Prescription drug use during pregnancy: a population-based study in Regione Emilia-Romagna, Italy

The Use of Multiple Medications During Pregnancy Among an Ethnically Diverse Population in South-Eastern Melbourne: A Retrospective Analysis to Explore Potential Risks and Complications

BACKGROUND AND OBJECTIVE

Medication use is increasing to treat both pre-existing and pregnancy-related medical conditions or complications. This study aims to investigate factors associated with multiple medication use during pregnancy, as well as any increased risk of pregnancy complications for women taking multiple medications.

METHODS

A retrospective analysis of routinely collected medical records of singleton pregnant women was conducted in Southeast Melbourne, Australia, between 2016 and 2021. Self-reported medication use was recorded as part of routine medical care, starting from the first antenatal booking appointment and continuing for every subsequent antenatal appointment until birth. Multimorbidity was defined as having two or more medical conditions. Logistic regression was used to assess factors influencing multiple medication use (defined as taking two or more non-supplemental medications at any stage of pregnancy) and associations with pregnancy complications.

RESULTS

Of 48,502 participants, 34.9% used one medication, while 11.7% used multiple medications. Women of older age (30-34, 35-39, and ≥  40 years), higher body mass index (25.0-29.9 kg/m2 and ≥  30 kg/m2), born in Australasia and Oceania, higher socioeconomic status, and multimorbidity were more likely to use multiple medications during pregnancy. Women taking multiple medications had a higher risk of preterm and caesarean deliveries, fetal death, and neonatal admissions to intensive care. Sensitivity analyses exploring different morbidity categories produced no changes to findings.

CONCLUSIONS

Medication use during pregnancy is prevalent, with many pregnant mothers taking multiple medications. Given the rising maternal age, body mass index, and morbidities in pregnancy, the use of medications during pregnancy is increasing. Such use correlates with an increased chance of adverse pregnancy outcomes. In the context of limited trials on the safety and efficacy of medications in pregnancy, timely harnessing of the information available within routine medical records for post-marketing surveillance is important.

Antihypertensive therapy during pregnancy: the prescription pattern in Italy

Drug use during pregnancy should be evidence-based and favor the safest and most appropriate prescription. The Italian Medicines Agency (AIFA) coordinates a network focusing on monitoring medication use in pregnancy. Hypertensive disorders are common medical complication of pregnancy and antihypertensive therapy is prescribed to reduce the risk of adverse feto-maternal complications. The objective of this study is to highlight the prescription pattern of antihypertensive drugs before pregnancy, during pregnancy and in the postpartum period in Italy and to evaluate their use with a specific attention to the prescription pattern of drugs considered safe during pregnancy. A multi-database cross-sectional population study using a Common Data Model (CDM) was performed. We selected all women aged 15-49 years living in eight Italian regions who gave birth in hospital between 1 April 2016 and 31 March 2018. In a cohort of 449.012 women, corresponding to 59% of Italian deliveries occurred in the study period, the prevalence of prescription of antihypertensive drugs in the pre-conceptional period was 1.2%, in pregnancy 2.0% and in the postpartum period 2.9%. Beta-blockers were the most prescribed drugs before pregnancy (0.28%-0.30%). Calcium channel blockers were the most prescribed drugs during pregnancy, with a prevalence of 0.23%, 0.33%, 0.75% in each trimester. Alfa-2-adrenergic receptor agonists were the second most prescribed during pregnancy with a prevalence of 0.16%, 0.26% and 0.55% in each trimester. The prescription of drugs contraindicated during pregnancy was below 0.5%. Only a small percentage of women switched from a contraindicated drug to a drug compatible with pregnancy. The analysis showed little variability between the different Italian regions. In general, the prescription of antihypertensive drugs in the Italian Mom-Network is coherent with the drugs compatible with pregnancy.

Global prevalence of antibiotic consumption during pregnancy: A systematic review and meta-analysis

BACKGROUND

Antibiotic use during pregnancy is widespread with notable variations across regions.

METHODS

This systematic review and meta-analysis (Prospero protocol CRD42023418979) examines the prevalence and variability of antibiotic use in pregnancy globally and regionally, considering different methodologies and maternal characteristics. We searched Embase, PubMed, and Web of Science for observational studies published in English from the year 2000 and onwards. Random-effect meta-analyses were used to pool the prevalence of antibiotic consumption during pregnancy, presented as percentages with 95% confidence intervals (CI). Joanna Briggs Institute Critical appraisal checklist for prevalence studies was used for bias assessment.

FINDINGS

Overall, 116 studies (14 from Africa, 24 from the Americas, six from Eastern Mediterranean, 57 from Europe, four from South-East Asia and 11 from Western Pacific) were included (33,821,194 pregnancies). The majority of studies (84.5%) were appraised with a low risk of bias. The prevalence of antibiotic consumption during pregnancy ranged between 0.04 to 90%, with a pooled estimate of 23.6% (95% CI: 20.1-27.5, I2 =100%). Low-income countries had the highest pooled prevalence (45.3%, 95% CI: 15.4-79.1, I2 =99.6%). Regionally, the Western Pacific had the highest pooled prevalence (34.4%, 95% CI: 13.4-64.1, I2 =100%). The prevalence of antibiotic consumption during pregnancy increased over time in the Americas and Western Pacific. The studies exhibited considerable heterogeneity (I2 >95%), and the trim-and-fill method estimated a potential 10% underestimation of the overall pooled prevalence, suggesting publication bias.

INTERPRETATION

This meta-analysis suggests that about 1/4 of women worldwide use antibiotics during pregnancy. This study suggests a high prevalence of antibiotic consumption during pregnancy with disparities according to region and level of country income, ethnicity and whether antibiotics were prescribed or self-medicated. There was a variability in reported findings across age categories, potential bias from small sample sizes, and language bias from including only studies published in English.

Variability in perfusion conditions and set-up parameters used in ex vivo human placenta models: A literature review

The ex vivo human placenta perfusion model has proven to be clinically relevant to study transfer- and fetal exposure of various drugs. Although the method has existed for a long period, the setup of the perfusion model has not been generalized yet. This review aims to summarize the setups of ex vivo placental perfusion models used to examine drug transfer across the placenta to identify generalized properties and differences across setups. A literature search was carried out in PubMed September 26, 2022. Studies were labeled as relevant when information was reported, between 2000 and 2022, on the setups of ex vivo placental perfusion models used to study drug transfer across the placenta. The placenta perfusion process, and the data extraction, was divided into phases of preparation, control, drug, and experimental reflecting the chronological timeline of the different phases during the entire placental perfusion process. 135 studies describing an ex vivo human placental perfusion experiment were included. Among included studies, the majority (78.5%) analyzed drug perfusion in maternal to fetal direction, 18% evaluated bi-directional drug perfusion, 3% under equilibrium conditions, and one study investigated drug perfusion in fetal to maternal direction. This literature review facilitates the comparison of studies that employ similar placenta perfusion protocols for drug transfer studies and reveals significant disparities in the setup of these ex vivo placental perfusion models. Due to interlaboratory variability, perfusion studies are not readily comparable or interchangeable. Therefore, a stepwise protocol with multiple checkpoints for validating placental perfusion is needed.

Belgian medication exposure during pregnancy (BeMeP), a new nationwide linked database: Linkage methods and prevalence of medication use

PURPOSE

This study aimed to describe the implementation of a new retrospective Belgian national cohort of pregnant women, the Belgian Medication Exposure during Pregnancy (BeMeP).

METHODS

We linked the national dispensing data to birth and death certificates and hospital stay data for a 7-year period between 2010 and 2016 for the first time in Belgium. We presented the characteristics of pregnancy events associated with the mothers enrolled in the linkage study. Next, we constructed a cohort of pregnancies and compared some characteristics computed using the BeMeP database with the national statistics. Finally, we described the use of medications during pregnancy based on the first level of the Anatomical Therapeutic Chemical (ATC) classification.

