Ensuring the safe and effective use of medications during pregnancy: planning and prevention through preconception care

A Comprehensive Review on Asthma Challenges in Pregnancy: Exploring First Trimester Exacerbations and the Spectrum of Congenital Anomalies

This comprehensive review delves into the intricate relationship between asthma and pregnancy, specifically focusing on the challenges encountered in the first trimester and the ensuing impact on maternal and fetal health. Examining physiological changes during pregnancy reveals the dynamic interplay influencing respiratory function and immune responses. Key findings underscore the vulnerability to asthma exacerbations in the critical first trimester, emphasizing the potential risks to both maternal and fetal well-being. Maternal and fetal outcomes are discussed, emphasizing the associations between poorly controlled asthma and adverse perinatal outcomes. Implications for clinical practice highlight the importance of preconception care, continuous monitoring, and collaborative efforts between obstetricians and pulmonologists. Patient education emerges as a fundamental aspect to empower pregnant women in managing their condition. The conclusion emphasizes the imperative for comprehensive care, advocating for individualized treatment plans, multidisciplinary collaboration, and public health initiatives. By adopting this holistic approach, healthcare providers can navigate the complexities of asthma during pregnancy, ultimately ensuring the optimal health of both the expectant mother and her developing fetus.

Community pharmacists' knowledge and awareness about isotretinoin therapy and its dispensing practice in Jordan

A validated self-reported questionnaire was used to evaluate pharmacists' knowledge about isotretinoin and their awareness of isotretinoin dispensing practice. The majority were not able to recognize the initial dose of isotretinoin, the potential side effects such as dyslipidemia and liver toxicity, the potential interaction with tetracycline and Vitamin A and the contraindications of isotretinoin. Around 41.3 % of the pharmacists dispensed isotretinoin without a prescription, and the majority did not recognize that isotretinoin should be dispensed for only 30 days, should not be dispensed without an emphasis on the appropriate indication, and did not know the appropriate duration of isotretinoin therapy. Male gender and postgraduate degree were associated with better awareness, while increased work experience and postgraduate degree were associated with better knowledge about isotretinoin therapy. Nevertheless, both male and female pharmacists demonstrated equivalent knowledge levels. The current study demonstrates the need to implement educational programs to improve pharmacists' knowledge and awareness about isotretinoin and its dispensing practice.

Transplacental Therapeutic Drug Monitoring in Pregnant Women with Fetal Tachyarrhythmia Using HPLC-MS/MS

Fetal arrhythmia develops in 0.1-5% of pregnancies and may cause fetal heart failure and fetal hydrops, thus increasing fetal, neonatal, and infant mortality. The timely initiation of transplacental antiarrhythmic therapy (ART) promotes the conversion of fetal tachycardia to sinus rhythm and the regression of the concomitant non-immune fetal hydrops. The optimal treatment regimen search for the fetus with tachyarrhythmia is still of high value. Polymorphisms of these genes determines the individual features of the drug pharmacokinetics. The aim of this study was to study the pharmacokinetics of transplacental anti-arrhythmic drugs in the fetal therapy of arrhythmias using HPLC-MS/MS, as well as to assess the effect of the multidrug-resistance gene ABCB1 3435C > T polymorphism on the efficacy and maternal/fetal complications of digoxin treatment. The predisposition to a decrease in the bioavailability of the digoxin in patients with a homozygous variant of the CC polymorphism showed a probable association with the development of ART side effects. A pronounced decrease in heart rate in women with the 3435TT allele of the ABCB1 gene was found. The homozygous TT variant in the fetus showed a probable association with an earlier response to ART and rhythm disruptions on the digoxin dosage reduction. high-performance liquid chromatography with tandem mass spectrometry (HPLC-MS/MS) methods for digoxin and sotalol therapeutic drug monitoring in blood plasma, amniotic fluid, and urine were developed. The digoxin and sotalol concentrations were determined in the plasma blood, urine, and amniotic fluid of 30 pregnant women at four time points (from the beginning of the transplacental antiarrhythmic therapy to delivery) and the plasma cord blood of 30 newborns. A high degree of correlation between the level of digoxin and sotalol in maternal and cord blood was found. The ratio of digoxin and sotalol in cord blood to maternal blood was 0.35 (0.27 and 0.46) and 1.0 (0.97 and 1.07), accordingly. The digoxin concentration in the blood of the fetus at the moment of the first rhythm recovery episode, 0.58 (0.46, 0.8) ng/mL, was below the therapeutic interval. This confirms the almost complete transplacental transfer of sotalol and the significant limitation in the case of digoxin. Previously, ABCB1/P-glycoprotein had been shown to limit fetal exposure to drugs. Further studies (including multicenter ones) to clarify the genetic features of the transplacental pharmacokinetics of antiarrhythmic drugs are needed.

