National patterns of medication use during pregnancy

The risk tolerance and decision-making processes of Australian women regarding medication trials in pregnancy

BACKGROUND

Pregnant women have historically been excluded from participation in medication trials, in part due to the perceived risks of drug exposure to mothers and fetuses. However, little is known about pregnant women's attitudes toward risk and participation in such trials.

AIMS

To address this knowledge gap and to identify factors that influence trial participation.

MATERIALS AND METHODS

Australian women over the age of 18, currently pregnant or within six months of delivery, were recruited to participate in an online survey (n = 623) and follow-up interviews (n = 11). The survey investigated willingness to participate in five hypothetical drug trial scenarios of varying risk. Demographic and obstetric information, including COVID-19 vaccination status, was also collected. The impact of these factors on trial participation was analysed using ordinal regression. Interviews were subjected to thematic framework analysis using a priori and emergent themes.

RESULTS

Nearly half of the respondents (48%) indicated a willingness to participate in at least one of the hypothetical trials. As trial risk increased participation likelihood decreased, especially if the risk was to the fetus, regardless of benefits to the mother. COVID-19 vaccination status and medication hesitancy were predictors of an unwillingness to participate. Three broad themes emerged from the qualitative data: risk-benefit analysis, quality of evidence, and trust.

CONCLUSIONS

Overall, participants expressed a positive attitude toward research and medication trials during pregnancy, but were concerned about fetal risk. The findings of this study may help enhance trial design and the participation of pregnant women in medication trials.

Use of non-steroidal anti-inflammatory drugs in pregnancy and oligohydramnios: a review

OBJECTIVE

The aim of this review is to evaluate the relationship between the use of non-steroidal anti-inflammatory drugs (NSAIDs) during last trimesters of the pregnancy and the reduction of amniotic fluid.

METHODS

Electronic databases were searched (PubMed, Medline, and Scopus). Selection criteria included studies reporting the relationship between oligohydramnios and use of NSAID during pregnancy. We analyzed the median age of women, weeks of pregnancy at the beginning of the drug administration, kind of medication, period of exposure and dosage, deepest vertical pocket (DVP), and amniotic fluid index (AFI).

RESULTS

Of the 68 records identified, we analyzed 29 studies investigating the administration of NSAIDs, including 11 studies examined the administration of the Indomethacin, four articles have focused on the use of Nimesulide, and only two manuscripts considered the use of Diclofenac. We found a strict correlation between the development of oligohydramnios and the use of NSAIDs. The oligohydramnios is reversible, and the normal amount of amniotic fluid is restored after the interruption of the treatment.

CONCLUSIONS

The use of NSAIDs should be considered when maternal benefits outweigh the potential fetal risk, at the lowest effective dose for shortest duration. Beyond 48 h of NSAIDs treatment, we consider ultrasound monitoring of amniotic fluid, and we suggest stopping therapy if a decline AFI is present.

Prevalence of polypharmacy in pregnancy: a systematic review

OBJECTIVES

The use of medications among pregnant women has been rising over the past few decades but the reporting of polypharmacy has been sporadic. The objective of this review is to identify literature reporting the prevalence of polypharmacy among pregnant women, the prevalence of multimorbidity in women taking multiple medications in pregnancy and associated effects on maternal and offspring outcomes.

DESIGN

MEDLINE and Embase were searched from their inception to 14 September 2021 for interventional trials, observational studies and systematic reviews reporting on the prevalence of polypharmacy or the use of multiple medications in pregnancy were included.Data on prevalence of polypharmacy, prevalence of multimorbidity, combinations of medications and pregnancy and offspring outcomes were extracted. A descriptive analysis was performed.

RESULTS

Fourteen studies met the review criteria. The prevalence of women being prescribed two or more medications during pregnancy ranged from 4.9% (4.3%-5.5%) to 62.4% (61.3%-63.5%), with a median of 22.5%. For the first trimester, prevalence ranged from 4.9% (4.7%-5.14%) to 33.7% (32.2%-35.1%). No study reported on the prevalence of multimorbidity, or associated pregnancy outcomes in women exposed to polypharmacy.

CONCLUSION

There is a significant burden of polypharmacy among pregnant women. There is a need for evidence on the combinations of medications prescribed in pregnancy, how this specifically affects women with multiple long-term conditions and the associated benefits and harms.

TWEETABLE ABSTRACT

Our systematic review shows significant burden of polypharmacy in pregnancy but outcomes for women and offspring are unknown.

PROSPERO REGISTRATION NUMBER

CRD42021223966.

Long noncoding RNA UCA1 promotes the expression and function of P-glycoprotein by sponging miR-16-5p in human placental BeWo cells

Investigations on placental P-glycoprotein (P-gp) regulation could provide more therapeutic targets for individualized and safe pharmacotherapy during pregnancy. The role of long noncoding RNA (lncRNA) on placental P-gp regulation is lacking. The present study was carried out to investigate the regulation and underlying mechanisms of lncRNA urothelial carcinoma associated 1 (UCA1) on P-gp in Bewo cells. lncRNA UCA1 inhibition or overexpression could decrease or increase ABCB1 mRNA expression, P-gp expression and its cellular efflux function, respectively. RNA-FISH revealed that lncRNA UCA1 was mainly located in the cytoplasm of Bewo cells. MicroRNA array was applied and 10 significant miRNAs was identified after lncRNA UCA1 inhibition. Databases of LncTarD, LncRNA2Target, and miRcode were further used to search potential target miRNAs of lncRNA UCA1 and miR-16-5p was screened out. Thereafter, we confirmed that miR-16-5p expression was significantly upregulated or reduced after lncRNA UCA1 knockdown or overexpression, respectively. Furthermore, we also proved that ABCB1 mRNA expression, P-gp expression and its cellular efflux function was enhanced or reduced after miR-16-5p inhibition or overexpression, respectively. The rescue experiment further indicated that miR-16-5p was involved in the positive regulation of lncRNA UCA1 on the expression and function of P-gp. Lastly, dual-luciferase reporter system, RNA-binding protein immunoprecipitation and RNA pull-down assays were performed to explore the relationships among lncRNA UCA1, miR-16-5p, and ABCB1. It was found that lncRNA UCA1(1103-1125) could directly interact with miR-16-5p and miR-16-5p could directly target ABCB1 coding DNA sequence region (882-907). In conclusion, LncRNA UCA1 could promote the expression and function of P-gp by sponging miR-16-5p in BeWo cells.

Nanotechnologies in Obstetrics and Cancer during Pregnancy: A Narrative Review

Nanotechnology, the art of engineering structures on a molecular level, offers the opportunity to implement new strategies for the diagnosis and management of pregnancy-related disorders. This review aims to summarize the current state of nanotechnology in obstetrics and cancer in pregnancy, focusing on existing and potential applications, and provides insights on safety and future directions. A systematic and comprehensive literature assessment was performed, querying the following databases: PubMed/Medline, Scopus, and Endbase. The databases were searched from their inception to 22 March 2022. Five independent reviewers screened the items and extracted those which were more pertinent within the scope of this review. Although nanotechnology has been on the bench for many years, most of the studies in obstetrics are preclinical. Ongoing research spans from the development of diagnostic tools, including optimized strategies to selectively confine contrast agents in the maternal bloodstream and approaches to improve diagnostics tests to be used in obstetrics, to the synthesis of innovative delivery nanosystems for therapeutic interventions. Using nanotechnology to achieve spatial and temporal control over the delivery of therapeutic agents (e.g., commonly used drugs, more recently defined formulations, or gene therapy-based approaches) offers significant advantages, including the possibility to target specific cells/tissues of interest (e.g., the maternal bloodstream, uterus wall, or fetal compartment). This characteristic of nanotechnology-driven therapy reduces side effects and the amount of therapeutic agent used. However, nanotoxicology appears to be a significant obstacle to adopting these technologies in clinical therapeutic praxis. Further research is needed in order to improve these techniques, as they have tremendous potential to improve the accuracy of the tests applied in clinical praxis. This review showed the increasing interest in nanotechnology applications in obstetrics disorders and pregnancy-related pathologies to improve the diagnostic algorithms, monitor pregnancy-related diseases, and implement new treatment strategies.