RESULTS

We included 630 457 pregnant women with 900 024 pregnancy-related events (843 780 livebirths, 1937 stillbirths, 6402 ectopic events, and 47 905 abortions) linked to medication exposure information. Overall, 96.3% of live births and 83.5% of stillbirths (national statistics as reference) were captured from the BeMeP. During pregnancy, excluding the week of birth, 78.9% of live birth pregnancies and 79.6% of stillbirth pregnancies were exposed to at least one medication. The most frequently dispensed medications were anti-infectives (ATC code J = 50.2%) for live births and for stillbirths (44.0%).

CONCLUSION

We linked information on pregnancies, all reimbursed medications dispensed by community pharmacists, all medications dispensed during hospitalization, sociodemographic status, and infant health to create the BeMeP database. The database represents a valuable potential resource for studying exposure-outcome associations for medication use during pregnancy.

Antidiabetic Therapy during Pregnancy: The Prescription Pattern in Italy

Pregestational and gestational diabetes mellitus are relevant complications of pregnancy, and antidiabetic drugs are prescribed to obtain glycemic control and improve perinatal outcomes. The objective of this study was to describe the prescription pattern of antidiabetics before, during and after pregnancy in Italy and to evaluate its concordance with the Italian guideline on treatment of diabetes mellitus. A multi-database cross-sectional population study using a Common Data Model was performed. In a cohort of about 450,000 women, the prescribing profile of antidiabetics seemed to be in line with the Italian guideline, which currently does not recommend the use of oral antidiabetics and non-insulin injection, even if practice is still heterogeneous (up to 3.8% in the third trimester used oral antidiabetics). A substantial variability in the prescription pattern was observed among the Italian regions considered: the highest increase was registered in Tuscany (4.2%) while the lowest was in Lombardy (1.5%). Women with multiple births had a higher proportion of antidiabetic prescriptions than women with singleton births both in the preconception period and during pregnancy (1.3% vs. 0.7%; 3.4% vs. 2.6%) and used metformin more frequently. The consumption of antidiabetics in foreign women was higher than Italians (second trimester: 1.8% vs. 0.9%, third trimester: 3.6% vs. 1.8%).

Patterns of Prescription Medication Use during the First Trimester of Pregnancy in the United States, 1997-2018

The objective of this analysis was to describe patterns of prescription medication use during pregnancy, including secular trends, with consideration of indication, and distributions of use within demographic subgroups. We conducted a descriptive secondary analysis using data from 9,755 women whose infants served as controls in two large United States case-control studies from 1997-2011 and 2014-2018. After excluding vitamin, herbal, mineral, vaccine, i.v. fluid, and topical products and over-the-counter medications, the proportion of women that reported taking at least one prescription medication in the first trimester increased over the study years, from 37% to 50% of women. The corresponding proportions increased with increasing maternal age and years of education, were highest for non-Hispanic White women (47%) and lowest for Hispanic women (24%). The most common indication for first trimester use of a medication was infection (12-15%). Increases were observed across the years for medications used for indications related to nausea/vomiting, depression/anxiety, infertility, thyroid disease, diabetes, and epilepsy. The largest relative increase in use among women was observed for medications to treat nausea/vomiting, which increased from 3.8% in the earliest years of the study (1997-2001) to 14.8% in 2014-2018, driven in large part by ondansetron use. Prescription medication use in the first trimester of pregnancy is common and increasing. Many medical conditions require treatments among pregnant women, often involving pharmacotherapy, which necessitates consideration of the risk and safety profiles for both mother and fetus.

A cross-sectional study on the knowledge, attitude, and practice of pregnant women regarding medication use and restriction during pregnancy

Background

The use of medication during pregnancy is a complex issue that requires careful consideration to avoid potential harm to the developing fetus. Despite the existence of guidelines and restrictions on medication use during pregnancy, pregnant women in Nigeria often have limited access to information regarding drug use and may rely on their own judgment or the advice of non-professionals when making decisions about medication use.

Objectives

To assess Nigerian pregnant women's knowledge, attitude, and practice toward the use of drugs and restriction/contraindications in pregnancy.

Methods

A descriptive cross-sectional study was conducted among pregnant women who visited the Federal Medical Center, Umuahia, from January to February 2023. A self-administered questionnaire was answered by conveniently sampled participants. Data were collected about their sociodemographic characteristics, knowledge, attitude, and practice. Descriptive statistics and inferential statistics utilizing the Pearson's chi-Square test were used for data analysis. The level of significance was set at p < 0.05.

Results

One hundred and fifty-two pregnant women completed the questionnaire (60.8% response rate) and were mostly married (n = 148; 95.0%). Majority were between the age of 25 to 35 years (n = 107; 70.4%), had a university/bachelor's degree (n = 94; 61.8%), and were business women (n = 85; 56.0%). About 35.5% of the respondents had good knowledge of medication restrictions in pregnancy. The majority of the respondents had a positive attitude (n = 98; 64.5%) and good practice (n = 139; 91.4%).

Conclusion

The findings established that a substantial proportion of the women had a positive attitude and good practice of medication use and restrictions in pregnancy. However, the level of knowledge was surprisingly poor among the study group. There is a need to educate pregnant women on safe medication use and avoidance during pregnancy.

Monitoring medicine prescriptions before, during and after pregnancy in Italy

BACKGROUND

The use of medications during pregnancy is a common event worldwide. Monitoring medicine prescriptions in clinical practice is a necessary step in assessing the impact of therapeutic choices in pregnant women as well as the adherence to clinical guidelines. The aim of this study was to provide prevalence data on medication use before, during and after pregnancy in the Italian population.

METHODS

A retrospective prevalence study using administrative healthcare databases was conducted. A cohort of 449,012 pregnant women (15-49 years) residing in eight Italian regions (59% of national population), who delivered in 2016-2018, were enrolled. The prevalence of medication use was estimated as the proportion (%) of pregnant women with any prescription.

RESULTS

About 73.1% of enrolled women received at least one drug prescription during pregnancy, 57.1% in pre-pregnancy and 59.3% in postpartum period. The prevalence of drug prescriptions increased with maternal age, especially during the 1st trimester of pregnancy. The most prescribed medicine was folic acid (34.6%), followed by progesterone (19%), both concentrated in 1st trimester of pregnancy (29.2% and 14.8%, respectively). Eight of the top 30 most prescribed medications were antibiotics, whose prevalence was higher during 2nd trimester of pregnancy in women ≥ 40 years (21.6%). An increase in prescriptions of anti-hypertensives, antidiabetics, thyroid hormone and heparin preparations was observed during pregnancy; on the contrary, a decrease was found for chronic therapies, such as anti-epileptics or lipid-modifying agents.

CONCLUSIONS

This study represents the largest and most representative population-based study illustrating the medication prescription patterns before, during and after pregnancy in Italy. The observed prescriptive trends were comparable to those reported in other European countries. Given the limited information on medication use in Italian pregnant women, the performed analyses provide an updated overview of drug prescribing in this population, which can help to identify critical aspects in clinical practice and to improve the medical care of pregnant and childbearing women in Italy.