Changes in Medication Use During Pregnancy for Women with Chronic Conditions: An Analysis of Claims Data

PURPOSE

Evaluation of drug safety during pregnancy is dependent on the number of exposed women during routine clinical practice with data available for analysis. We examined medication fills in pregnant and nonpregnant women within select disease cohorts: general population, migraine, diabetes, and hyperlipidemia to explore the potential use of claims data to assess medication use and safety during pregnancy.

METHODS

This cohort study, using IBM MarketScan® Research Databases claims data, included women 10-54 years of age with pregnancy resulting in a liveborn infant between January 2010 and September 2015 and matched nonpregnant women. Medication use (antidepressants, antihypertensives, sedatives, glucose-lowering medications, antiepileptics, antipsychotics, lipid-lowering medications) was abstracted from pharmacy claims 180 days before last menstrual period through 180 days postdelivery.

RESULTS

Among 753,760 women in the general pregnancy population (including 73,268 migraine, 50,155 hyperlipidemia, and 8361 diabetes; non-exclusive cohorts), antidepressants, antihypertensives, and sedatives were the most commonly used medications during pregnancy. Medications of interest were less commonly used in the pregnancy cohort than in the matched nonpregnant cohort within each time period (e.g., 3.7% vs 13.1% antidepressant use in 1st trimester). Most prescription fills were less common during pregnancy then pre-pregnancy. Post-pregnancy, prescription fills increased to or exceeded pre-pregnancy levels, except antihypertensive and glucose-lowering medications, which increased during pregnancy.

CONCLUSIONS

Medication use among pregnant women was low and different from that among matched nonpregnant women. The underlying size of large commercial claims databases offer opportunities for efficient evaluation of potential safety concerns, particularly for rare drug exposures, compared to traditional pregnancy registries.

Gestational Age Variation in Human Placental Drug Transporters

Patient and providers’ fear of fetal exposure to medications may lead to discontinuation of treatment, disease relapse, and maternal morbidity. Placental drug transporters play a critical role in fetal exposure through active transport but the majority of data are limited to the 3rd trimester, when the majority of organogenesis has already occurred. Our objective was to define gestational age (GA) dependent changes in protein activity, expression and modifications of five major placental drug transporters: SERT, P-gp, NET, BCRP and MRP3. Apical brush border membrane fractions were prepared from fresh 1st, 2nd and 3rd trimester human placentas collected following elective pregnancy termination or planned cesarean delivery. A structured maternal questionnaire was used to identify maternal drug use and exclude exposed subjects. Changes in placental transporter activity and expression relative to housekeeping proteins were quantified. There was evidence for strong developmental regulation of SERT, NET, P-gp, BCRP and MRP3. P-gp and BCRP decreased with gestation (r = −0.72, p < 0.001 and r = −0.77, p < 0.001, respectively). Total SERT increased with gestation but this increase was due to a decrease in SERT cleavage products across trimesters. Uncleaved SERT increased with GA (r = 0.89, p < 0.001) while cleaved SERT decreased with GA (r = −0.94, p < 0.001). Apical membrane NET overall did not appear to be developmentally regulated (r = −0.08, p = 0.53). Two forms of MRP3 were identified; the 50 kD form did not change across GA; the 160 kD form was steady in the 1st and 2nd trimester and increased in the 3rd trimester (r = 0.24, p = 0.02). The 50 kD form was expressed at higher levels. The observed patterns of SERT, NET P-gp, BCRP and MRP3 expression and activity may be associated with transporter activity or decreased placental permeability in the 1st trimester to transporter specific substrates including commonly used psychoactive medications such as anti-depressants, anti-psychotics, and amphetamines, while transport of nutrients and serotonin is important in the 1st trimester. Overall these observations are consistent with a strong protective effect during organogenesis. 3rd trimester estimates of fetal exposure obtained from cord blood likely significantly overestimate early fetal exposure to these medications at any fixed maternal dose.

Patients' Knowledge and Information Needs about Isotretinoin Therapy Use in Jordan

BACKGROUND

Despite being the first-line treatment for severe or moderate acne, isotretinoin has several serious side effects that necessitate the evaluation of patients' knowledge about isotretinoin side effects and its proper use.

OBJECTIVE

The current study aim was to explore information needs about isotretinoin by evaluating patients' knowledge about the appropriate use of isotretinoin and its associated side effects.

