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Liao MZ, Flood Nichols SK, Ahmed M, Clark S, Hankins GD, Caritis S, Venkataramanan R, Haas D, Quinney SK, Haneline LS, Tita AT, Manuck T, Wang J, Thummel KE, Brown LM, Ren Z, Easterling TR, Hebert MF. Effects of Pregnancy on the Pharmacokinetics of Metformin. Drug Metab Dispos 2020; 48:264-271. [PMID: 31980499 PMCID: PMC7076518 DOI: 10.1124/dmd.119.088435] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 12/30/2019] [Indexed: 12/22/2022] Open
Abstract
This study's primary objective was to fully characterize the pharmacokinetics of metformin in pregnant women with gestational diabetes mellitus (GDM) versus nonpregnant controls. Steady-state oral metformin pharmacokinetics in pregnant women with GDM receiving either metformin monotherapy (n = 24) or a combination with glyburide (n = 30) as well as in nonpregnant women with type 2 diabetes mellitus (T2DM) (n = 24) were determined utilizing noncompartmental techniques. Maternal and umbilical cord blood samples were collected at delivery from 38 women. With both 500- and 1000-mg doses, metformin bioavailability, volume of distribution beta (V β ), clearance, and renal clearance were significantly increased during pregnancy. In addition, in the women receiving metformin 500 mg, significantly higher metformin apparent oral clearance (CL/F) (27%), weight-adjusted renal secretion clearance (64%), and apparent oral volume of distribution beta (V β /F) (33%) were seen during pregnancy. Creatinine clearance was significantly higher during pregnancy. Increasing metformin dose from 500 to 1000 mg orally twice daily significantly increased V β /F by 28%, weight-adjusted V β /F by 32% and CL/F by 25%, and weight-adjusted CL/F by 28% during pregnancy. Mean metformin umbilical cord arterial-to-venous plasma concentration ratio was 1.0 ± 0.1, venous umbilical cord-to-maternal concentration ratio was 1.4 ± 0.5, and arterial umbilical cord-to-maternal concentration ratio was 1.5 ± 0.5. Systemic exposure after a 500-mg dose of metformin was lower during pregnancy compared with the nonpregnant women with T2DM. However, in patients receiving metformin 1000 mg, changes in estimated bioavailability during pregnancy offset the changes in clearance leading to no significant change in CL/F with the higher dose. SIGNIFICANCE STATEMENT: Gestational diabetes mellitus complicates 5%-13% of pregnancies and is often treated with metformin. Pregnant women undergo physiological changes that alter drug disposition. Preliminary data suggest that pregnancy lowers metformin concentrations, potentially affecting efficacy and safety. This study definitively describes pregnancy's effects on metformin pharmacokinetics and expands the mechanistic understanding of pharmacokinetic changes across the dosage range. Here we report the nonlinearity of metformin pharmacokinetics and the increase in bioavailability, clearance, renal clearance, and volume of distribution during pregnancy.
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Affiliation(s)
- Michael Z Liao
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Shannon K Flood Nichols
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Mahmoud Ahmed
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Shannon Clark
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Gary D Hankins
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Steve Caritis
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Raman Venkataramanan
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - David Haas
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Sara K Quinney
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Laura S Haneline
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Alan T Tita
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Tracy Manuck
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Joanne Wang
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Kenneth E Thummel
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Linda Morris Brown
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Zhaoxia Ren
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Thomas R Easterling
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
| | - Mary F Hebert
- University of Washington, Departments of Pharmaceutics (M.Z.L., J.W., K.E.T.), Obstetrics and Gynecology (T.R.E., M.F.H.), and Pharmacy (T.R.E., M.F.H.), Seattle, Washington; Madigan Army Medical Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tacoma, Washington (S.K.F.N.); University of Texas Medical Branch in Galveston, Department of Obstetrics and Gynecology, Galveston, Texas (M.A., S.Cl., G.D.H.); University of Pittsburgh, Departments of Obstetrics and Gynecology (S.Ca.), Pharmacy and Pharmaceutical Sciences (R.V.), Pittsburgh, Pennsylvania; Indiana University, Departments of Obstetrics and Gynecology (D.H., S.K.Q.) and Pediatrics (L.S.H.), Indianapolis, Indiana; University of Alabama at Birmingham, Department of Obstetrics and Gynecology, Birmingham, Alabama (A.T.T.); University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina (T.M.); Biostatistics and Epidemiology Division, Environmental and Health Science Unit, RTI International, Rockville, Maryland (L.M.B.); and Obstetric and Pediatric Pharmacology and Therapeutic Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland (Z.R.)
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