Drug Prescriptions among Italian and Immigrant Pregnant Women Resident in Italy: A Cross-Sectional Population-Based Study

Ensuring drug safety for pregnant women through prescription drug monitoring is essential. The aim of this study was to describe the prescription pattern of medicines among pregnant immigrant women from countries with high migratory pressure (HMPCs) compared to pregnant Italian women. The prevalence of drug prescriptions among the two study populations was analysed through record linkage procedures applied to the administrative databases of eight Italian regions, from 2016 to 2018. The overall prevalence of drug prescription was calculated considering all women who received at least one prescription during the study period. Immigrants had a lower prevalence of drug prescriptions before (51.0% vs. 58.6%) and after pregnancy (55.1% vs. 60. 3%). Conversely, during pregnancy, they obtained a slightly higher number of prescriptions (74.9% vs. 72.8%). The most prescribed class of drugs was the blood and haematopoietic organs category (category ATC B) (56.4% vs. 45.9%, immigrants compared to Italians), followed by antimicrobials (31.3% vs. 33.7%). Most prescriptions were appropriate, while folic acid administration 3 months before conception was low for both study groups (3.9% immigrants and 6.2% Italians). Progesterone seemingly was prescribed against early pregnancy loss, more frequently among Italians (16.5% vs. 8.1% immigrants). Few inappropriate medications were prescribed among antihypertensives, statins and anti-inflammatory drugs in both study groups.

Real-world pharmacological treatment patterns of patients with threatened miscarriage in China from 2014 to 2020: A cross-sectional analysis

WHAT IS KNOWN AND OBJECTIVE

Approximately half of the patients with threatened miscarriage suffer an abortion, and consistent medication therapy to prevent threatened miscarriage is lacking. Our goal was to investigate the real-world pharmacological treatment patterns of patients with threatened miscarriage in China, with a focus on the trend and rationality of progestogen use over the last 7 years.

METHODS

We performed a cross-sectional analysis of data from the Hospital Prescription Analysis Cooperation Project that is overseen by the Chinese Pharmaceutical Association. Information was extracted from prescriptions of outpatients with threatened miscarriage between January 2014 and December 2020. We quantified the types of medications using the first level anatomical therapeutic chemical (ATC) classification code and the frequency of use of medicines classified as category X by the United States Food and Drug Administration (FDA). We also calculated the prevalence of the most frequently used progestogens by assessing prescription rates, determined the sum of the defined daily doses (DDDs) and defined daily cost (DDC) and evaluated the rationality of progestogens according to drug labels and guidelines.

RESULTS AND DISCUSSION

Of the 91,464 patients included in this study, 69.4% were from the eastern region, 92.5% were from tertiary hospitals, and 72.9% were between 25 and 34 years old. The average number of medications per patient was 1.4. The following types of medicines were the most prevalent: "genitourinary system and sex hormones" (90.7%), "alimentary tract and metabolism" (10.8%) and "blood and blood-forming organs" (9.9%). Progestogens were prescribed for 81,080 patients (88.6%), among which oral progesterone (39.7%) was the most commonly used, followed by oral dydrogesterone (34.4%), progesterone injection (26.0%), oral allylestrenol (0.7%) and progesterone gel (0.4%). In other words, 10,991 (12.0%) patients used more than one progestogen, and the top three combinations were oral dydrogesterone plus progesterone injection (5.6%), oral progesterone plus progesterone injection (4.7%) and oral dydrogesterone plus oral progesterone (1.1%). The prescription rate of dydrogesterone increased gradually, whereas that of progesterone, especially progesterone injection, obviously decreased. Among 34,760 prescriptions of progestogens with complete usage information, the primary errors of progestogen use were "low frequency" (18.4%), "high single dose" (15.9%) and "low single dose" (11.3%). In addition, 137 prescriptions were identified with drug-progestogen interactions, and 61 were identified with contraindications for progestogens. A total of 4.5% of prescriptions included FDA category X medicines.

WHAT IS NEW AND CONCLUSION

Our findings are the first to provide information on medication use in patients with threatened miscarriage over the last seven years in China. Medicines targeting the "genitourinary system and sex hormones," especially progestogens, were the most commonly prescribed medications, among which dydrogesterone was the most prevalent. However, it is remarkable that the use of progestogens for the treatment of threatened abortion is still controversial; thus, high-quality large sample studies are still required, especially among Chinese patients. Since usage errors in progestogen records and exposure to category X medicines were common, more efforts are needed to guarantee the safety and rationality of medicines used in pregnant women.

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.

The Italian Network for Monitoring Medication Use During Pregnancy (MoM-Net): Experience and Perspectives

There is an acute need for research to acquire high-quality information on the use of medicines in pregnancy, both in terms of appropriateness and safety. For this purpose, the Italian Medicines Agency established a Network for Monitoring Medication use in pregnancy (MoM-Net) through the conduction of population-based studies using administrative data available at regional level. This paper aimed to describe the experiences and challenges within the network. MoM-Net currently involves eight regions and several experts from public and academic institutions. The first study conducted aimed to identify drug use before, during and after pregnancy investigating specific therapeutic categories, analysing regional variability and monitoring drug use in specific subpopulations (i.e. foreign women/multiple pregnancies). Aggregated demographic, clinical, and prescription data were analysed using a distributed network approach based on common data model. The study population included all women delivering during 2016–2018 in the participating regions (n = 449,012), and corresponding to 59% of deliveries in Italy. Seventy-three per cent of the cohort had at least one drug prescription during pregnancy, compared to 57% before and 59% after pregnancy. In general, a good adherence to guidelines for pregnant women was found although some drug categories at risk of inappropriateness, such as progestins and antibiotics, were prescribed. A strong variability in the use of drugs among regions and in specific subpopulations was observed. The MoM-Net represents a valuable surveillance system on the use of medicines in pregnancy, available to monitor drug categories at high risk of inappropriateness and to investigate health needs in specific regions or subpopulations.

Using administrative healthcare database records to study trends in prescribed medication dispensed during pregnancy in Belgium from 2003 to 2017

PURPOSE

The aim of this study was to describe trends in medication prescriptions dispensed during pregnancy in Belgium using administrative healthcare database records from a representative sample of the Belgian population.

METHODS

Pregnant women were identified with reimbursement codes associated with the delivery of a baby. Data were extracted for three study periods, each over 3 years: 2003-2005, 2009-2011, and 2015-2017. The age-standardized prevalence of dispensed medications during pregnancy were computed and logistic regression models were used to evaluate the trends in prevalence across the study periods. The most frequently dispensed medications were listed for each study period.

RESULTS

The study included 23 912 pregnancies. The age-standardized prevalence of pregnant women with at least one dispensed medication increased across the three study periods from 81.8.% to 89.3%. The median number and interquartile range of the different medications dispensed during pregnancy rose from 2 (1-6) to 3 (1-7) between the first and last study periods. In the 2015-2017 period, the most frequently dispensed medications during pregnancy included progesterone (25.5%), paracetamol (17.8%), and amoxicillin (17.1%). The data also showed an increasing trend for the dispensation of ibuprofen and ketorolac during pregnancy across the three study periods.

CONCLUSIONS

The prevalence of prescribed medications dispensed during pregnancy increased in Belgium from 2003 to 2017 with high proportion for Progesterone and Antibiotics. Utilization of certain nonsteroidal anti-inflammatory drugs (NSAIDs) increased between 2003 and 2017, despite recommendations to avoid them.

Reduction in unplanned hospitalizations associated with a physician focused intervention to reduce potentially inappropriate medication use among older adults: a population-based cohort study

Background

A multimodal general practitioner-focused intervention in the Local Health Authority (LHA) of Parma, Italy, substantially reduced the prevalence of potentially inappropriate medication (PIM) use among older adults. Our objective was to estimate changes in hospitalization rates associated with the Parma LHA quality improvement initiative that reduced PIM use.

Methods

This population-based longitudinal cohort study was conducted among older residents (> 65 years) using the Parma LHA administrative healthcare database. Crude and adjusted unplanned hospitalization rates were estimated in 3 periods (pre-intervention: 2005–2008, intervention: 2009–2010, post-intervention: 2011–2014). Multivariable negative binomial models estimated trends in quarterly hospitalization rates among individuals at risk during each period using a piecewise linear spline for time, adjusted for time-dependent and time-fixed covariates.