Racial/Ethnic Differences in Prenatal Supplement and Medication Use in Low-Risk Pregnant Women

OBJECTIVE

This study aimed to describe the overall quantity and type of supplements and medications used during pregnancy in a low-risk cohort and to examine any racial/ethnic differences in intake.

STUDY DESIGN

We used data from 2,164 racially/ethnically diverse, nonobese, and low-risk pregnant women participating without pre-pregnancy chronic conditions in a prospective cohort study at 12 sites across the United States. Medication data were self-reported as free text in enrollment, follow-up visit questionnaires, and abstracted from medical records at delivery. Supplements and medications data were mapped to their active ingredients and categorized into corresponding classes using the Slone Drug Dictionary. The total number and classes of supplements and medications consumed during pregnancy were calculated. Modified Poisson regression models were used to estimate the racial/ethnic differences in supplements and medications intake. All models were adjusted for maternal sociodemographic factors and study site.

RESULTS

98% of women took at least one supplement during pregnancy, with prenatal vitamins/multivitamins being most common. While only 31% reported taking no medications during pregnancy, 23% took one, 18% took two, and 28% took three or more. The percentage of women taking at least one medication during pregnancy was highest among non-Hispanic white women and lowest among Asians (84 vs. 55%, p < 0.001). All racial/ethnic groups reported taking the same top four medication classes including central nervous system agents, gastrointestinal drugs, anti-infective agents, and antihistamines. Compared with non-Hispanic white women, Hispanic (adjusted relative risk [aRR]: 0.84, 95% confidence interval [CI]: 0.71-0.98), and Asian women (aRR: 0.83, 95% CI: 0.70-0.98) were less likely to take central nervous system agents, as well as gastrointestinal drugs (Hispanics aRR: 0.79, 95% CI: 0.66-0.94; Asians aRR = 0.75, 95% CI: 0.63-0.90), and antihistamines (Hispanics aRR: 0.65, 95% CI: 0.47-0.92).

CONCLUSION

Supplement intake was nearly universal. Medication use was also common among this low-risk pregnancy cohort and differed by race/ethnicity.

CLINICALTRIALS

GOV IDENTIFIER

NCT00912132.

KEY POINTS

· In women without chronic conditions, medication use is common.. · Racial/ethnic differences exist in prenatal medications use.. · Almost all women use supplements during pregnancy..

Dispensing of Potentially Harmful Prescription Drugs in 1.8 Million Pregnant Women in France: A Nationwide Study Based on Two Risk Classification Systems

Introduction

Nationwide prevalence of potentially harmful drug prescribing during pregnancy is unknown in France, and several risk classification systems (RCS) exist to guide prescribers.

Objective

The aim of this study was to estimate the nationwide prevalence of potentially harmful drug prescribing during pregnancy in France and to describe maternal characteristics associated with this prescription.

Methods

This drug utilisation study, conducted on the French health databases (67 million beneficiaries), included all pregnancies beginning in 2016–2017, regardless of pregnancy outcome. Potentially harmful drug prescribing was defined as at least one reimbursement during pregnancy of Swedish RCS category D drugs, Australian RCS category D/X drugs, or contraindicated drugs in France for drugs not listed in these two RCSs. Maternal characteristics associated with potentially harmful drug prescribing were described using a univariate logistic regression analysis.

Results

Among the 1,844,447 pregnant women identified, the prevalence of potentially harmful drug prescribing was higher according to the Australian RCS (3.9%) than according to the Swedish RCS (2.2%), with good agreement between the two RCSs (Kappa = 0.81 [0.74–0.87]). This prevalence increased to 9.2% and 6.9%, respectively, when considering contraindications in France. Prescribing of teratogenic drugs, including retinoids and valproate, was highest during the first trimester, whereas prescribing of foetotoxic drugs decreased after the first trimester but remained high for nonsteroidal anti-inflammatory drugs (N = 10,021). In women with no chronic diseases, polymedication (five or more drugs) was the strongest maternal characteristic associated with potentially harmful drug prescribing in both RCSs.

Conclusions

Potentially harmful drug prescribing during pregnancy is not uncommon in France. This study supports the comparative analysis of RCS to assess potentially harmful drug prescribing in claims databases.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40264-021-01117-4.

Herbal Medicinal Product Use During Pregnancy and the Postnatal Period: A Systematic Review

Synthesis of pooled data on herbal medicinal products used during and after pregnancy highlights the need for robust safety studies.

OBJECTIVE:

To report the incidence and nature of herbal medicinal products' adverse events and herb–drug interactions used by some pregnant and postnatal women.

DATA SOURCES:

The Allied and Complementary Medicine Database, the Cumulative Index to Nursing and Allied Health Literature, EMBASE, the Cochrane Library, MEDLINE, Scopus, Web of Science, and ClinicalTrials.gov were searched from inception until August 2018.

METHODS OF STUDY SELECTION:

Any studies reporting adverse events, herb–drug interactions or absence thereof associated with herbal medicinal products used during pregnancy or the postnatal period were included. Conference abstracts, pilot studies, and nonhuman studies were excluded. All included studies were critically appraised by two independent reviewers.

TABULATION, INTEGRATION AND RESULTS:

Database searches retrieved 3,487 citations. After duplicate removal and review of titles, abstracts, and full-text, 115 articles were critically appraised. After excluding irrelevant and low-quality articles, 74 articles were included for data extraction and synthesis. Adverse drug reactions, congenital malformations, fetal growth retardation or herb–drug interactions were the primary study objective reported by 19 of the 74 included studies, 16 cohort studies, one cross-sectional survey, and two randomized controlled trials. A total of 47 herbal medicinal products and 1,067,071 women were included in this review. Use of almond oil was associated with preterm birth (odds ratio 2.09, 95% CI 1.07–4.08), oral raspberry leaf was associated with cesarean delivery (adjusted odds ratio [AOR] 3.47, 95% CI 1.45–8.28); heavy licorice use was associated with early preterm birth by 3.07-fold (95% CI 1.17–8.05). African herbal medicine mwanaphepo was associated with maternal morbidity (AOR 1.28; 95% CI 1.09–1.50), and neonatal death or morbidity. Fourteen studies reported absence of adverse events. Four studies reported herb–drug interactions, but none studied adverse events arising from them.

CONCLUSION:

The use of herbal medicinal products during pregnancy and the postnatal period should be discouraged until robust evidence of safety is available.

SYSTEMATIC REVIEW REGISTRATION:

PROSPERO, CRD42017081058.

Medication Use During Pregnancy in Mainland China: A Cross-Sectional Analysis of a National Health Insurance Database

Purpose

This study aims to illustrate the prevalence and patterns of medication use among pregnant women in mainland China.

Patients and methods

Hospital and drugstore service data for a nationally representative sample of basic medical insurance (BMI) beneficiaries in 2015 were obtained from the China Health Insurance Association (CHIRA) database. A total of 7946 women who had singleton deliveries in 2015, aged between 12 and 54, and whose records in the CHIRA database covered at least one trimester were included in this study. We conducted descriptive analyses of sample characteristics, medication use prevalence, and number and types of medications used.

Results

We found that 11.7% of women used at least one medication during the course of pregnancy (median number of medications used = 6.7). Medication use was more common among those who were older, residing in Eastern China, or employed. Most commonly used medication groups by the Anatomical Therapeutic Chemical Classification System were B (Blood and blood forming organs, 49.3%), A (Alimentary tract and metabolism, 48.1%), G (Genito urinary system and sex hormones, 38.1%) and J (Antiinfectives for systemic use, 31.6%). Intravenous solutions, vitamins and minerals, progestogens, and beta-lactam antibacterials were the most frequently used medications from each of these four ATC groups, respectively. Moreover, 7.1% used at least one medication contraindicated in pregnancy.

Conclusion

This study showed that around one in 10 women used medication during pregnancy in mainland China and found possible cases of inappropriate or unsafe medication use.

Safety of medication use during pregnancy in mainland China: based on a national health insurance database in 2015

Background

Medication safety during pregnancy has drawn global attention, little of which has been reported about the Chinese population. This study aims to describe patterns and risks of medication use among pregnant women in mainland China with reference to the U.S. Food and Drug Administration (FDA) pregnancy risk category.