METHODS

In addition to the sociodemographic variables, a validated online questionnaire was adopted from the literature to evaluate patients' knowledge about isotretinoin use and its potential side effects. Independent t-test and one-way analysis of variance (ANOVA) test were implemented to find the correlation between the study variables and the knowledge score.

RESULTS

The most recognized side effect of isotretinoin therapy was dryness (98.1%). The study patients showed good knowledge about isotretinoin use with a mean knowledge score of 8.1 (SD = 0.7). However, more than half of them (61.0%) mistakenly thought that isotretinoin therapy should be taken continuously for more than 6 months without stop, and some of them did not know that isotretinoin is recommended to be taken with fatty meal (24%) and sunblock (24.6%). Female gender (8.2 (SD = 0.8)) and using isotretinoin for more than 6 months (8.3 (SD = 1.2)) were significantly associated with a higher knowledge score of isotretinoin use (p=0.01), when compared with male patients (7.8 (SD = 0.7)) and less than 6-month use of isotretinoin (7.7 (SD = 0.7)).

CONCLUSIONS

The lack of patients' information about the potential side effects, duration of therapy, and some instructions on isotretinoin use, such as taking the medication with fatty meal and sunblock, shed the light on the necessity to prepare leaflets, educational brochures, and educational posts via social media in order to improve patients' knowledge about isotretinoin therapy and its optimal use.

Beliefs and Risk Awareness on Medications Among Pregnant Women Attending the Antenatal Care Unit in Ethiopia University Hospital. Overestimating the Risks Is Another Dread

Background: Most studies on drug use during pregnancy were generally focused on potential teratogenic effects. However, beliefs and risk awareness of medications can also influence medication use and fetal well-being. Objective: This study aimed at assessing the risk awareness and beliefs on medication use among pregnant women attending antenatal care unit in an Ethiopian university hospital. Method: A cross-sectional study was employed in pregnant women who were attending for antenatal care service at Gondar University Referral Hospital from March 15, to April 15, 2016. A pretested structured interview questionnaire adopted from the Beliefs About Medicines Questionnaire (BMQ) was used for data collection. Chi-square test and binary logistic regression were used to identify possible predictors influencing the outcome variables. Result: Of the 423 women approached, 384 agreed to complete the questionnaire (90.8% response rate), and the mean age of the participants was 27.22 ± 5.5 years. More than two-thirds of the respondents had two to three (46.1%) or greater than three (25.8%) pregnancy histories. A third and nearly half (45.6%) of the respondents were on the first trimester and second trimester of their gestational age, respectively. The majority (70%) of pregnant women thought all drugs are harmful if taken during pregnancy. Only few (4.2%) of the participants did not mind taking drugs without professional advice. Most (90%) of the respondents were not willing to take drugs without professional advice. Pregnant women who came from rural areas had 25% less likelihood to self-medicate, with an adjusted odds ratio of 95% CI, 0.75 (0.37, 0.96). Conclusion: In this study, overestimated and exaggerated beliefs of medication risks during pregnancy are a concern, though cautious drug use is necessary and warranted. Adequate counseling has to be provided by physicians, pharmacists, and other healthcare professionals to change pregnant women's conservative attitudes and misinformed beliefs on medication risk.

The ethical justification for inclusion of neonates in pragmatic randomized clinical trials for emergency newborn care

BACKGROUND

Research guidelines generally recognize vulnerable populations to include neonates with the aim of enhancing protections from harm. In practice, such guidance results in limiting participation in randomized clinical trials (RCTs). Yet while medical care of neonates should be based on best research evidence to ensure that safe, efficacious treatment or procedures are used, this seldom happens in contemporary practice.

DISCUSSION

The compelling need to generate information on effectiveness and safety of procedures and medications that are already in use during neonatal care has led to increase in calls for pragmatic randomized clinical trials (PCTs). This raises ethical concerns as to whether exclusion of the vulnerable populations from research participations constitutes harm. First, neonates are denied access to both potentially beneficial research outputs and an opportunity to generate data on how interventions or medications perform in diverse clinical settings and inform clinical decision-making. Secondly, risks and harms in PCTs may differ from traditional RCTs, and can be reduced by modifications in study designs. The latter may involve assessment of effectiveness of comparable medication, devices or practices (whose safety data is available), randomization at the group level rather than at the individual level, avoidance of invasive and innovative study procedures, reliance on locally available data on relevant patient outcomes, and employment of procedures that tend to meet the criteria of minimal risk for human subject research. Thirdly, informed consent procedures should be modified from those of traditional RCTs, as neonates in traditional RCTs may be vulnerable to different extents in PCTs. Lastly, regulatory and oversight procedures designed for traditional RCT settings need modification, as they may not be translatable, feasible, appropriate or even ethical to apply in PCTs.