Results

The pre-intervention, intervention, and post-intervention periods included 117,061, 107,347, and 121,871 older adults and had crude hospitalization rates of 146.2 (95% CI: 142.2–150.3), 146.8 (95% CI: 143.6–150.0), and 140.8 (95% CI: 136.9–144.7) per 1000 persons per year, respectively. The adjusted pre-intervention hospitalization rate was declining by 0.7% per quarter (IRR = 0.993; 95% CI: 0.991–0.995). The hospitalization rate declined more than twice as fast during the intervention period (1.8% per quarter, IRR = 0.982; 95% CI: 0.979–0.985) and was nearly constant post-intervention (IRR: 0.999; 95% CI: 0.997–1.001). Contrasting model predictions for the intervention period (Q1 2009 to Q4 2010), the intervention was associated with 1481 avoided hospitalizations.

Conclusion

In a large population of older adults, a multimodal general practitioner-focused intervention to decrease PIM use was associated with a decline in the unplanned hospitalization rate. Such interventions to reduce high risk medication use among older adults warrant consideration by health systems seeking to improve health outcomes and reduce high-cost acute care utilization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02172-3.

COVID-19: can we treat the mother without harming her baby?

Medical care is predicated on 'do no harm', yet the urgency to find drugs and vaccines to treat or prevent COVID-19 has led to an extraordinary effort to develop and test new therapies. Whilst this is an essential cornerstone of a united global response to the COVID-19 pandemic, the absolute requirements for meticulous efficacy and safety data remain. This is especially pertinent to the needs of pregnant women; a group traditionally poorly represented in drug trials, yet a group at heightened risk of unintended adverse materno-fetal consequences due to the unique physiology of pregnancy and the life course implications of fetal or neonatal drug exposure. However, due to the complexities of drug trial participation when pregnant (be they vaccines or therapeutics for acute disease), many clinical drug trials will exclude them. Clinicians must determine the best course of drug treatment with a dearth of evidence from either clinical or preclinical studies, where at least in the short term they may be more focused on the outcome of the mother than of her offspring.

Drug use for gastrointestinal symptoms during pregnancy: A French nationwide study 2010-2018

PURPOSE

To describe drug prescription for gastrointestinal symptoms during pregnancy.

METHODS

Using the French national health database, we identified pregnancies ending with a birth between April 2010 and December 2018, in France. We studied prescription of antacids, antispasmodics, antinauseants, laxatives and antidiarrheals during pregnancy, between two trimesters before and two trimesters after delivery. We also assessed hospitalization for gastrointestinal symptoms during pregnancy.

RESULTS

Among 6,365,471 pregnancies, 4,452,779 (74.0%) received at least one gastrointestinal drug during pregnancy; 2,228,275 (37.0%) received an antacid, 3,096,858 (51.5%) an antispasmodic, 1,861,731 (31.0%) an antinauseant, 919,116 (15.3%) a laxative and 617,808 (10.3%) an antidiarrheal. Prescription of proton pump inhibitors doubled from 12.2% in 2010 to 26.0% in 2018, while domperidone use decreased from 18.3% in 2010 to 2.2% in 2018. In addition, prescription of antacids increased from 7.0% during the trimester before pregnancy to 11.8% during the 1st trimester, 17.0% during the 2nd trimester and 23.4% during the 3rd trimester. Antispasmodic use was 10.6% during the trimester before pregnancy, 23.1% during the 1st trimester, 25.2% during the 2nd trimester and 24.0% during the 3rd trimester. Prescription of antinauseant drugs increased from 5.0% during the trimester before pregnancy to 25.7% during the 1st trimester, then decreased to 6.4% during the 2nd trimester and 3.2% during the 3rd trimester. Nausea/vomiting was the most common cause of hospitalization for gastrointestinal symptoms or diseases during pregnancy, although it accounted for only 1.0% of pregnancies.

CONCLUSIONS

Approximately three-quarters of women use drugs for gastrointestinal symptoms during pregnancy in France. Prescription of gastrointestinal drugs during pregnancy should be the subject of more detailed risk-benefit assessment and recommendations.

Drug prescriptions in French pregnant women between 2015 and 2016: A study in the EGB database

PURPOSE

To describe drug prescriptions in pregnant women in France and to identify teratogenic and fetotoxic drug prescriptions.

METHODS

This study was carried out using data from Échantillon Généraliste des Bénéficiaires (EGB), a French national health database which includes 1/97^th of the French population. Our study population included all pregnant women, aged 10 to 60, who were registered in the EGB and had a pregnancy outcome between 2015 and 2016. Drugs prescribed and dispensed to women during pregnancy and the 3 months before, were collected and described for each year and according to pregnancy trimesters. Prescriptions of major teratogen or fetotoxic drugs were described.

RESULTS

We identified 18,279 pregnancies. Among them, 93% received drug prescriptions and dispensations during pregnancy with an average of 7.4±5.5 different drugs. "Alimentary tract and metabolism (75.4%)", "nervous system (64.0%)" and "blood and blood forming organs (58.7%)" classes were the most frequently prescribed to pregnant women. The 5 most frequently prescribed drugs were paracetamol (60.6%), iron (49.2%), folic acid (45.6%), phloroglucinol (44.0%) and colecalciferol (41.4%). The most commonly prescribed drugs included some that have not yet been well evaluated in pregnancy. Prescriptions and dispensations of teratogenic or fetotoxic drugs, as Non-Steroidal Anti-Inflammatory Drugs and retinoids were observed. Valproic acid prescriptions to pregnant women have become extremely rare.

CONCLUSION

This descriptive study demonstrates that numerous drugs are prescribed and dispensed to pregnant women in France. These include drugs with a proven teratogenic or fetotoxic effect and many drugs that have not yet been well evaluated in pregnancy.

Patterns of prescription medicine dispensing before and during pregnancy in New Zealand, 2005-2015

Objective

To describe prescription medicine dispensing before and during pregnancy in New Zealand, 2005–2015.

Methods

Members of the New Zealand Pregnancy Cohort were linked with their dispensing records in a national database of prescription products dispensed from community pharmacies. We identified the proportion of pregnancies during which at least one prescription medicine was dispensed, the number of different medicines used and the most commonly dispensed medicine groups both during pregnancy and in the 270 days before conception. Dispensing during pregnancy was assessed by several maternal characteristics.

Results

874,884 pregnancies were included. Over the study timeframe, the proportion of pregnancies exposed to a non-supplement prescription medicine increased from 38.5% to 67.2%. The mean number of different non-supplement medicines dispensed during pregnancy increased from 2.5 to 3.2. Dispensing during pregnancy was weakly associated with body mass index, smoking status and ethnicity. Pregnancy exposure was highest for Antibacterials (26.0%), Analgesics (16.7%) and Antinausea & Vertigo Agents (11.0%).

Conclusions

From 2005–2015, both the proportion of exposed pregnancies and the number of different medicines dispensed to pregnant women in New Zealand increased.

Use and Intentional Avoidance of Prescribed Medications in Pregnancy: A Cross-Sectional, Web-Based Study among 926 Women in Italy

Nation-wide information about medication use in pregnancy is lacking for Italy, and no study has so far investigated the prescribed medications which pregnant women deliberately avoid. In this study, we map medication use patterns in pregnancy, as well as the extent and type of prescribed medications which are purposely avoided by pregnant women in Italy. This is a sub-study within the "Multinational Medication Use in Pregnancy Study"-a cross-sectional, web-based study conducted in Italy from 7 November 2011 to 7 January 2012. Using an anonymous electronic questionnaire, we collected data from pregnant women and new mothers on medication use and deliberate avoidance during pregnancy and maternal characteristics. The sample included 926 women residing in Italy. The point prevalence of total medication use was 71.2%. Whereas 61.4% and 12.4% of women reported medication use for the treatment of short and longer-term illnesses, respectively, only 8.8% reported medication use for the treatment of both a short and a longer-term illness in pregnancy. We found no substantial differences in estimates across various geographical areas of Italy. Overall, 26.6% of women reported to have deliberately avoided a prescribed medication in pregnancy-most often nimesulide or ketoprofen, but also antibiotics. We conclude that prenatal exposure to medication is common among women in Italy, but estimates are lower than in other Western countries. Intentional avoidance of important medications by pregnant women raises concerns about the safeguarding of maternal-child health.