Methods

Hospital diagnostic and drug dispensing information of a national representative sample of basic medical insurance (BMI) beneficiaries was obtained from the China Health Insurance Association (CHIRA) database in 2015. Prevalence of use and number of medicines involved in each risk category were calculated. Most commonly used medicines from each risk category were illustrated. Factors associated with the use of category D/X medicines were evaluated through multiple logistic regression.

Results

Out of 11,373 women who had singleton deliveries in 2015, there were 2896 women with records covering their entire pregnancies, 5377, and 7946 women with records through the 2nd, and the 3rd trimester, respectively. It was found that 11.1% pregnant women used at least one medication and a total of 321 medications had been used during pregnancy. Most pregnant women used medicines which were classified FDA category C (66.2%), followed by category B (57.8%), category A (16.8%), category X (7.5%) and category D (5.0%). The most commonly used medicines from category D and X were anxiolytics and hormonal preparations respectively. Women who were from mid-western area (p = 0.045) or used four or more medications (p < 0.001) were more likely to use category D/X medicines.

Conclusions

This study revealed that about one in ten pregnant women used at least one medication during pregnancy in China and a significant number of them used FDA Category D or X medicines. The usage patterns identified in the present study indicate that sub-optimal medicine use might exist warranting further evaluation and intervention in future studies. More efforts are needed to uncover the safety concerns about medication use during pregnancy and improve current information system for clinical practice.

Prescription and Other Medication Use in Pregnancy

OBJECTIVE

To characterize prescription and other medication use in a geographically and ethnically diverse cohort of women in their first pregnancy.

METHODS

In a prospective, longitudinal cohort study of nulliparous women followed through pregnancy from the first trimester, medication use was chronicled longitudinally throughout pregnancy. Structured questions and aids were used to capture all medications taken as well as reasons they were taken. Total counts of all medications taken including number in each category and class were captured. Additionally, reasons the medications were taken were recorded. Trends in medications taken across pregnancy and in the first trimester were determined.

RESULTS

Of the 9,546 study participants, 9,272 (97.1%) women took at least one medication during pregnancy with 9,139 (95.7%) taking a medication in the first trimester. Polypharmacy, defined as taking at least five medications, occurred in 2,915 (30.5%) women. Excluding vitamins, supplements, and vaccines, 73.4% of women took a medication during pregnancy with 55.1% taking one in the first trimester. The categories of drugs taken in pregnancy and in the first trimester include the following: gastrointestinal or antiemetic agents (34.3%, 19.5%), antibiotics (25.5%, 12.6%), and analgesics (23.7%, 15.6%, which includes 3.6%; 1.4% taking an opioid pain medication).

CONCLUSION

In this geographically and ethnically diverse cohort of nulliparous pregnant women, medication use was nearly universal and polypharmacy was common.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT01322529.

Prescription medication use during pregnancies that resulted in births and abortions (2001-2013): A retrospective population-based study in a Canadian population

We aimed to describe medication use in pregnancies that resulted in births and abortions, as well as use after a pregnancy-related visit to characterize the receipt of medication after knowledge of pregnancy. Abortions included both spontaneous and induced abortions. Rates of medication use among women with a pregnancy outcome (2001–2013) were described using the Manitoba Population Research Data Repository at the Manitoba Centre for Health Policy. Use was determined as ≥ 1 prescription filled during pregnancies that resulted in births (livebirth/stillbirth) and abortions. Rates were calculated at any time during pregnancy and after a pregnancy-related visit. Rates were additionally characterized by risk in pregnancy using Briggs classification (2017). Of 174,848 birth pregnancies, overall 64.9% filled ≥ 1 prescription during pregnancy (a significant increase from 62.3% to 68.8% from 2001–2013, p<0.0001); 55.4% filled ≥ 1 prescription after a pregnancy-related visit. Of 71,967 abortions, 44.7% filled ≥ 1 prescription (a significant increase from 42.6% to 46.8% from 2001–2013, p<0.0001). Only 3.7% of birth pregnancies had at least one prescription for a contraindicated medication (according to Briggs classification), whereas 10.8% of abortions filled a prescription for a contraindicated medication. The most common drugs used in pregnancy were amoxicillin, doxylamine, codeine combinations, nitrofurantoin, cephalexin, salbutamol and ranitidine. Fewer women filled prescriptions for undesirable medications according to Briggs classification during pregnancy after a pregnancy-related visit.

Effect of Histone Deacetylase Inhibition on the Expression of Multidrug Resistance-associated Protein 2 in a Human Placental Trophoblast Cell Line

BACKGROUND

Placental multidrug resistance-associated protein 2 (MRP2), encoded by ABCC2 gene in human, plays a significant role in regulating drugs' transplacental transfer rates. Studies on placental MRP2 regulation could provide more therapeutic targets for individualized and safe pharmacotherapy during pregnancy. Currently, the roles of epigenetic mechanisms in regulating placental drug transporters are still unclear. This study aimed to investigate the effect of histone deacetylases (HDACs) inhibition on MRP2 expression in the placental trophoblast cell line and to explore whether HDAC1/2/3 are preliminarily involved in this process.

METHODS

The human choriocarcinoma-derived trophoblast cell line (Bewo cells) was treated with the HDAC inhibitors-trichostatin A (TSA) at different concentration gradients of 0.5, 1.0, 3.0, and 5.0 μmol/L. Cells were harvested after 24 and 48 h treatment. Small interfering RNA (siRNA) specific for HDAC1/HDAC2/HDAC3 or control siRNA was transfected into cells. Total HDAC activity was detected by colorimetric assay kits. HDAC1/2/3/ABCC2 messenger RNA (mRNA) and protein expressions were determined by real-time quantitative polymerase chain reaction and Western-blot analysis, respectively. Immunofluorescence for MRP2 protein expression was visualized and assessed using an immunofluorescence microscopy and ImageJ software, respectively.

RESULTS

TSA could inhibit total HDAC activity and HDAC1/2/3 expression in company with increase of MRP2 expression in Bewo cells. Reduction of HDAC1 protein level was noted after 24 h of TSA incubation at 1.0, 3.0, and 5.0 μmol/L (vs. vehicle group, all P < 0.001), accompanied with dose-dependent induction of MRP2 expression (P = 0.045 for 1.0 μmol/L, P = 0.001 for 3.0 μmol/L, and P < 0.001 for 5.0 μmol/L), whereas no significant differences in MRP2 expression were noted after HDAC2/3 silencing. Fluorescent micrograph images of MRP2 protein were expressed on the cell membrane. The fluorescent intensities of MRP2 in the control, HDAC2, and HDAC3 siRNA-transfected cells were week, and no significant differences were noticed among these three groups (all P > 0.05). However, MRP2 expression was remarkably elevated in HDAC1 siRNA-transfected cells, which displayed an almost 3.19-fold changes in comparison with the control siRNA-transfected cells (P < 0.001).

CONCLUSIONS

HDACs inhibition could up-regulate placental MRP2 expression in vitro, and HDAC1 was probably to be involved in this process.

Pregnancy, prescription medicines and the potential risk of herb-drug interactions: a cross-sectional survey

Background

Pregnant women are routinely prescribed medicines while self-medicating with herbal natural products to treat predominantly pregnancy related conditions. The aim of this study was to assess the potential for herb-drug interactions (HDIs) in pregnant women and to explore possible herb-drug interactions and their potential clinical significance.

Methods

A cross-sectional survey of women during early pregnancy or immediately postpartum in North-East Scotland. Outcome measures included; Prescription medicines use excluding vitamins and potential HDIs assessed using Natural Medicines Comprehensive Database.

Results

The survey was completed by 889 respondents (73% response rate). 45.3% (403) reported the use of at least one prescription medicine, excluding vitamins. Of those taking prescription medicines, 44.9% (181) also reported concurrent use of at least one HNP (Range 1–12). A total of 91 different prescription medicines were reported by respondents using HNPs. Of those taking prescription medicines, 44.9% (181) also reported concurrent use of at least one HNP (Range 1–12). Thirty-four herb-drug interactions were identified in 23 (12.7%) women with the potential to increase the risk of postpartum haemorrhage, alter maternal haemodynamics, and enhance maternal/fetal CNS depression.

