for gastroschisis and omphalocele in the National Birth Defects Prevention Study

BACKGROUND

Primary prevention efforts for both gastroschisis and omphalocele are limited by the lack of known risk factors. Our objective was to investigate associations between potential maternal risk factors and gastroschisis and omphalocele within a large population-based sample of participants enrolled in the National Birth Defects Prevention Study (NBDPS).

METHODS

Demographic, health-related, and environmental exposure data from the NBDPS were collected from women with expected delivery dates between October 1997 and December 2003. Data were collected on 485 cases of gastroschisis, 168 cases of omphalocele, and 4967 controls.

RESULTS

Women who had offspring with gastroschisis were younger (adjusted odds ratio [AOR], 0.84; 95% confidence interval [CI], 0.81-0.86) and less likely to be black (AOR, 0.54; 95% CI, 0.34-0.85) than controls. They also were more likely to have smoked (AOR, 1.51; 95% CI, 1.12-2.03), taken ibuprofen (AOR, 1.61; 95% CI, 1.23-2.10), and consumed alcohol (AOR, 1.38; 95% CI, 1.06-1.79) than controls. Women who had offspring with omphaloceles were more likely to have consumed alcohol (AOR, 1.53; 95% CI, 1.04-2.25) and be heavy smokers (AOR, 4.26; 95% CI, 1.58-11.52) than controls.

CONCLUSIONS

Our results suggest a moderately increased risk of gastroschisis among women who used tobacco, alcohol, and ibuprofen during early pregnancy. A modestly elevated risk was observed for omphaloceles among women who used alcohol during the first trimester and among women who were heavy smokers.

Maternal vasoactive exposures, amniotic bands, and terminal transverse limb defects

BACKGROUND

Limb reduction deficiencies that are accompanied by amniotic bands (AB-Ls) and terminal transverse limb deficiencies (TLDs) have each been attributed to vascular disruption; for the former, however, it is not clear if amniotic bands are the primary cause of or are secondary to vascular disruption. If amniotic bands are secondary to vascular disruption, then a shared pathogenesis for each case group might be exhibited by similar risk factors.

METHODS

We evaluated maternal age, education, race/ethnicity, parity, pregnancy wantedness, and vasoactive exposures among 139 AB-L and 373 TLD cases, using interview data collected from mothers in 10 states by the National Birth Defects Prevention Study. Vasoactive exposures included maternal cigarette smoking and use of decongestants, nonsteroid anti-inflammatory drugs, and antihypertensive drugs in the periconceptional period.

RESULTS

Increased risk estimates were observed for Black mothers (OR 2.5; 95% CI: 1.5-4.1) and nulliparous mothers (2.1; 1.4-3.0) in relation to AB-L, while neither was associated with TLD. Hispanic women (1.4; 1.0-1.9) and those not wanting the pregnancy (1.5; 1.1-2.1) had increased risks of TLD, but not AB-L. Maternal cigarette smoking and aspirin use each increased the risk of AB-L, but not TLD; while decongestants and possibly antihypertensive medications increased the risk of TLD, but not AB-L.

CONCLUSIONS

The lack of consistent findings for the two case groups suggests that AB-L and TLD may be distinct entities. The inconsistencies also suggest that these vasoactive exposures may not be markers for vascular disruption or that vascular disruption may not play a major role in the pathogenesis of these two types of limb deficiencies.

Periconceptional use of weight loss products including ephedra and the association with birth defects

BACKGROUND

: Weight loss products are frequently used by reproductive-aged women and these products may be taken (inadvertently or intentionally) during pregnancy. This study assessed the association between periconceptional use of weight loss products and major structural birth defects.

METHODS

: Mothers of infants with birth defects (case infants) and a random sample of livebirths (control infants) born during the period 1998-2003 in 10 states participated in the National Birth Defects Prevention Study. Adjusted ORs (aORs) for the association between self-reported use of weight loss products and 23 categories of birth defects were calculated.