Clinical Pharmacokinetic Studies in Pregnant Women and the Relevance of Pharmacometric Tools

BACKGROUND

In clinical pharmacokinetic (PK) studies, pregnant women are significantly underrepresented because of ethical and legal reasons which lead to a paucity of information on potential PK changes in this population. As a consequence, pharmacometric tools became instrumental to explore and quantify the impact of PK changes during pregnancy.

METHODS

We explore and discuss the typical characteristics of population PK and physiologically based pharmacokinetic (PBPK) models with a specific focus on pregnancy and postpartum.

RESULTS

Population PK models enable the analysis of dense, sparse or unbalanced data to explore covariates in order to (partly) explain inter-individual variability (including pregnancy) and to individualize dosing. For population PK models, we subsequently used an illustrative approach with ketorolac data to highlight the relevance of enantiomer specific modeling for racemic drugs during pregnancy, while data on antibiotic prophylaxis (cefazolin) during surgery illustrate the specific characteristics of the fetal compartments in the presence of timeconcentration profiles. For PBPK models, an overview on the current status of reports and papers during pregnancy is followed by a PBPK cefuroxime model to illustrate the added benefit of PBPK in evaluating dosing regimens in pregnant women.

CONCLUSIONS

Pharmacometric tools became very instrumental to improve perinatal pharmacology. However, to reach their full potential, multidisciplinary collaboration and structured efforts are needed to generate more information from already available datasets, to share data and models, and to stimulate cross talk between clinicians and pharmacometricians to generate specific observations (pathophysiology during pregnancy, breastfeeding) needed to further develop the field.

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.

Health products' and substance use among pregnant women visiting a tertiary hospital in Belgium: A cross-sectional study

PURPOSE

To investigate the prevalence and type of health products used among pregnant women visiting a tertiary hospital in Belgium, as well as who advises these products, where women buy these products, which determinants are associated with medication and pregnancy vitamin intake, and preconception lifestyle changes such as folic acid intake and substance use.

METHODS

A cross-sectional study was performed at the outpatient obstetrics clinics of the University Hospital Leuven, Belgium between November 2016 and March 2017. All pregnant women 18 years and older and understanding Dutch, French, or English were asked to participate in an online survey.

RESULTS

In total, 379 pregnant women participated. Prevalence of medication use during the preceding week was 52%. Paracetamol (14%), levothyroxine (13%), and antacids (9%) were the most frequently used medicines. Pregnancy vitamins were used by 86% of women, and 97% had used a pregnancy vitamin somewhere during pregnancy. Only 56% initiated folic acid supplementation at least 1 month before pregnancy. Preconception use of folic acid among women following assisted reproductive technology was 73%. Inappropriate use of health products was observed among 3% of women. Prevalence of alcohol use and/or smoking during the preceding week was 6%. Alcohol and smoking cessation mainly occurred after pregnancy diagnosis.

CONCLUSION

Pregnant women living in Belgium frequently use medicines, pregnancy vitamins, and other health products. Preconception lifestyle changes such as folic acid intake and alcohol and smoking cessation are poorly implemented. Public campaigns and interventions are needed to improve preconception care and counselling.

Use of opioids during pregnancy and effects of pregnancy outcomes

PURPOSE

To evaluate the use of opioids in pregnant primiparous women and study the effect of opioid use on maternal and offspring delivery outcomes.

METHODS

The study cohort (N = 6231) consists of all primiparous women with a Finnish background who delivered a singleton between 2009 and 2015 in the city of Vantaa, Finland. Data on births, maternal characteristics, pregnancy outcomes, and purchases of prescription drugs were obtained from National Health Registers.

RESULTS

Of the primiparous women, 5.1% used opioids during pregnancy. Of these, 95.9% used codeine. No differences were observed in purchases of opioids between the different trimesters but more women purchased opioids as pregnancy progressed (.002). Users of opioids more often also purchased other prescription drugs compared with non-users of opioids, 89% versus 58% (P < .001); age, smoking, education, and body mass index adjusted odds ratio 5.66 (95% confidence interval 3.96 to 8.09). Caesarean sections were more common in users of opioids than in non-users, 28.3% versus 21.9% (.007). Before the age of 7 days, the offspring of users of opioids more often needed respirator treatment compared with the offspring of non-users, 3.1% versus 1.6% (.044).

CONCLUSIONS

One out of 20 pregnant women used opioids. Use of opioids during pregnancy was associated with the risk for deliveries by caesarean sections and need for respiratory treatment among the offspring during the first week of life. Further safety evaluations are needed.

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.

Improving pregnancy outcomes in humans through studies in sheep

Experimental studies that are relevant to human pregnancy rely on the selection of appropriate animal models as an important element in experimental design. Consideration of the strengths and weaknesses of any animal model of human disease is fundamental to effective and meaningful translation of preclinical research. Studies in sheep have made significant contributions to our understanding of the normal and abnormal development of the fetus. As a model of human pregnancy, studies in sheep have enabled scientists and clinicians to answer questions about the etiology and treatment of poor maternal, placental, and fetal health and to provide an evidence base for translation of interventions to the clinic. The aim of this review is to highlight the advances in perinatal human medicine that have been achieved following translation of research using the pregnant sheep and fetus.

Trends in prescription drug use during pregnancy and postpartum in Norway, 2005 to 2015

PURPOSE

To explore trends in use of maternal medication 3 months prior to, during and 3 months after pregnancy.

METHODS

Data on births from the Medical Birth Registry of Norway were linked to the Norwegian Prescription Database, identifying women's use of medications around pregnancy. All women giving birth in Norway during 2005 to 2015 (638 532 singleton births to 414 567 women) were included. Proportions of pregnant women using different medications in association with pregnancy, and annual relative change in medication use during 2005 to 2015, were calculated.

RESULTS

In Norway, 60% of pregnant women used prescription medications during pregnancy (2005-15), increasing from 57% in 2005 to 62% in 2015. The annual relative increase was 0.9% (95% CI: 0.8-1.0). In the first trimester, approximately 17% of the women used medications regarded as potentially teratogenic during 2005 to 2015, increasing from 15% to 19%. Overall, this proportion was higher in the first than in the second (8.9%) and third (8.0%) trimesters, and higher than in the 3 months after pregnancy (14%). The annual relative increase of medications regarded as potentially teratogenic in the first trimester was 2.5% (95% CI: 2.3-2.7).

CONCLUSIONS

The proportion of women using potentially teratogenic medications in the first trimester of pregnancy have increased during the last decade. Clinicians need to be aware of the possibility of pregnancy when prescribing potentially teratogenic medication to women of fertile age and focus this in the consultations. The increasing trends call for the need of routine surveillance of adverse birth outcomes linked to medication use in pregnancy.