Almost all were rated as moderate (93.9%), one as a potentially major (ginger and nifedipine) and only one minor (ondansetron and chamomile).

Conclusion

Almost half of pregnant women in this study were prescribed medicines excluding vitamins and minerals and almost half of these used HNPs. Potential moderate to severe HDIs were identified in an eighth of the study cohort. Healthcare professionals should be aware that the concurrent use of HNPs and prescription medicines during pregnancy is common and carries potential risks.

HDAC2 was involved in placental P-glycoprotein regulation both in vitro and vivo

INTRODUCTION

Placental P-glycoprotein (P-gp) plays a significant role in regulating drugs' transplacental transfer rates. Investigations on placental P-gp regulation could provide more therapeutic targets for individualized and safe pharmacotherapy during pregnancy. Currently, the epigenetic regulation of placental P-gp is rare. Our previous study has demonstrated that HDACs inhibition could up-regulate placental P-gp and HDAC1/2/3 might be involved in this process. The present study was carried out to further explore whether HDAC1/2/3 were indeed involved in the regulation of placental P-gp or not and screen out the subtype engaged in this process.

METHODS

BeWo and JAR cells were transfected with HDAC1/2/3 specific siRNA. After 48 h of transfection, cells were harvested for real-time quantitative PCR (qRT-PCR), Western blot, immunofluorescence and fluorescent dye efflux assay to evaluate P-gp expression, localization, and efflux activity, respectively. Hdac2 siRNA was intraperitoneally injected to pregnant mice every 48 h from E7.5 to E15.5 and digoxin was administered by gavages 1 h prior to euthanasia at E16.5. Placental Hdac1/2/3 and P-gp expression were determined by qRT-PCR and Western blot. Maternal plasma and fetal-unit digoxin concentrations were detected by enzyme-multiplied immunoassay.

RESULTS

In vitro, HDAC2 inhibition could significantly elevate P-gp expression and reduce intracellular accumulation of P-gp substrates (DiOC₂ (3) and Rh 123) both in BeWo and JAR, while knockdown of HDAC1/3 had no influence on P-gp expression and its efflux activity. Additionally, in vivo, Hdac2 silencing in pregnant mice also elevated placental P-gp expression and decreased digoxin transplacental transfer rate.

CONCLUSION

HDAC2 inhibition could result in induction of placental P-gp expression and functionality both in vitro and in vivo.

The effect of 17α-ethynylestradiol induced intrahepatic cholestasis of pregnancy on placental P-glycoprotein in mice: Implications in the individualized transplacental digoxin treatment for fetal heart failure

INTRODUCTION

Placental P-glycoprotein (P-gp) plays a significant role in controlling transplacental digoxin transfer rate. Investigations on P-gp regulation in placenta of women with different pregnant pathological states are of great significance to individualized transplacental digoxin treatment for fetal heart failure (FHF). This study aimed to explore the effect of 17α-ethynylestradiol induced intrahepatic cholestasis of pregnancy (ICP) on placental P-gp in mice.

METHODS

ICP model in mice was induced by subcutaneous injection of 17α-ethynylestradiol dissolved in propylene glycol once daily from E12.5 to E16.5. Maternal plasma ALT, AST, TB, DBIL, γ-GT, LDH, ALP and TBA concentrations were measured. HE staining was applied for observation of maternal liver cells degeneration, necrosis and intrahepatic cholestasis. Placental Abcb1a/Abcb1b/HIF-1α mRNA and P-gp/HIF-1α protein expression were determined by real-time quantitative PCR and western-blot. Maternal plasma and fetal-unit digoxin concentrations were detected by a commercial kit assay.

RESULTS

The ICP group showed higher levels of maternal plasma ALT, AST, TB, DBIL, γ-GT, LDH, ALP and TBA concentrations, reduction in fetal survival rates, lower placental and fetal weights, and typical liver cells degeneration, necrosis and intrahepatic cholestasis. The placental Abcb1a mRNA and P-gp expression of ICP group were significantly elevated, while transplacental digoxin transfer rates were significantly decreased. Both placental HIF-1α mRNA and protein expression was significantly elevated in the ICP group, and there was a positive correlation between Abcb1a mRNA and HIF-1α mRNA.

CONCLUSIONS

17α-ethynylestradiol induced ICP could up-regulate placental P-gp expression and reduce transplacental digoxin transfer rate in mice, which might be partly associated with higher expression of HIF-1α.

The pregnant women as a drug orphan: a global survey of registered clinical trials of pharmacological interventions in pregnancy

OBJECTIVE

To undertake a survey of the world's clinical trial registries to provide current data on the number, nature, funding source and geographical distribution of pregnancy drug trials (PDT).

DESIGN AND SETTING

Comprehensive analysis of WHO-certified clinical trial registries.

METHODS

Sixteen registries containing 301 538 trials (168 826 active in 2013-2014) were analysed to identify the numbers, location, funding sources, and areas of interest/development of PDTs.

RESULTS

The percentage of PDTs varied from 0 to 7.4% across registries. Overall, just 0.32% (534) of all active registered studies were PDTs. The US registry (Clinicaltrials.gov) was the largest database, but contributed just 14% of all active PDTs. The majority of PDTs focused on anaesthesia/analgesia, preterm birth/tocolysis, labour induction, endocrine and hypertensive disorders. Less than 6% of active PDTs focused on maternal or fetal health as a specific primary outcome, and only 4.4% included a preplanned pharmacokinetic analysis of the trial medications. A third of all active PDTs involved repurposing of existing medicines for applications in pregnancy, whereas only three new investigational drugs had been developed for a pregnancy indication. Seven percent of all active PDTs identified were pharmaceutical industry-funded. Inter-disease comparisons identified a ~50-fold disparity in trial activity between pregnancy and other comparable areas.

CONCLUSIONS

This study demonstrates unequivocally the marked under-representation of medication development, evaluation and safety trials in pregnancy. The likelihood that the current pharmaceutical landscape in pregnancy will improve in the foreseeable future is slim. Advocacy and increased awareness of the issue is necessary to achieve positive change.

TWEETABLE ABSTRACT

Pregnant women are significantly under-represented in global clinical drug trials.

Regulation of Multidrug Resistance P-Glycoprotein in the Developing Blood-Brain Barrier: Interplay between Glucocorticoids and Cytokines

P-glycoprotein (P-gp) encoded by Abcb1 provides protection to the developing brain from xenobiotics. P-gp in brain endothelial cells (BECs) derived from the developing brain microvasculature is up-regulated by glucocorticoids and inhibited by pro-inflammatory cytokines in vitro. However, little is known about how prenatal maternal glucocorticoid treatment can affect Abcb1/P-gp function and subsequent cytokine regulation in foetal BECs. We hypothesised that glucocorticoid exposure increases Abcb1/P-gp in the foetal brain microvasculature and enhances the sensitivity of Abcb1/P-gp in BECs to the inhibitory effects of cytokines. BECs isolated from dexamethasone- or vehicle-exposed foetal guinea pigs were cultured and treated with interleukin-1β, interleukin-6 or tumour necrosis factor-α, and Abcb1/P-gp expression and function were assessed. Prenatal dexamethasone exposure significantly increased Abcb1/P-gp expression/activity and cytokine receptor levels in BECs of the foetal brain microvasculature. Foetal dexamethasone exposure in vivo also increased the subsequent responsiveness of BECs to pro-inflammatory cytokines in vitro. In conclusion, maternal treatment with synthetic glucocorticoids appears to prematurely mature P-gp mediated drug resistance at the foetal BBB in vivo and profoundly impact the subsequent responsiveness of P-gp to pro-inflammatory cytokines in the foetal BEC. The significance of these findings to foetal brain protection against xenobiotics and other P-gp substrates in vivo requires further elaboration. However, the results of the present study may have implications for human pregnancy and foetal brain protection, particularly in cases of preterm birth combined with infection.