CONCLUSION

The principle of justice, commonly interpreted as preventing an inequitable burden of research, should also allow fair access to potential benefits from PCTs for neonates and other vulnerable populations. Under certain conditions, prospective randomized trials involving neonates should be ethically permissible to allow inclusion of neonates in research. This may require modification of the research design, consent procedures or regulations for research oversight.

The critical need for clinical decision support systems for identification and management of teratogenic medications

OBJECTIVES

To describe the critical need for clinical decision support systems to identify and manage use of potentially teratogenic medications in women of reproductive potential in the United States.

DATA SOURCES

Medline, CINAHL Plus, Academic Search Complete, International Pharmaceutical Abstracts, and the Cochrane Library databases were searched on November 1, 2018, with the key words (teratogen* OR birth defect OR Category D OR Category X OR (pregnancy or pregnant)) AND (clinical decision support OR decision support OR electronic record) to identify primary literature published in peer-reviewed journals describing clinical decision support systems implemented in outpatient settings in the United States to promote safe prescribing and clinician counseling for teratogenic medications. A hand search of the reference lists of relevant articles, including review articles, found through this search strategy was also performed.

SUMMARY

Despite the great potential for clinical decision support to assist clinicians in minimizing inadvertent fetal exposure to potentially teratogenic medications, there were only seven primary articles meeting the criteria. The results of these studies have shown some evidence of effectiveness yet had several notable limitations. No published clinical decision system showed great success. An eighth article, published in 2017, details the design of an intervention that had been implemented but not yet evaluated.

CONCLUSION

There is a relative paucity of data regarding clinical decision support systems focused on teratogenic medications in the outpatient setting in the United States. Additional clinical decision support systems in this area need to be developed.

Discussing Appropriate Medication Use and Multivitamin Intake with a Healthcare Provider: An Examination of Two Elements of Preconception Care Among Latinas

BACKGROUND

Counseling for appropriate medication use and folic acid consumption are elements of preconception care critical for improving pregnancy outcomes. Hispanic women receive less preconception care than women of other race/ethnic groups. The objective of this analysis is to describe differences in these two elements of preconception care among Hispanic subsegments.

MATERIALS AND METHODS

Porter Novelli's 2013 Estilos survey was sent to 2,609 U.S. Hispanic adults of the Offerwise QueOpinas Panel. Surveys were completed by 1,000 individuals (calculated response rate 42%), and results were weighted to the 2012 U.S. Census Hispanic proportions for sex, age, income, household size, education, region, country of origin, and acculturation. Responses were analyzed with weighted descriptive statistics, linear regression, and Rao-Scott chi-square tests.

RESULTS

Of the 499 female respondents, 248 had a child under the age of 18 years and were asked about healthcare provider discussions concerning medication use before or during their last pregnancy. Timing of discussions varied by maternal age, marital status, income, youngest child's country of birth, and acculturation. Discussions before pregnancy were reported by 47% of the female respondents; high acculturated women more often reported never having such discussions. Among female respondents, 320 were of reproductive age, and 27% of those reported daily multivitamin use. Multivitamin use varied by pregnancy intention and youngest child's country of birth, but did not vary significantly by acculturation.

CONCLUSIONS

Differences in discussions concerning medication use in pregnancy and multivitamin use exist among Hispanic subsegments based on pregnancy intention, marital status, income, youngest child's country of birth, and level of acculturation.

Utility of reproductive life plans in identification of potentially teratogenic medication use: A pilot study

BACKGROUND

Teratogenic medications increase risks of miscarriage, fetal death, and/or birth defects. It is important to identify whether women of childbearing potential are taking these medications and to minimize exposure to these agents through change in drug therapy before conception and/or use of effective contraception to prevent conception.

OBJECTIVE

To determine the utility of reproductive life plans as tools to identify women using potentially teratogenic medications.

METHODS

A retrospective review was conducted on reproductive life plans completed by women receiving services as part of the Toledo-Lucas County Healthy Start program. The medication section of the reproductive life plan was reviewed to determine: if it was completed; categories of medications reported (prescription, over-the-counter, vitamin/herbal); potentially teratogenic medications listed; contraception use and method.

RESULTS

Medication lists were completed for 437 of the 580 reproductive life plans reviewed (75%). Thirty-five women (8%) reported use of a potentially teratogenic medication; most commonly reported agents included blood pressure medications and antidepressants. Only 10 women taking a potentially teratogenic medication (29%) reported using some form of contraception, half of which reported use of a less effective method such as condoms.