Knowledge, attitudes, and practice regarding medication use in pregnant women in Southern Italy

The study assessed knowledge, attitudes, and medication use of a random sample of pregnant women attending outpatient Gynecology and Obstetrics clinics at randomly selected public General and Teaching hospitals in Naples, Italy. A total of 503 women participated. Those more likely to know that a pregnant woman with chronic condition must discuss whether or not to take a medication with the physician were Italian, aged 31-40 years, employed, with no history of abortion, having had a medical problem within the previous year, with a better self-perceived health status, who knew how to use medications during pregnancy, and who needed information on medications. The knowledge of the potential risk of using non-prescribed medications during pregnancy was significantly higher in employed women, who received information from physicians, who knew how to use medications during pregnancy, and who knew the possible damages related to medications use. More than half had used at least one medication. Those aged 26-35 years, Italian, non-graduated, in the third trimester, having had a medical problem within the previous year, with a risky pregnancy, and with a knowledge that women with chronic condition must discuss whether or not to take a medication with the physician were more likely to use medication. Less than half had used medication without a physician's advice. Those who were more likely to self-medicate were older, Italian, multiparous, with no history of abortion, who knew that women with chronic condition must discuss whether or not to take a medication with the physician, who did not know the potential risk of using non-prescribed medication during pregnancy, who had used prescribed medication during pregnancy, and who needed information about medications. Educational programs for women about medication use are important to increase their knowledge of the potential risks to the pregnant women and the unborn child in order to reduce self-medication.

Intrauterine growth restriction may reduce hepatic drug metabolism in the early neonatal period

The effects of intrauterine growth restriction (IUGR) extend well into postnatal life. IUGR is associated with an increased risk of adverse health outcomes, which often leads to greater medication usage. Many medications require hepatic metabolism for activation or clearance, but hepatic function may be altered in IUGR fetuses. Using a sheep model of IUGR, we determined the impact of IUGR on hepatic drug metabolism and drug transporter expression, both important mediators of fetal drug exposure, in late gestation and in neonatal life. In the late gestation fetus, IUGR decreased the gene expression of uptake drug transporter OATPC and increased P-glycoprotein protein expression in the liver, but there was no change in the activity of the drug metabolising enzymes CYP3A4 or CYP2D6. In contrast, at 3 weeks of age, CYP3A4 activity was reduced in the livers of lambs born with low birth weight (LBW), indicating that LBW results in changes to drug metabolising capacity in neonatal life. Together, these results suggest that IUGR may reduce hepatic drug metabolism in fetal and neonatal life through different mechanisms.

Drug prescribing during pregnancy in a central region of Italy, 2008-2012

Background

Drug consumption during pregnancy is a matter of concern, especially regarding drugs known or suspected to be teratogens. Little is known about drug use in pregnant women in Italy. The present study is aimed at examining the prevalence, and to detect potential inappropriateness of drug prescribing among pregnant women in Latium, a region of central Italy.

Methods

This retrospective study was conducted on a cohort of women aged 18-45 years who delivered between 2008 and 2012 in public hospitals. Women were enrolled through the Regional Birth Register. After linking the regional Health Information Systems and the Regional Drug Claims Register, women’s clinical data and prescribed medications were analyzed. Italian Medicine Agency (AIFA) and US Food and Drug Administration (FDA) evidence were used to investigate inappropriate prescribing and teratogenic risk.

Results

Excluding vitamins and minerals, 80.6% (n = 153,079) of the women were prescribed at least one drug during pregnancy, with an average of 4.6 medications per pregnancy. Drugs for blood and hematopoietic organs were the most commonly prescribed (53.0%,), followed by anti-infectives for systemic use (50.7%). Among the inappropriate prescriptions, progestogen supplementation was given in 20.1% of pregnancies; teratogen drugs were prescribed in 0.8%, mostly angiotensin co-enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) (0.3%).

Conclusions

In Latium, drugs are widely used in pregnancy. Prescriptions of inappropriate drugs are observed in more than a fifth of pregnancies, and teratogens are still used, despite their known risk. Continuous updates of information provided to practitioners and an increased availability of information to women might reduce inappropriate prescribing.

Assessing the value of Western Cape Provincial Government health administrative data and electronic pharmacy records in ascertaining medicine use during pregnancy

Background

In African settings, where there is a high disease burden, there is a need to improve the science of documenting and analysing accurate information regarding medicine exposures in women immediately before and during pregnancy to assess the extent of use and safety in pregnant women and their unborn children.

Objectives

To compare evidence of medicine use during pregnancy, as documented in paper-based clinical records (maternity case records (MCRs)) against electronic health information resources (Provincial Health Data Centre (PHDC)) and assess the level of concordance between the two as part of baseline investigations before piloting a provincial pregnancy exposure registry and birth defect surveillance system. The PHDC consolidates electronic clinical and pharmacy data.

Methods

A folder review of completed pregnancies between November 2013 and January 2016 was conducted on randomly selected MCRs from midwife-run obstetric units and a secondary maternity hospital in Cape Town, South Africa. Medication exposures in the MCR were captured and compared with a customised PHDC data extract. The type and timing of drug exposures were compared. Total exposures were compiled from all data sources.

Results

Two hundred and six MCRs from three facilities were sampled: 83 women had documented antiretroviral therapy (ART) exposure; all but 1 (1%) had been recorded in the PHDC extract. There was no evidence of ART use in the MCRs of 4 (5%) cases, despite evidence in the PHDC. There were imprecise drug names in the MCRs of 14 (17%) ART patients, discordant dates of onset between the MCRs and PHDC extracts in 10/83 (12%) and inaccurate medicine names and incorrect dates in 1 (1%) case each. Nine of 10 (90%) women who were administered antituberculosis medication were recorded in the PHDC extract. Ten of 21 (48%) isoniazid preventive therapy treatments appeared in the MCRs and PHDC; 9 (42%) in the PHDC only and 2 (10%) in the MCRs only. Half (n=18/36) of all antibiotic use was reflected only in the MCRs, while 13/36 (36%) appeared only in the PHDC extract. In the former cases, antibiotics used for treatment of sexually transmitted infections and urinary tract infections were dispensed from ward stock and not captured electronically. Antibiotics reflected only in the PHDC were either dispensed at a referral facility or before the first recorded antenatal clinic visit. Folic acid and iron were mostly documented in the MCR only (n=79/99 (80%) and n=107/128 (84%), respectively). However, analgesics and antihistamines more often appeared in the PHDC extract only (n=11/16 (73%) and n=5/5 (100%), respectively).

Conclusions

The PHDC extract provided a better and more complete reflection of chronic drug exposures compared with the MCRs, especially when women sought care at facilities other than the antenatal care unit where they first attended, or when exposures occurred before the initial antenatal visit. The exception was antibiotics dispensed from ward stock to treat sexually transmitted and urinary tract infections.

The limitations of some European healthcare databases for monitoring the effectiveness of pregnancy prevention programmes as risk minimisation measures

PURPOSE

Pregnancy prevention programmes (PPPs) exist for some medicines known to be highly teratogenic. It is increasingly recognised that the impact of these risk minimisation measures requires periodic evaluation. This study aimed to assess the extent to which some of the data needed to monitor the effectiveness of PPPs may be present in European healthcare databases.

METHODS

An inventory was completed for databases contributing to EUROmediCAT capturing pregnancy and prescription data in Denmark, Norway, the Netherlands, Italy (Tuscany/Emilia Romagna), Wales and the rest of the UK, to determine the extent of data collected that could be used to evaluate the impact of PPPs.

RESULTS

Data availability varied between databases. All databases could be used to identify the frequency and duration of prescriptions to women of childbearing age from primary care, but there were specific issues with availability of data from secondary care and private care. To estimate the frequency of exposed pregnancies, all databases could be linked to pregnancy data, but the accuracy of timing of the start of pregnancy was variable, and data on pregnancies ending in induced abortions were often not available. Data availability on contraception to estimate compliance with contraception requirements was variable and no data were available on pregnancy tests.

CONCLUSION

Current electronic healthcare databases do not contain all the data necessary to fully monitor the effectiveness of PPP implementation, and thus, special data collection measures need to be instituted.

Prescription drug use during pregnancy in France: a study from the national health insurance permanent sample

PURPOSE

To provide an up-to-date account of drug prescription during pregnancy in France from 2011 to 2014 using the permanent sample of the French national computerized healthcare database and with a focus on recommended supplementations, fetotoxic drugs and teratogenic drugs.