Trends in prescription of pregnancy-contraindicated drugs in Korea, 2007-2011

This study aims to evaluate changes in use of contraindicated drugs during pregnancy in Korea using the nationwide Health Insurance and Assessment Service (HIRA) database. Study drugs were 314 drugs that were announced as pregnancy-contraindicated on December 11, 2008. The study population consisted of the pregnant women who gave birth and were prescribed any of the drugs in 2007-2011 before giving birth. Pregnancy-contraindicated drug use was defined as the proportion of prescriptions among pregnant women that were for study drugs. The relative and absolute reductions in contraindicated drug use after the 2008 action were estimated with 95% confidence interval (CI) by medical institution type, region, and drug class. The predicted monthly contraindicated drug use was estimated by performing ordinary least-squares regression analysis of data before the action and compared with observed data after the action. Between 2007 and 2011, a total of 1,468,588 pregnant women received 1,796,208 prescriptions. Contraindicated drug use accounted for 15.96% of total prescriptions (N = 355,783) before the action but decreased to 11.52% (N = 453,832) afterward. Overall, the relative reduction was 27.77% (95% CI: 27.64%-27.90%) and greatest for hormones at 46.56% (95% CI: 46.21%-46.93%). The relative reduction was 55.43% (95% CI: 54.60%-55.43%) for all category X drugs, 17.09% (95% CI: 16.46%-17.75%) for category X drugs excluding hormones, and 0.14% (95% CI: 0.14%-0.15%) for category D drugs including hormones. A regulatory action toward pregnancy-contraindicated drugs led to moderate decrease in contraindicated drug use during pregnancy. Despite the decreases, contraindicated drugs were still widely prescribed to pregnant women, highlighting the need to develop strategies to assess and improve drug safety during pregnancy.

Determinants of prescribed drug use among pregnant women in Bahir Dar city administration, Northwest Ethiopia: a cross sectional study

Background

Drug use during pregnancy may be dangerous to the fetus. There is high consumption of prescribed drugs among pregnant women. This condition may be much higher in developing countries. There is no sufficient evidence on prescribed drug use among pregnant women in Bahir Dar town. The aim of this study was to assess the level of prescribed drug use and associated factors among pregnant women attending antenatal care (ANC) service at government health centers in Bahir Dar city administration.

Methods

Institution based cross sectional study was used. Data were collected from randomly selected 510 pregnant women. Data were analyzed using SPSS version 16.0. Back ward stepwise logistic regression model was used and p-values <0.05 were considered statistically significant.

Result

A total of 510 pregnant women were included in the study of which 88.4% were prescribed at least one drug during pregnancy. Nearly 11% of the pregnant women were prescribed with drugs from category D or X of the US-FDA risk classification.

Prescribed drug use among pregnant women was more likely when the pregnancy is wanted, (AOR = 2.4, 95% CI: 1.3 - 4.6), if the mother had maternal illness (AOR = 8.5, 95% CI: 5.4-13.4), when the educational level of ANC provider is diploma (AOR = 2.7, 95% CI: 1.5-4.7) and when number of pregnancies is more (AOR =2.1, 95% CI: 1.3-3.3).

Conclusion

Prescribed drug use including those with potential harm to the fetus during pregnancy was very high in Bahir Dar city administration. Prescribed drug use is more when the woman had illness, when the woman was multi gravida and when the educational level of ANC provider was low (diploma). It is important to upgrade providers’ educational level and institute prevention of diseases like malaria to reduce the level of prescribed drug use during pregnancy.

Early-life glucocorticoid exposure: the hypothalamic-pituitary-adrenal axis, placental function, and long-term disease risk

An adverse early-life environment is associated with long-term disease consequences. Adversity early in life is hypothesized to elicit developmental adaptations that serve to improve fetal and postnatal survival and prepare the organism for a particular range of postnatal environments. These processes, although adaptive in their nature, may later prove to be maladaptive or disadvantageous if the prenatal and postnatal environments are widely discrepant. The exposure of the fetus to elevated levels of either endogenous or synthetic glucocorticoids is one model of early-life adversity that contributes substantially to the propensity of developing disease. Moreover, early-life glucocorticoid exposure has direct clinical relevance because synthetic glucocorticoids are routinely used in the management of women at risk of early preterm birth. In this regard, reports of adverse events in human newborns have raised concerns about the safety of glucocorticoid treatment; synthetic glucocorticoids have detrimental effects on fetal growth and development, childhood cognition, and long-term behavioral outcomes. Experimental evidence supports a link between prenatal exposure to synthetic glucocorticoids and alterations in fetal development and changes in placental function, and many of these alterations appear to be permanent. Because the placenta is the conduit between the maternal and fetal environments, it is likely that placental function plays a key role in mediating effects of fetal glucocorticoid exposure on hypothalamic-pituitary-adrenal axis development and long-term disease risk. Here we review recent insights into how the placenta responds to changes in the intrauterine glucocorticoid environment and discuss possible mechanisms by which the placenta mediates fetal hypothalamic-pituitary-adrenal development, metabolism, cardiovascular function, and reproduction.

Pharmacology and pharmacogenomics of neurological medications used in pregnancy

Pregnancy increases the pharmacological management challenge of numerous neurological diseases as a result of complex physiological changes. Understanding pregnancy-induced changes in pharmacokinetic and pharmacodynamic parameters can lead to better outcomes for both the mother and baby. Although the application of pharmacogenomics in maternal-fetal medicine is in its infancy, further research and developments will provide important new developments for managing the efficacy of drug treatments during pregnancy and improving maternal-fetal safety. Although a wide variety of neurological medications are used during pregnancy, this article will focus on the drugs with currently known pharmacogenomic implications.

Characteristics and publication patterns of obstetric studies registered in ClinicalTrials.gov

Physiologic changes during pregnancy alter the pharmacokinetics, safety, and efficacy of many drugs. For clinicians, there is often uncertainty regarding the safety of these drugs due to a scarcity of published data. This study aimed to comprehensively evaluate the characteristics and publication patterns of obstetric studies registered in ClinicalTrials.gov from 2007 to 2012. Primary outcome measures, funding sources, inclusion criteria, and the reporting of study results were evaluated. A manual review of Medline/PubMed was performed to identify publications associated with studies registered in ClinicalTrials.gov. Of 93,709 total studies, there were 5,203 (6%) obstetric studies registered in ClinicalTrials.gov. Interventional studies accounted for 70% and 30% were observational. Clinical trials of drugs (49%), procedures (13%), and behavioral interventions (12%) were most common. Among interventional drug trials, 84% featured randomized allocation to study arms and 93% included measures of safety and/or efficacy as primary endpoints. Of 946 (18%) studies completed more than 2 years ago, only 11% had reported results and <7% had been published. In an area with a great need for evidence of safe and effective therapies, the low publication rate of completed studies incorporating elements of high-quality trial design is concerning. The sources of this trend should be closely investigated.

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.

A systematic review of the application of spatial analysis in pharmacoepidemiologic research

PURPOSE

Although current reviews of the use of spatial analysis in general epidemiologic research illustrate an important and well-established role in exploring and predicting health, its application has not been reviewed in the subspecialty field of pharmacoepidemiology.

METHODS

We systematically reviewed the scientific literature to assess to what extent spatial analysis has been applied in pharmacoepidemiologic research and explored its potential added value.

RESULTS

A systematic search in PubMed and Embase/MEDLINE yielded 823 potentially relevant articles; 45 articles met our criteria for review. The studies were reviewed on study objective, applied spatial methods and units of analysis, and author-reported added value of the geographic approach used. Of the 45 included studies, 34 (76%) reported a geographic research objective. Comparative spatial methods were most often used (n = 25; 56%). Eleven studies used spatial statistics (32%); cluster analysis (n = 5) and aggregate data analysis (n = 4) being most common. Mapping was done in 15 studies (33%). The most common added value reported was to aid the planning of health policies and interventions (n = 24; 53%). A minority of pharmacoepidemiologic studies used a geographic approach and the applied methods were less advanced compared with the broader field of epidemiology.

CONCLUSIONS

Further advancements are needed to incorporate currently available spatial techniques to impact health care planning.

Counseling of female veterans about risks of medication-induced birth defects

BACKGROUND

Medications that may increase risk of birth defects if used during pregnancy or immediately preconception are dispensed to approximately half of female Veterans who fill prescriptions at a VA pharmacy.