RESULTS

: Mothers of control infants (2.4%) and 2.6% of mothers of case infants reported periconceptional use of weight loss products; 1.2% of mothers of control infants and 1.3% of mothers of case infants reported using an ephedra-containing product. Use of any weight loss product was associated with anencephaly (aOR 2.6; 95% CI: 1.3-5.3), dextro-transposition of the great arteries (aOR 2.1; 95% CI: 1.1-4.3), and aortic stenosis (aOR 3.4; 95% CI: 1.5-7.9). Use of products containing ephedra showed an increased aOR with anencephaly (aOR 2.8; 95% CI: 1.0-7.3), while other weight loss products were associated with dextro-transposition of the great arteries (aOR 1.8; 95% CI: 1.2-2.7), and aortic stenosis (aOR 2.1; 95% CI: 1.3-3.5).

CONCLUSIONS

: These results suggest an association between periconceptional use of weight loss products and certain birth defects but the possible mechanism is not clear. This is the first finding of such an association and, because we examined a large number of exposure-outcome associations in a hypothesis-generating analysis, these results might have been due to chance.

Treating common problems of the nose and throat in pregnancy: what is safe?

Although all kinds of medications should be avoided during pregnancy, the majority of pregnant women receive at least one drug and 6% of them during the high-risk period of the first trimester. The aim of the present paper is to discuss the appropriate management of rhinologic and laryngeal conditions that may be encountered during pregnancy. A literature review from Medline and database sources was carried out. Related books and written guidelines were also included. Controlled clinical trials, prospective and retrospective studies, case-control studies, laboratory studies, clinical and systematic reviews, metanalyses, and case reports were analysed. The following drugs are considered relatively safe: beta-lactam antibiotics (with dose adjustment), macrolides (although the use of erythromycin and clarithromycin carries a certain risk), clindamycin, metronidazole (better avoided in the first trimester), amphotericin-B (especially in immunocompromised situations during the second and third trimester) and acyclovir. First-line antituberculous agents isoniazid, ethambutol, pyrazinamide, and ciprofloxacine in drug-resistant tuberculosis can be also used. Non-selective NSAIDs (until the 32nd week), nasal decongestants (with caution and up to 7 days), intranasal corticosteroids, with budesonide as the treatment of choice, second generation antihistamines (cetirizine in the third trimester, or loratadine in the second and third trimester), H2 receptor antagonists (except nizatidine) and proton pump inhibitors (except omeprazole) can be used to relieve patients from the related symptoms. In cases of emergencies, epinephrine, prednisone, prednisolone, methylprednisolone, dimetindene and nebulised b(2) agonists can be used with extreme caution. By contrast, selective COX-2 inhibitors and BCG vaccination are contraindicated in pregnancy. When prescribing to a pregnant woman, the safety of the materno-foetal unit is considered paramount. Although medications are potentially hazardous, misconceptions and suboptimal treatment of the mother might be more harmful to the unborn child. Knowledge update is necessary to avoid unjustified hesitations and provide appropriate counselling and treatment for pregnant women.

Treating common ear problems in pregnancy: what is safe?

In everyday practise, more than 80% of pregnant women receive one at least medication, often for ENT causes. The aim of the present paper is to review the literature on safety and administration of medical treatment for ear diseases, in pregnant women. The literature review includes Medline and database sources. Electronic links, related books and written guidelines were also included. The study selection was as follows: controlled clinical trials, prospective trials, case-control studies, laboratory studies, clinical reviews, systematic reviews, metanalyses, and case reports. The following drugs are considered relatively safe: beta-lactam antibiotics (with dose adjustment), macrolides (although the use of erythromycin and clarithromycin carries a certain risk), and acyclovir. Non-selective NSAIDs (until the 32nd week), nasal decongestants (with caution and up to 7 days), intranasal corticosteroids, with budesonide as the treatment of choice, first generation antihistamines, or cetirizine (third trimester) and loratadine (second and third trimester) from the second generation, H2 receptor antagonists (except nizatidine) and proton pump inhibitors (except omeprazole), can be used to relieve patients from the related symptoms. Meclizine and dimenhydrinate, as antiemetics in vertigo attacks; metoclopramide, vitamin B6 and ginger rhizome, alternatively. Low-dose diazepam and diuretics in severe cases of Meniere's disease (with caution). Systemic administration of prednisone and prednisolone can be considered in selected cases. By contrast, selective COX-2 inhibitors, betahistine and vasodilating agents are contraindicated in pregnancy. Since otologic and neurotologic manifestations during pregnancy tend to seriously affect the quality of life of the expectant mothers, ENT surgeons should familiarise themselves with the basic guidelines and safety precautions for any related medication, in order to provide appropriate treatment.