CONCLUSION

The reproductive life plan can be a useful tool to identify women of childbearing age who require intervention due to use of potentially teratogenic medications. Efforts are needed to ensure complete and accurate reporting of medication use in reproductive life plans, and to promote effective contraceptive use among women taking potentially teratogenic medications.

Most Frequently Reported Prescription Medications and Supplements in Couples Planning Pregnancy: The LIFE Study

OBJECTIVE

To identify frequently reported prescription medications and supplements among couples planning pregnancy because there is a lack of descriptive information on these agents in women and men who are trying to conceive.

METHODS

Five hundred one couples enrolled in the Longitudinal Study of Infertility and the Environment, which took place between 2005 and 2009. Participants reported prescription medications as well as prescription and over-the-counter supplements used through interviews at study enrollment and through daily dairies during the 12-month follow-up. We identified prescription medications and supplements prospectively reported by ≥1% of women and men at baseline and from daily journal information grouped into 3-month preconception follow-up intervals while couples tried for pregnancy.

RESULTS

The 5 most reported prescription medications among women were levothyroxine (5.8%), cetirizine (2.6%), fluticasone (2.4%), escitalopram (1.8%), and fluoxetine (1.8%) and for men were lisinopril (2.0%), mometasone (2.0%), fexofenadine (1.8%), atorvastatin (1.6%), and montelukast (1.6%). The most reported supplements were multivitamins (63.3%, 43.5%) and fish oil (13.2%, 9.4%) for women and men, respectively, and prenatal vitamins (22.0%) for women. For women during the first 3 months of follow-up, prenatal vitamins (6.0%) and antibiotics (1.2%-2.6%) were among the most frequently started medications. During the next 3 months, clomiphene (4.5%) was the most frequently initiated medication.

CONCLUSIONS

Couples trying for pregnancy reported a variety of prescription medications and supplements, and they differed by gender. Preconception guidance should address medication and supplement use to avoid potential exposures associated with adverse reproductive and perinatal outcomes.

Why do women invest in pre-pregnancy health and care? A qualitative investigation with women attending maternity services

BACKGROUND

Despite the importance attributed to good pre-pregnancy care and its potential to improve pregnancy and child health outcomes, relatively little is known about why women invest in pre-pregnancy health and care. We sought to gain insight into why women invested in pre-pregnancy health and care.

METHODS

We carried out 20 qualitative in-depth interviews with pregnant or recently pregnant women who were drawn from a survey of antenatal clinic attendees in London, UK. Interviewees were purposively sampled to include high and low investors in pre-pregnancy health and care, with variation in age, partnership status, ethnicity and pre-existing medical conditions. Data analysis was conducted using the Framework method.

RESULTS

We identified three groups in relation to pre-pregnancy health and care: 1) The "prepared" group, who had high levels of pregnancy planning and mostly positive attitudes to micronutrient supplementation outside of pregnancy, carried out pre-pregnancy activities such as taking folic acid and making changes to diet and lifestyle. 2) The "poor knowledge" group, who also had high levels of pregnancy planning, did not carry out pre-pregnancy activities and described themselves as having poor knowledge. Elsewhere in their interviews they expressed a strong dislike of micronutrient supplementation. 3) The "absent pre-pregnancy period" group, had the lowest levels of pregnancy planning and also expressed anti-supplement views. Even discussing the pre-pregnancy period with this group was difficult as responses to questions quickly shifted to focus on pregnancy itself. Knowledge of folic acid was poor in all groups.

CONCLUSION

Different pre-pregnancy care approaches are likely to be needed for each of the groups. Among the "prepared" group, who were proactive and receptive to health messages, greater availability of information and better response from health professionals could improve the range of pre-pregnancy activities carried out. Among the "poor knowledge" group, better response from health professionals might yield greater uptake of pre-pregnancy information. A different, general health strategy might be more appropriate for the "absent pre-pregnancy period" group. The fact that general attitudes to micronutrient supplementation were closely related to whether or not women invested in pre-pregnancy health and care was an unanticipated finding and warrants further investigation.

Preconception care and reproductive planning in primary care

Preconception care is designed to identify and reduce biomedical, behavioral, and social risks to the health of a woman or her baby before pregnancy occurs. Few women present requesting preconception care; however, 1 in 10 US women of childbearing age will become pregnant each year. As primary care physicians (PCPs) care for reproductive-aged women before, between, and after their pregnancies, they are ideally positioned to help women address health risks before conception, including optimizing chronic conditions, to prevent adverse pregnancy and longer-term health outcomes. PCPs can help women make informed decisions both about preparing for pregnancy and about using effective contraception when pregnancy is not desired.