OBJECTIVE

To assess receipt of counseling about risk of medication-induced birth defects among female Veterans of reproductive age and to examine Veterans' confidence that their healthcare provider would counsel them about teratogenic risks.

DESIGN AND PARTICIPANTS

Cross-sectional analysis of data provided by 286 female Veterans of Operation Iraqi Freedom and/or Operation Enduring Freedom who completed a mailed survey between July 2008 and October 2010.

MAIN MEASURES

We examined associations between demographic, reproductive, and health service utilization variables and female Veterans' receipt of counseling and confidence that they would receive such counseling.

KEY RESULTS

The response rate was 11 %; the large majority (89 %) of responding female Veterans reported use of a prescription medication in the last 12 months. Most (90 %) of the 286 female Veterans who reported medication use were confident that they would be told by their healthcare provider if a medication might cause a birth defect. However, only 24 % of women who received prescription medications reported they had been warned of teratogenic risks. Female Veterans who used medications that are known to be teratogenic were not more likely than women using other medications to report having been warned about risks of medication-induced birth defects, and fewer were confident that their health care providers would provide teratogenic risk counseling when needed.

CONCLUSIONS

Female Veterans may not receive appropriate counseling when medications that can cause birth defects are prescribed.

Ethnic differences in drug utilization pattern during pregnancy: a cross-sectional study

OBJECTIVE

To investigate the differences in exposure to medications in a cohort of multi-ethnic pregnant women.

METHODS

Six hundred and forty-one pregnant women of Western, Arab/Turkish and "other origins" participated in this cross-sectional study using a questionnaire in a university hospital in Brussels, Belgium. Assessment of the drug safety was done using the food and drug administration (FDA) risk classification system. Data analysis was performed using SPSS (Chicago, IL).

RESULTS

In overall cohort, 83.8% used at least one preparation (including multivitamins) during pregnancy and 37.0% of women used at least one drug (excluding multivitamins). Significantly more Western women (43.7%) used one or more medications compared to Arab/Turkish women (28.7%; p = 0.000). This difference in exposure was most pronounced for over-the-counter (OTC) drugs for occasional and pregnancy-related complaints, and was observed for potentially unsafe drugs or drugs with unknown safety. None of the women reported use of FDA X category drugs.

CONCLUSIONS

The use of drugs known to be harmful was not observed, but a higher prevalence of exposure to potentially harmful drugs (FDA C/D) was found among Western women who also consumed more OTC drugs. This highlights the need for cautious prescribing for women in the fertile age in general and for continuous monitoring of medication use during pregnancy.

Predictors of the use of medications before and during pregnancy

BACKGROUND

Drug use in pregnancy is often reason of concern for mothers and their physicians. However, only few studies investigated predictors of drug use in pregnancy.

OBJECTIVES

To examine maternal characteristics as predictors of medication use in the 6 months before pregnancy and during the first 6 months of pregnancy. To examine whether prescription and over-the-counter (OTC) medication use in the 6 months before pregnancy had an impact on medication use in pregnancy.

SETTING

Six maternity care units and five community pharmacies.

METHOD

Data were collected using a specially designed self-reported questionnaire during the period March 2009-March 2010. Logistic regression was used to identify factors associated with medication use.

MAIN OUTCOME MEASURE

Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were used as association measures.

RESULTS

A total of 236 women were included in the analysis. After controlling for maternal characteristics, parity of more than one was associated with lower prescription medication use in pregnancy (aOR 0.46; 95% CI 0.22-0.93), higher household income with higher OTC medication use before pregnancy (aOR 3.13; 95% CI 1.22-8.00), and miscarriage with higher C and D Food and Drug Administration (FDA) risk category medication use in pregnancy (aOR 3.65; 95% CI 1.30-10.25). Prescription medication use before pregnancy was associated with higher prescription medication use in pregnancy (aOR 2.49; 95% CI 1.12-5.52), OTC medication use before pregnancy with higher OTC medication use in pregnancy (aOR 35.95; 95% CI 7.95-162.49), and C and D FDA risk category medication use before pregnancy with the same category medication use in pregnancy (aOR 3.54; 95% CI 1.23-10.17).

CONCLUSION

Different maternal characteristics were shown as predictors of medication use before and during pregnancy. However, medication use before pregnancy was shown as the most important predicting factor for the medication use in pregnancy.

Pharmacotherapy in pregnancy; effect of ABC and SLC transporters on drug transport across the placenta and fetal drug exposure

Pharmacotherapy during pregnancy is often inevitable for medical treatment of the mother, the fetus or both. The knowledge of drug transport across placenta is, therefore, an important topic to bear in mind when deciding treatment in pregnant women. Several drug transporters of the ABC and SLC families have been discovered in the placenta, such as P-glycoprotein, breast cancer resistance protein, or organic anion/cation transporters. It is thus evident that the passage of drugs across the placenta can no longer be predicted simply on the basis of their physical-chemical properties. Functional expression of placental drug transporters in the trophoblast and the possibility of drug-drug interactions must be considered to optimize pharmacotherapy during pregnancy. In this review we summarize current knowledge on the expression and function of ABC and SLC transporters in the trophoblast. Furthermore, we put this data into context with medical conditions that require maternal and/or fetal treatment during pregnancy, such as gestational diabetes, HIV infection, fetal arrhythmias and epilepsy. Proper understanding of the role of placental transporters should be of great interest not only to clinicians but also to pharmaceutical industry for future drug design and development to control the degree of fetal exposure.

Pro-inflammatory cytokine regulation of P-glycoprotein in the developing blood-brain barrier

Placental P-glycoprotein (P-gp) acts to protect the developing fetus from exogenous compounds. This protection declines with advancing gestation leaving the fetus and fetal brain vulnerable to these compounds and potential teratogens in maternal circulation. This vulnerability may be more pronounced in pregnancies complicated by infection, which is common during pregnancy. Pro-inflammatory cytokines (released during infection) have been shown to be potent inhibitors of P-gp, but nothing is known regarding their effects at the developing blood-brain barrier (BBB). We hypothesized that P-gp function and expression in endothelial cells of the developing BBB will be inhibited by pro-inflammatory cytokines. We have derived brain endothelial cell (BEC) cultures from various stages of development of the guinea pig: gestational day (GD) 50, 65 (term ∼68 days) and postnatal day (PND) 14. Once these cultures reached confluence, BECs were treated with various doses (10⁰–10⁴ pg/mL) of pro-inflammatory cytokines: interleukin-1β (IL-1β), interleukin-6 (IL-6) or tumor necrosis factor- α (TNF-α). P-gp function or abcb1 mRNA (encodes P-gp) expression was assessed following treatment. Incubation of GD50 BECs with IL-1β, IL-6 or TNF-α resulted in no change in P-gp function. GD65 BECs displayed a dose-dependent decrease in function with all cytokines tested; maximal effects at 42%, 65% and 34% with IL-1β, IL-6 and TNF-α treatment, respectively (P<0.01). Inhibition of P-gp function by IL-1β, IL-6 and TNF-α was even greater in PND14 BECs; maximal effects at 36% (P<0.01), 84% (P<0.05) and 55% (P<0.01), respectively. Cytokine-induced reductions in P-gp function were associated with decreased abcb1 mRNA expression. These data suggest that BBB P-gp function is increasingly responsive to the inhibitory effects of pro-inflammatory cytokines, with increasing developmental age. Thus, women who experience infection and take prescription medication during pregnancy may expose the developing fetal brain to greater amounts of exogenous compounds – many of which are considered potentially teratogenic.

Clinical decision support to promote safe prescribing to women of reproductive age: a cluster-randomized trial

BACKGROUND

Potentially teratogenic medications are frequently prescribed without provision of contraceptive counseling.

OBJECTIVE

To evaluate whether computerized clinical decision support (CDS) can increase primary care providers' (PCPs') provision of family planning services when prescribing potentially teratogenic medications.

DESIGN

Cluster-randomized trial conducted in one academic and one community-based practice between October of 2008 and April of 2010.