METHODS

All pregnancies identified by the International Classification of Diseases, 10th Revision codes list in the hospitalization database, lasting more than 9 weeks of amenorrhea and whose delivery occurred between 01/01/2011 and 12/31/2014, were included. Drugs delivered between the trimester before and until the end of the pregnancy were included. Drug exposure prevalence was calculated for each year and according to pregnancy trimesters.

RESULTS

The study included 28,491 pregnancies with a median number of 9 [5-13] (median [IQ range]) drugs delivered. The most prescribed drug class was antianemia (in 72.5% of exposed). The prescription rate of recommended vitamins (B9 and D) increased over the study period (+10%). Influenza vaccination also increased but remained at a low rate (1%). Exposure to fetotoxic drugs decreased as pregnancy advanced. Exposure to the main teratogenic antiepileptics was stable over the study period. Low-income pregnant women had a higher average drug consumption except for recommended vitamins.

CONCLUSION

Pregnant French women are among the largest consumers of prescription medications worldwide. Overall, the dispensation trends observed in this study are in line with the recommendations of the French National College of Gynecologists and Obstetricians. Nevertheless, while being low, exposure to fetotoxic drugs, teratogenic drugs or those under safety alerts still occurred. Supplementations and vaccines in low-income pregnant women should also be increased.

Safety profile of medication used during pregnancy: results of a multinational European study

PURPOSE

The present study describes the safety profile of medications used during pregnancy across European countries and examines maternal factors associated with the use of risky medications during pregnancy.

METHODS

This study is based on a multinational, web-based study conducted in 15 European countries from October 2011 to February 2012. Information about maternal demographics, illnesses, and medication use during pregnancy was collected via an electronic questionnaire. Pregnant women and new mothers with a child less than 1-year-old could participate. The Swedish, Australian, and U.S. risk classification systems were used to evaluate medication safety. Descriptive statistics and generalized estimating equation models were used.

RESULTS

A total of 587 medications were reported by the study sample (n = 6657). Sixty-nine percent of the women used medications classified as safe, 28% used medications classified as risky, and 3% used medications with no classification available. Both socio-demographic and medical factors were associated with the use of risky medications during pregnancy. Having a chronic disorder was the factor with the strongest association with the use of risky medications during pregnancy (adjusted odds ratio = 3.99, 95% confidence interval 3.54-4.49).

CONCLUSIONS

The majority of women used medications classified as safe to use during pregnancy. However, a considerable proportion of women still used medications classified as risky. Having a chronic disorder was an important driver for using risky medications. Such use may still be appropriate when considering the woman's underlying condition. Pre-pregnancy counselling is important to ensure safe medication use for both mother and child. © 2017 The Authors. Pharmacoepidemiology & Drug Safety Published by John Wiley & Sons Ltd.

Drug Use before and during Pregnancy in Japan: The Japan Environment and Children's Study

Purpose: To elucidate drug use before and during pregnancy in Japan. Methods: The Japan Environment and Children's Study (JECS) is an ongoing nationwide birth cohort study. We analyzed data from JECS involving cases where drugs were used for 12 months before pregnancy was diagnosed, between the time of diagnosis of pregnancy until week 12 of pregnancy, and after week 12 of pregnancy. Results: We analyzed data from 97,464 pregnant women. The percentages of pregnant women who had taken one or more drugs and supplements before diagnosis of pregnancy, between the time of diagnosis of pregnancy until week 12 of pregnancy, and after week 12 of pregnancy, were 78.4%, 57.1%, and 68.8% respectively. Excluding iron supplements, folic acid, and other vitamins and minerals, the percentages of women taking supplements were 75.3%, 36.0%, and 51.7% at each respective time point. The following drugs and supplements were frequently used for 12 months before pregnancy diagnosis: Commercially available antipyretics, analgesics, and/or medicine for treating common cold (34.7%), antipyretics, analgesics, and/or medicine for treating common colds, which were prescribed in hospitals (29.8%), antimicrobial drugs (14.0%), and anti-allergy drugs (12.5%). The following drugs and supplements were frequently used from the time of pregnancy diagnosis until week 12 of pregnancy, and after week 12 of pregnancy: folic acid (28.9% and 26.2%), antipyretics, analgesics and/or medicines for treating common cold, that were prescribed in hospitals (7.8% and 13.3%), Chinese herbal medicines (6.0% and 9.4%, and uterine relaxants (5.1% and 15.2%). Conclusions: The analysis of a nationwide cohort study showed that a high percentage of Japanese pregnant women were taking medicinal drugs. Further research is required to elucidate the relationship between drug use during pregnancy and birth defects in Japan.

Pregnancy-Associated Changes in Pharmacokinetics: A Systematic Review

BACKGROUND

Women are commonly prescribed a variety of medications during pregnancy. As most organ systems are affected by the substantial anatomical and physiological changes that occur during pregnancy, it is expected that pharmacokinetics (PK) (absorption, distribution, metabolism, and excretion of drugs) would also be affected in ways that may necessitate changes in dosing schedules. The objective of this study was to systematically identify existing clinically relevant evidence on PK changes during pregnancy.

METHODS AND FINDINGS

Systematic searches were conducted in MEDLINE (Ovid), Embase (Ovid), Cochrane Central Register of Controlled Trials (Ovid), and Web of Science (Thomson Reuters), from database inception to August 31, 2015. An update of the search from September 1, 2015, to May 20, 2016, was performed, and relevant data were added to the present review. No language or date restrictions were applied. All publications of clinical PK studies involving a group of pregnant women with a comparison to nonpregnant participants or nonpregnant population data were eligible to be included in this review. A total of 198 studies involving 121 different medications fulfilled the inclusion criteria. In these studies, commonly investigated drug classes included antiretrovirals (54 studies), antiepileptic drugs (27 studies), antibiotics (23 studies), antimalarial drugs (22 studies), and cardiovascular drugs (17 studies). Overall, pregnancy-associated changes in PK parameters were often observed as consistent findings among many studies, particularly enhanced drug elimination and decreased exposure to total drugs (bound and unbound to plasma proteins) at a given dose. However, associated alterations in clinical responses and outcomes, or lack thereof, remain largely unknown.

CONCLUSION

This systematic review of pregnancy-associated PK changes identifies a significant gap between the accumulating knowledge of PK changes in pregnant women and our understanding of their clinical impact for both mother and fetus. It is essential for clinicians to be aware of these unique pregnancy-related changes in PK, and to critically examine their clinical implications.

Improving Information on Maternal Medication Use by Linking Prescription Data to Congenital Anomaly Registers: A EUROmediCAT Study

Introduction

Research on associations between medication use during pregnancy and congenital anomalies is significative for assessing the safe use of a medicine in pregnancy. Congenital anomaly (CA) registries do not have optimal information on medicine exposure, in contrast to prescription databases. Linkage of prescription databases to the CA registries is a potentially effective method of obtaining accurate information on medicine use in pregnancies and the risk of congenital anomalies.

Methods

We linked data from primary care and prescription databases to five European Surveillance of Congenital Anomalies (EUROCAT) CA registries. The linkage was evaluated by looking at linkage rate, characteristics of linked and non-linked cases, first trimester exposure rates for six groups of medicines according to the prescription data and information on medication use registered in the CA databases, and agreement of exposure.

Results

Of the 52,619 cases registered in the CA databases, 26,552 could be linked. The linkage rate varied between registries over time and by type of birth. The first trimester exposure rates and the agreements between the databases varied for the different medicine groups. Information on anti-epileptic drugs and insulins and analogue medicine use recorded by CA registries was of good quality. For selective serotonin reuptake inhibitors, anti-asthmatics, antibacterials for systemic use, and gonadotropins and other ovulation stimulants, the recorded information was less complete.

Conclusion

Linkage of primary care or prescription databases to CA registries improved the quality of information on maternal use of medicines in pregnancy, especially for medicine groups that are less fully registered in CA registries.