The pharmacist's role in promoting preconception health

OBJECTIVE

To review the pharmacist's role in preconception health.

DATA SOURCES

PubMed search using the terms preconception, immunizations, epilepsy, diabetes, depression, tobacco, asthma, hypertension, anticoagulation, pharmacist, pregnancy, and current national guidelines.

DATA SYNTHESIS

Preconception health has become recognized as an important public health focus to improve pregnancy outcomes. Pharmacists have a unique role as accessible health care providers to optimize preconception health by screening women for tobacco use, appropriate immunizations, and current medication use. Counseling patients on preconception risk factors and adequate folic acid supplementation as well as providing recommendations for safe and effective management of chronic conditions are also critical and within the scope of practice for pharmacists.

CONCLUSION

Pharmacists play an important role in medication screening, chronic disease state management, and preconception planning to aid women in preparing for healthy pregnancies.

Clinical features, current treatments and outcome of pregnant women with preeclampsaia/eclampsia in northern afghanistan

In Afghanistan, preeclampsia/eclampsia is the second leading cause of maternal deaths following maternal hemorrhage. This study aimed to describe clinical features, current treatments, and outcome among preeclampsia and eclampsia patients in the north region of Afghanistan. This was a retrospective study based on medical records of four center hospitals (one regional hospital and three provincial hospitals) in the north region of Afghanistan. Subjects were 322 patients with preeclampsia/eclampsia, admitted from March 2012 to March 2013. Out of 322 cases, 72.7% were diagnosed as preeclampsia and the rest as eclampsia. Those aged 30-39 years were 41.0% among preeclampsia patients and 29 years and younger were 35.2% among eclampsia patients (p= 0.002). The first delivery was significantly higher (p=0.045) among eclampsia patients (51.1%) than among preeclampsia patients (36.8%). While none died among the preeclampsia patients, 12 out of 88 eclampsia patients died in the hospitals. The causes of the 12 deaths were pulmonary edema (6 patients), renal failure (3 patients), cerebrovascular attack (2 patients), and hemorrhage (1 patient). There were no clinical findings at admission significantly associated with the deaths within the eclampsia patient group. Although the sample size was not large enough, patients admitted to the regional/provincial hospitals at the stage of preeclampsia had a low risk of death. Access at the stage of preeclampsia and improvement in treatments for eclampsia would reduce maternal mortality in Afghanistan.

Assessment of clinical outcomes and prescribing behavior among inpatients with severe preeclampsia and eclampsia: an Indian experience

Objectives:

The study aims to evaluate the management, maternal-fetal outcomes, and prescription behavior among inpatients with severe preeclampsia and eclampsia.

Materials and Methods:

This prospective cohort study in a tertiary referral center was conducted in 164 inpatient pregnant women who fulfilled the inclusion criteria. The study was conducted between November 2005 and February 2007. The patients were followed-up till delivery. Antepartum and intrapartum care and maternal and perinatal outcome were noted. Chief outcome measures were maternal and perinatal mortality and drug use indicators.

Results:

Median age at delivery of the women was 25 (22-28) years. Majority were suffering from antepartum eclampsia (52.5%), followed by preeclampsia (31%) and postpartum eclampsia (16.5%). Nulliparity (61.6%) was more common in eclampsia, while multiparity in preclamptic group. A total of 48% had preterm delivery. Most presented with headache (50%) and hyperreflexia (29%). Only 15% presented with all three prodromal symptoms and 86% had hypertension. There was increased morbidity, operative intervention, and admission to intensive care unit. Most babies (67%) weighed <2.5 kg and had poor outcome. The maternal mortality was 0.4/1000. Average number of drugs prescribed in patients of preeclampsia, antepartum eclampsia, and postpartum eclampsia were 13.2, 14.9, and 14.2, respectively. Antibiotics (24.6%) were the most common class of the drugs prescribed in all the groups, followed by vitamin and calcium supplements (22.7%) and antihypertensives (13.5%). Most common antihypertensive used were calcium channel blockers and anticonvulsant magnesium sulphate.

Conclusions:

There was increased maternal and perinatal morbidity. Protocols for the management of eclampsia, including antihypertensive and anticonvulsant therapies, should be available and reviewed regularly to improve the standard of care and reduce the prevalence of this dangerous condition.