PARTICIPANTS/INTERVENTIONS

Forty-one PCPs were randomized to receive one of two types of CDS which alerted them to risks of medication-induced birth defects when ordering potentially teratogenic medications for women who may become pregnant. The 'simple' CDS provided a cautionary alert; the 'multifaceted' CDS provided tailored information and links to a structured order set designed to facilitate safe prescribing. Both CDS systems alerted PCPs about medication risk only once per encounter.

MAIN MEASURES

We assessed change in documented provision of family planning services using data from 35,110 encounters and mixed-effects models. PCPs completed surveys before and after the CDS systems were implemented, allowing assessment of change in PCP-reported counseling about the risks of medication-induced birth defects and contraception.

KEY RESULTS

Both CDS systems were associated with slight increases in provision of family planning services when potential teratogens were prescribed, without a significant difference in improvement by CDS complexity (p = 0.87). Because CDS was not repeated, 13% of the times that PCPs received CDS they substituted another potential teratogen. PCPs reported significant improvements in several counseling and prescribing practices. The multifaceted group reported a greater increase in the number of times per month they discussed the risks of medication use during pregnancy (multifaceted: +4.9 ± 7.0 vs. simple: +0.8 ± 3.2, p = 0.03). The simple CDS system was associated with greater clinician satisfaction.

CONCLUSIONS

CDS systems hold promise for increasing provision of family planning services when fertile women are prescribed potentially teratogenic medications, but further refinement of these systems is needed.

[Prescribed and unprescribed drug use among pregnant patients attended by the Unified Health System in Santa Rosa (State of Rio Grande do Sul, Brazil)]

In order to ascertain the use of prescribed and unprescribed drugs among pregnant patients of the Unified Health System (SUS), a descriptive study comprised of a sample of pregnant women was carried out in the city of Santa Rosa, State of Rio Grande do Sul, Brazil. Data were collected by means of structured interviews and consultation of patient records of pregnant women in the prenatal period. The prevalence of drug use was 90%, corresponding to an average of 4.1 drugs per pregnant woman, of which 83.6% were prescribed and 16.4% were self-medicated. Of this total, 17.5% of the drugs were included in fetal risk category C. The use of drugs during pregnancy is frequent and the majority of the pregnant women used one or more prescribed and unprescribed drugs during pregnancy. These data suggest the need for preventive measures to promote rational drug use during pregnancy.

How do we know if an exposure is actually teratogenic in humans?

The only way we can be certain that an exposure is teratogenic in humans is to recognize that it causes birth defects in babies. The goal of clinical teratology research is, therefore, to identify when a teratogenic exposure has harmed babies as quickly and effectively as possible. We use several kinds of human data to characterize teratogenic effects-case reports, case series, pregnancy registries, cohort studies, case-control studies, and record linkage studies. Each approach can be helpful, but each has limitations as well. Drawing a causal inference requires analysis of all available data, their consistency, and their biological plausibility.

Drug use in pregnancy: Knowledge of drug dispensers and pregnant women in Dar es Salaam, Tanzania

More than 90% of pregnant women take prescription or non-prescription drugs at some time during pregnancy. In general, unless absolutely necessary, drugs should not be used during pregnancy because many of them are harmful to the fetus. Appropriate dispensing is one of the steps for rational drug use; so, it is necessary that drug dispensers should have relevant and updated knowledge and skills regarding drug use in pregnancy. To assess the knowledge of drug dispensers and pregnant women regarding drug use in pregnancy, focusing on four commonly used drugs that are teratogenic or cause unwanted effects to the fetus and babies. The study was conducted in two parts: consumers′ perception and providers′ practice. It was a cross-sectional study involving visits to 200 private retail community pharmacies (as simulated client) within Temeke, Ilala and Kinondoni municipals in Dar es Salaam, Tanzania. The second part of the study was conducted at the antenatal clinics of the three municipal hospitals in Dar es Salaam. A semi-structured questionnaire was used to gather information from pregnant women. In total, 200 pregnant women were interviewed. Out of 200 drug dispensers, 86 (43%) were willing to dispense artemether-lumefantrine (regardless of the age of pregnancy), 56 (29%) were willing to dispense sodium valproate, 104 (52%) were willing to dispense captopril and 50 (25%) were willing to dispense tetracycline. One hundred and thirty-three (66.5%) pregnant women reported that they hesitated to take medications without consulting their physicians, 47 (23.5%) indicated that it was safe to take medications during pregnancy, while 123 (61.5%) mentioned that it was best to consult a doctor, while 30 (15%) did not have any preference. Sixty-three (31.5%) women reported that they were aware of certain drugs that are contraindicated during pregnancy. It is evident that most drug dispensers have low knowledge regarding the harmful effects of drugs during pregnancy. Drug dispensing personnel should be considered part of the therapeutic chain and, if appropriately trained, they will play a very important role in promoting rational use of medicines.

Medication use during pregnancy in Omani women

OBJECTIVE

The aim of this study was to evaluate medication use pattern in a university tertiary hospital in the Sultanate of Oman.

SETTING

The study was conducted at the Sultan Qaboos University Hospital (SQUH) and the SQUH Family and Community Medicine clinic (FAMCO), Muscat, Sultanate of Oman during 7th to 25th June 2008.

METHOD

The medication use pattern was evaluated in women attending FAMCO and the standard antenatal clinics at the hospital. Women were interviewed in different gestational ages using a structured questionnaire. The Electronic Patient Record (EPR) was reviewed to acquire additional information on medication use. Medications were classified according to the US FDA risk classification.

MAIN OUTCOME MEASURE

Medication used including prescribed medications, OTC medications, or herbal treatment during the current pregnancy and 3 months prior to conception.

RESULTS

The study included a total of 139 pregnant mothers with an overall mean age of 28 ± 5 years ranging from 19 to 45 years. There was a slight overall reduction in the medication use including prescribed medications. However, there was a significant increase in utilization of vitamins and supplements (84-95% vs. 12% in the 3-months prior, P < 0.001) as well as herbal preparations (16-19% vs. 7% in the 3-months prior, P = 0.011) throughout pregnancy (P < 0.010). The use of category A medications increased in all trimester (43-52% vs. 13% in the 3 months prior, P < 0.010) while a reduction in the use of category C (for first and third trimester, P < 0.050) and D medications was seen. A reduction in the use of teratogenic drugs in all trimesters (P < 0.010) was also observed.

CONCLUSION

The prescribing of vitamins and minerals was optimal. However, the common use of herbal supplements observed warrants special attention due to their unknown risks. The conclusions should be interpreted in light of the study's limitations.

Drug use during pregnancy in Sweden - assessed by the Prescribed Drug Register and the Medical Birth Register

Purpose:

The purpose of this research is to study drug use during pregnancy in Sweden and agreement between use according to antenatal medical records and dispensed drugs from a pharmacy database.

Patients and methods:

From the Swedish Medical Birth Register (MBR), we established a population-based cohort of 102,995 women who gave birth in 2007. Using the unique personal registration number, information on dispensed drugs from the Prescribed Drug Register (PDR) was obtained prior to, during, and after the pregnancies and compared with MBR information on drug use from standardized antenatal medical records.

Results:

According to the PDR, 57.6% of the 102,995 women filled a prescription with at least one drug during pregnancy and 50.9% during the lactating period (until 3 months after delivery). The most dispensed drugs during pregnancy were B-lactam antibacterials and penicillins. Agreement between drugs recorded in antenatal medical records and dispensed drugs was highest for drugs used for chronic conditions. The agreement was particularly high for thyroid therapy (85.3%), anti-intestinal inflammatory drugs (80.3%), antiepileptics (69.2%), immunosuppressants (67.4%), and insulin (63.8%). Agreement for drugs used for occasional use was generally lower, ranging between 42.5% for antihistamines and 0.8% for gynecological anti-infectives.

Conclusions:

A large proportion of women filled a prescription during pregnancy or the lactating period. Agreement between drug use in medical antenatal records and register information from a national pharmacy database was high for drugs used for chronic conditions but low for occasional use. For occasionally used drugs, medical record and register-based data may provide incomplete exposure information because of nonreporting or noncompliance.