Women's beliefs about medication use during their pregnancy: a UK perspective

Background Previous research has examined the number and extent of medicines taking in pregnant women but not their beliefs and risk perception surrounding their use. Objective To describe beliefs and risk perception associated with medicines use for the treatment of common acute conditions among UK women and explore whether this is related to actual medicines use. Settings Cross-sectional, web-based study in the UK. Methods Pregnant women and mothers within 1 year of giving birth were invited to participate in an online cross-sectional questionnaire-based study via a pregnancy website in the UK. Anonymous data were collected from women regarding their use of medicines (both over-the-counter and prescribed) and their beliefs regarding medicines use during pregnancy. Main outcome measures Pregnant women’s beliefs about medicines and their relation to pharmacological treatment of acute conditions in pregnancy. Results Pharmacological treatment of conditions in pregnancy ranged from 65.4 % for urinary tract infections (UTIs) to 1.1 % for sleeping problems. Almost three out of ten women avoided using some medications during pregnancy. For heartburn and UTIs, women who did not treat the condition viewed medicines in general as being overused, more harmful and less beneficial, than those who treated the condition. In general, UK pregnant women perceived medicines to be beneficial and slightly overused. Conclusions Women’s beliefs about medications impact on treatment of specific conditions in pregnancy such as heartburn and UTIs. Healthcare professionals should explore patient’s beliefs regarding medication at the first maternity care visit to promote appropriate medication use in pregnancy.

Prescribing of Antidiabetic Medicines before, during and after Pregnancy: A Study in Seven European Regions

AIM

To explore antidiabetic medicine prescribing to women before, during and after pregnancy in different regions of Europe.

METHODS

A common protocol was implemented across seven databases in Denmark, Norway, The Netherlands, Italy (Emilia Romagna/Tuscany), Wales and the rest of the UK. Women with a pregnancy starting and ending between 2004 and 2010, (Denmark, 2004-2009; Norway, 2005-2010; Emilia Romagna, 2008-2010), which ended in a live or stillbirth, were identified. Prescriptions for antidiabetic medicines issued (UK) or dispensed (non-UK) during pregnancy and/or the year before or year after pregnancy were identified. Prescribing patterns were compared across databases and over calendar time.

RESULTS

1,082,673 live/stillbirths were identified. Pregestational insulin prescribing during the year before pregnancy ranged from 0.27% (CI95 0.25-0.30) in Tuscany to 0.45% (CI95 0.43-0.47) in Norway, and increased between 2004 and 2009 in all countries. During pregnancy, insulin prescribing peaked during the third trimester and increased over time; third trimester prescribing was highest in Tuscany (2.2%) and lowest in Denmark (0.5%). Of those prescribed an insulin during pregnancy, between 50.5% in Denmark and 88.8% in the Netherlands received an insulin analogue alone or in combination with human insulin, this proportion increasing over time. Oral products were mainly metformin and prescribing was highest in the 3 months before pregnancy. Metformin use during pregnancy increased in some countries.

CONCLUSION

Pregestational diabetes is increasing in many areas of Europe. There is considerable variation between and within countries in the choice of medication for treating pregestational diabetes in pregnancy, including choice of insulin analogues and oral antidiabetics, and very large variation in the treatment of gestational diabetes despite international guidelines.

Clinical correlates of prescription opioid analgesic use in pregnancy

A 2012 committee opinion from the American College of Obstetricians and Gynecologists highlights the considerable increase in opioid addiction in recent years, yet little is known about clinical correlates of prescribed opioids among pregnant women. This study examines clinical and demographic factors associated with the use of opioid analgesics in pregnancy. Data were derived from a prospective cohort study of pregnant women. Participants were administered the Composite International Diagnostic Interview to identify depressive and anxiety disorders and data on medication use were gathered at three assessment points and classified according to the Anatomical Therapeutic Chemical Code (ATC) classification system ATC group N02A. Participants included 2,748 English or Spanish speaking pregnant women. Six percent (n = 165) of women used opioid analgesics at any point in pregnancy. More pregnant women using opioids met diagnostic criteria for major depressive disorder (16 vs. 8 % for non users), generalized anxiety disorder (18 vs. 9 % for non users), post-traumatic stress disorder (11 vs. 4 % for non users) and panic disorder (6 vs. 4 % for non users). Women who reported opioid use were also significantly more likely than non users to report using illicit drugs and almost three times as likely to report smoking cigarettes in the second or third trimester of pregnancy (4 and 23 %, respectively) as compared to non-opioid users (0.5 and 8 %). The use of opioids in pregnancy was associated with higher levels of psychiatric comorbidity and use of other substances as compared to non-opioid users.

Asthma medication prescribing before, during and after pregnancy: a study in seven European regions

OBJECTIVES

To explore utilisation patterns of asthma medication before, during and after pregnancy as recorded in seven European population-based databases.

DESIGN

A descriptive drug utilisation study.

SETTING

7 electronic healthcare databases in Denmark, Norway, the Netherlands, Italy (Emilia Romagna and Tuscany), Wales, and the Clinical Practice Research Datalink representing the rest of the UK.

PARTICIPANTS

All women with a pregnancy ending in a delivery that started and ended between 2004 and 2010, who had been present in the database for the year before, throughout and the year following pregnancy.

MAIN OUTCOME MEASURES

The percentage of deliveries where the woman received an asthma medicine prescription, based on prescriptions issued (UK) or dispensed (non-UK), during the year before, throughout or during the year following pregnancy. Asthma medicine prescribing patterns were described for 3-month time periods and the choice of asthma medicine and changes in prescribing over the study period were evaluated in each database.

RESULTS

In total, 1,165,435 deliveries were identified. The prevalence of asthma medication prescribing during pregnancy was highest in the UK and Wales databases (9.4% (CI95 9.3% to 9.6%) and 9.4% (CI95 9.1% to 9.6%), respectively) and lowest in the Norwegian database (3.7% (CI95 3.7% to 3.8%)). In the year before pregnancy, the prevalence of asthma medication prescribing remained constant in all regions. Prescribing levels peaked during the second trimester of pregnancy and were at their lowest during the 3-month period following delivery. A decline was observed, in all regions except the UK, in the prescribing of long-acting β-2-agonists during pregnancy. During the 7-year study period, there were only small changes in prescribing patterns.

CONCLUSIONS

Differences were found in the prevalence of prescribing of asthma medications during and surrounding pregnancy in Europe. Inhaled β-2 agonists and inhaled corticosteroids were, however, the most popular therapeutic regimens in all databases.

Medication Safety During Pregnancy: Improving Evidence-Based Practice

Nearly 90% of women in the United States have taken medications during pregnancy. Medication exposures during pregnancy can result in adverse pregnancy and neonatal outcomes including birth defects, fetal loss, intrauterine growth restriction, prematurity, and longer-term neurodevelopmental outcomes. Advising pregnant women about the safety of medication use during pregnancy is complicated by a lack of data necessary to engage the woman in an informed discussion. Routinely, health care providers turn to the package insert, yet this information can be incomplete and can be based entirely on animal studies. Often, adequate safety data are not available. In a busy clinical setting, health care providers need to be able to quickly locate the most up-to-date information in order to counsel pregnant women concerned about medication exposure. Deciding where to locate the best available information is difficult, particularly when the needed information does not exist. Pregnancy registries are initiated to obtain more data about the safety of specific medication exposures during pregnancy; however, these studies are slow to produce meaningful information, and when they do, the information may not be readily available in a published form. Health care providers have valuable data in their everyday practice that can expand the knowledge base about medication safety during pregnancy. This review aims to discuss the limitations of the package insert regarding medication safety during pregnancy, highlight additional resources available to health care providers to inform practice, and communicate the importance of pregnancy registries for expanding knowledge about medication safety during pregnancy.