How do women prepare for pregnancy? Preconception experiences of women attending antenatal services and views of health professionals

MAIN OBJECTIVE

To determine the extent to which women plan and prepare for pregnancy.

METHODS

Cross-sectional questionnaire survey of pregnant women attending three maternity services in London about knowledge and uptake of preconception care; including a robust measure of pregnancy planning, and phone interviews with a range of health care professionals.

MAIN RESULTS

We recruited 1173/1288 (90%) women, median age of 32 years. 73% had clearly planned their pregnancy, 24% were ambivalent and only 3% of pregnancies were unplanned. 51% of all women and 63% of those with a planned pregnancy took folic acid before pregnancy. 21% of all women reported smoking and 61% reported drinking alcohol in the 3 months before pregnancy; 48% of smokers and 41% of drinkers reduced or stopped before pregnancy. The 51% of all women who reported advice from a health professional before becoming pregnant were more likely to adopt healthier behaviours before pregnancy [adjusted odds ratios for greatest health professional input compared with none were 2.34 (95% confidence interval 1.54-3.54) for taking folic acid and 2.18 (95% CI 1.42-3.36) for adopting a healthier diet before pregnancy]. Interviews with 20 health professionals indicated low awareness of preconception health issues, missed opportunities and confusion about responsibility for delivery of preconception care.

SIGNIFICANCE OF THE FINDINGS

Despite a high level of pregnancy planning, awareness of preconception health among women and health professionals is low, and responsibility for providing preconception care is unclear. However, many women are motivated to adopt healthier behaviours in the preconception period, as indicated by halving of reported smoking rates in this study. The link between health professional input and healthy behaviour change before pregnancy is a new finding that should invigorate strategies to improve awareness and uptake of pre-pregnancy health care, and bring wider benefits for public health.

Asthma and pregnancy

Asthma is probably the most common serious medical disorder that may complicate pregnancy. A third of pregnant women with asthma will experience worsening of their symptoms, a third will see improvement of their symptoms and a third will see no change. The primary goal is to maintain optimal control of asthma for maternal health and well-being as well as fetal maturation. Vital patient education should cover the use of controller medication, avoidance of asthma triggers and early treatment of asthma exacerbations. Proper asthma management should ideally be started in the preconception period. Since smoking is probably the most modifiable risk factor of asthma, pregnant woman should avoid active and passive smoking. Acute asthma exacerbation during the first trimester is associated with an increased risk of congenital malformations. Poorly controlled asthma is associated with low birth weight, preeclampsia, and preterm birth. Medications used for asthma control in the non-pregnant population are generally the same in pregnancy with a few exceptions. Inhaled corticosteroids (ICS) are the preferred controller therapy. Budesonide is the preferred ICS. Long-acting B-agonists (LABA) are the preferred add-on therapy to medium to high dose ICS. Major triggers for asthma exacerbations during pregnancy are viral infections and ICS nonadherence.

Management of prescription and nonprescription drug use during pregnancy

OBJECTIVE

To assess screening and treatment patterns of obstetrician-gynecologists regarding medication use during pregnancy.

METHODS

A questionnaire was mailed to 770 members of the American College of Obstetricians and Gynecologists who participate in the Collaborative Ambulatory Research Network.

RESULTS

The response rate was 58%. Most respondents reported always asking pregnant patients about use of over-the-counter (OTC) (86%) and prescription (98%) drugs; 24% reported not always asking about alternative medications. Far fewer reported always asking nonpregnant patients about use of alcohol (67%), illegal drugs (51%) and OTC medications (52%) than pregnant patients. Two-fifths (41%) reported prescribing a medication during pregnancy for which they had insufficient information about potential effects on the fetus; nearly half (47%) reported that there are medical conditions for which they would like to prescribe medications but do not due to insufficient safety information. Physician responses indicate that they are less likely to refer pregnant than nonpregnant patients to a specialist for treatment of certain conditions.

CONCLUSIONS

These results indicate that obstetrician-gynecologists sometimes prescribe medications for pregnant patients under less than optimal conditions and emphasize the importance of generating up-to-date information on effects of medications during pregnancy and having it readily available to health care providers.

Isotretinoin use and compliance with the Dutch Pregnancy Prevention Programme: a retrospective cohort study in females of reproductive age using pharmacy dispensing data

BACKGROUND

Isotretinoin is very effective in the treatment of severe acne. However, because of the teratogenic properties of this agent an isotretinoin Pregnancy Prevention Programme (PPP) was implemented in the Netherlands to guarantee that treatment is contraindicated in women of reproductive age unless at least one effective method of contraception is used. Furthermore, the PPP stipulates that isotretinoin treatment should be managed by physicians or specialists experienced in treatment with this drug and that only monthly prescriptions are issued.