Drugs dispensed in primary care during pregnancy: a record-linkage analysis in Tayside, Scotland

BACKGROUND

For many regularly used drugs, evidence for safe use in pregnancy has not been established. Despite this, international studies have identified high levels of drug prescribing among pregnant women.

OBJECTIVE

To investigate the patterns of prescribing of drugs to women who gave birth in Tayside, Scotland, in 2007.

METHODS

Scottish maternity records were linked to dispensed prescribing data for all women who gave birth in Tayside in 2007. Drugs prescribed were coded according to the US FDA classification for risks of drugs in pregnancy. Patterns of prescribing were investigated during the 3 trimesters of pregnancy and the 3 months prior to conception.

RESULTS

Prescribing in pregnancy was common, with 21 093 prescriptions dispensed to 3356 (85.2%) of the 3937 women. The most frequently prescribed drugs were antacids, antibacterials, oral iron, folic acid preparations and analgesics. Category A drugs (positive evidence of safety in pregnancy) and Category B drugs (some evidence of safety in pregnancy) accounted for 19.6% and 26.9% of all prescriptions dispensed, respectively. Prescribing of Category X drugs (evidence of risk to the fetus; use contraindicated in women who are or may become pregnant) during pregnancy was rare, with 112 prescriptions dispensed to 68 women (1.7%). Most of these were oral contraceptives or sex hormones. Prescribing of Category X drugs fell markedly during the first trimester and remained very low thereafter. Category D drugs (evidence of risk to the fetus but benefits of therapy may outweigh the potential risk) [432] were dispensed to 166 women (4.2%) during pregnancy. The most commonly prescribed Category D drugs were anxiolytics, nicotine replacement therapy and antiepileptic drugs. The frequency of prescribing of Category D drugs reduced in the third trimester. Prescribing of Category C drugs (insufficient evidence to know whether they are harmful) was common. Thirty percent of women received a total of 3641 Category C prescriptions, which accounted for 17.3% of all prescriptions issued during pregnancy. Prescribing of Category C drugs showed only a very modest decline during pregnancy. No FDA code was available for 4035 prescriptions issued (87 different items), the majority of which were for antacids and preparations for indigestion. More than 40% of women received such medications.

CONCLUSIONS

Prescribing of drugs during pregnancy was very common, but the levels of prescribing of drugs that are known to be harmful were low. Much of the prescribing was for drugs related to the pregnancy. While this study provides some evidence that primary-care prescribers in Tayside are prescribing potentially harmful drugs appropriately and with caution during pregnancy, safety data during pregnancy are unavailable for many drugs that are commonly prescribed.

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

PURPOSE

To examine the extent, nature and determinants of medication use in early pregnancy.

METHODS

We reviewed early pregnancy medication use, as reported to a midwife at the booking interview, in women delivering between 2000 and 2007 in a large maternity hospital in Dublin, Ireland (n = 61 252).

RESULTS

Excluding folic acid, at least one medication was reported in 23 989 (39.2%) pregnancies. Over the counter (OTC) medications were reported in 11 970 (19.5%) pregnancies, illicit drugs or methadone in 545 (0.9%) and herbal medicines/supplements in 352 (0.58%). FDA category D and X medications were reported by 1532 (2.5%) and 1987 (3.2%) women. Asthma, depression and hypertension were among the most commonly reported chronic medical disorders. Medications with potential for foetal harm were reported by 86 (15.7%) women treated for depression and 68 (20%) women treated for hypertension. Factors associated with reporting the use of medications with potential for foetal harm included unplanned pregnancy (adjusted odds ratio [aOR] 1.31, 95% confidence interval [CI] 1.12-1.52), booking at less than 12 weeks gestation (aOR 1.83, 95%CI 1.58-2.13), being above 25 years of age, unemployed (aOR 2.58, 95%CI 2.03-3.29), nulliparous (aOR 1.41; 95%CI 1.22-1.63), single (aOR 1.28; 95%CI 1.06-1.54) or smoking during pregnancy (aOR 1.96, 95%CI 1.67-2.28).

CONCLUSIONS

Women frequently report medication use in early pregnancy. Women and prescribers need to be aware of the lack of pregnancy safety data for many medications, and the need for pre-pregnancy planning. Prescribers should ensure that optimal medications are used when treating women of childbearing potential with chronic medical disorders.

Providing contraception for women taking potentially teratogenic medications: a survey of internal medicine physicians' knowledge, attitudes and barriers

BACKGROUND

The majority of women prescribed category D or X medications may not receive adequate contraceptive counseling or a reliable contraceptive method. Physicians who prescribe potentially teratogenic medications have a responsibility to provide women with contraceptive counseling, a method of highly-effective contraception, or both.

OBJECTIVE

Investigate the knowledge, beliefs and barriers of primary care physicians toward providing adequate contraception to women taking potential teratogens.

DESIGN & PARTICIPANTS

Self-administered confidential survey of primary care internal medicine physicians at an urban, academic medical center.

MEASUREMENTS

Knowledge of potential teratogenic medications and contraceptive failure rates was assessed. Participants' beliefs about adequacy of their medical education, practice limitations and attitudes toward improving provision of contraception to women on potential teratogens were assessed.

RESULTS

One hundred and ten physicians responded (57.3%). Nearly two-thirds (62.3%) of participants had cared for reproductive aged women taking category D or X medications in the past year. The mean percent of correctly identified category D or X medications was 58.4% (SD 22.1%). The mean percent correct for knowledge of published contraceptive failure rates was 64.6% (SD 23.1%). Most respondents (87.6%) felt it is the responsibility of primary care physicians to provide contraception. Time constraints were reported to be somewhat or very limiting by 61.3% and over half felt medical school (63.2%) or residency (58.1%) inadequately prepared them to prescribe or counsel about contraceptives.

CONCLUSIONS

Primary care physicians commonly encounter reproductive age women taking category D or X medications, but may lack sufficient knowledge and time to counsel about potential teratogens and contraception to prevent fetal exposure to these drugs.

Ethical issues in perinatal mental health research

PURPOSE OF REVIEW

To review the background of current ethical standards for the conduct of perinatal mental health research and describe the ethical challenges in this research domain.

RECENT FINDINGS

Current literature reflects a growing sentiment in the scientific community that having no information regarding the impact of psychiatric treatment on the mother and developing fetus/infant poses dangers that may exceed the risks involved in research. However, without sufficient consensus across the scientific community, both regulatory bodies and perinatal researchers find themselves without a framework for decision making that satisfactorily limits the risks and facilitates the benefits of participation of pregnant and lactating women in clinical research.

SUMMARY

Psychiatric research in perinatal mental health is critically important as it enables clinicians and patients to participate in informed decision-making concerning treatment for psychiatric disorders. Specific areas of concern include fetal safety, maternal risk, the therapeutic misconception, commercial interests, forensic/legal issues, the informed consent process, and study design. Developing guidelines that address ethical challenges and include the views and concerns of multiple stakeholders could improve the access of perinatal women to the benefits of participation in mental health research in addition to providing evidence-based mental healthcare for this subpopulation.

Assessment of drug use among pregnant women in Addis Ababa, Ethiopia

PURPOSE

To assess the drug use among antenatal care (ANC) attendant pregnant women in Addis Ababa.

METHODS

Institution-based cross sectional study was conducted reviewing the antenatal care follow up cards and interviewing pregnant women using semi-structured questionnaire.

RESULTS

A total of 1268 women were included in the study; of which 71.3% of them were prescribed at least one drug during pregnancy. Twelve point four per cent of the pregnant women who reported illness in the 2 weeks prior to the date of the interview, self-medicated themselves with either over the counter or prescription drugs or traditional herbs. The majority of the drugs prescribed were iron and vitamins followed by anti-infectives. Nearly 4% of the pregnant women were prescribed with drugs from category D or X of the US-FDA risk classification.

CONCLUSION

A considerable proportion of pregnant women were exposed to drugs, including those with potential harm to the fetus. Furthermore, pregnant women self-medicated themselves with modern medications or traditional herbs. Health care providers should thus weigh the therapeutic benefits of the drug to the mother against its potential risk to the developing fetus before prescribing. In addition it is essential to routinely inquire about the woman's self-medication practice and provide the appropriate advice to the pregnant women.