OBJECTIVE

To assess compliance with the Dutch isotretinoin PPP in women of reproductive age during the study period of 1 January 2005 to 31 December 2008.

METHODS

Detailed information on dispensed medication and co-medication was available from the Dutch Foundation of Pharmaceutical Statistics. Four types of outcome were studied: concomitant dispensing of hormonal contraceptive with isotretinoin; the proportion of specialist prescribing of isotretinoin; prescribing of conventional acne therapy prior to isotretinoin initiation; and isotretinoin dispensing exceeding the maximum amount. The use of contraceptives in women aged between 15 and 45 years was defined as concomitant if the period of systemic contraceptive use overlapped the period of isotretinoin dispensing for at least 10 days, or if any dispensing of an intrauterine or intravaginal contraceptive was recorded since the year 2000. Dispensings were separated into those prescribed by either specialists or general practitioners (GPs). The use of antibacterials, antiandrogens or topical agents against acne was checked 4 months prior to an isotretinoin dispensing, and a possible excess of the maximum amount of isotretinoin was defined as prescriptions of more than 100 defined daily doses.

RESULTS

During the study period, data were available for 442 Dutch pharmacies encompassing 4881 women of reproductive age using isotretinoin at least once during study period. Among women of reproductive age, the use of isotretinoin increased during the study period. The proportion of isotretinoin initiation with concomitant oral hormonal or intrauterine contraceptives was low (59.3% [95% CI 57.6, 61.0]). Initiation of isotretinoin by a specialist increased the chance for concomitant contraception by 26% (95% CI 6.0, 49.0); in 78.2% (95% CI 76.8, 79.6) of women, isotretinoin was initiated by a specialist. Conventional acne therapy up to 16 months prior to isotretinoin initiation was found in 70% of the women (70.3% [95% CI 66.0, 74.6]). In 1.4% (95% CI 1.0, 1.8) of cases of treatment initiation, the amount of isotretinoin dispensed on one prescription seemed too high.

CONCLUSION

Attention should be paid to improving the implementation of the isotretinoin PPP. Despite clear guidelines and warnings in the product information, our study strongly suggests that concomitant use of isotretinoin and contraceptives is too low. Even though we will have missed non-pharmacological forms of contraception, these results raise doubts about the safe use of isotretinoin in women of reproductive age in the Netherlands. Furthermore, isotretinoin does not seem to be used in cases of severe acne only. Reserving isotretinoin prescribing to specialists may improve adherence to the PPP.

Embryonic development and pregnancy test sensitivity: the importance of earlier pregnancy detection

Embryogenesis research provides information on a time of heightened vulnerability in embryo development: the time from conception to the day a woman misses her menstrual period. During this period, it is vital for the woman to be aware of exposures, behaviors and nutritional factors that could negatively impact the developing embryo. This article discusses this critical, often-overlooked window of development and will review the various types of teratogens that affect pregnancy. Over-the-counter pregnancy tests are widely used to determine pregnancy status. Earlier test models detected only the pregnancy hormone human chorionic gonadotropin in the urine, but it is now known that there are other key forms of human chorionic gonadotropin that are relevant when determining pregnancy status. This article will explain why early knowledge of pregnancy status is important for both woman and embryo, and the role that patient education and pregnancy test choice can have on normal embryonic development.

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.

The clinical content of preconception care: the use of medications and supplements among women of reproductive age

The use of prescription and over-the-counter medications and dietary supplements are common among women of reproductive age. For medications, little information about the teratogenic risks or safety is available, as pregnant women are traditionally excluded from clinical trials, and premarketing animal studies do not necessarily predict the effects of treatment in human pregnancy. Even less is typically known about the effects of dietary supplements on pregnancy outcomes, as they are not held to the same rigorous safety and efficacy standards as prescription medications. Congenital anomalies associated with medication use are potentially preventable, because they are linked with modifiable maternal exposures during the period of organogenesis. However, as women of reproductive age experience acute and chronic conditions that can result in adverse outcomes for the woman and her offspring, the benefits of use of a particular medication before or early in pregnancy may outweigh the risks. Resources and principles outlined in this article will aid healthcare providers in selecting appropriate medication regimens for women of reproductive age, particularly those with chronic health conditions, those who are planning a pregnancy, and those who may become pregnant.

The second wave: Toward responsible inclusion of pregnant women in research

Though much progress has been made on inclusion of non-pregnant women in research, thoughtful discussion about including pregnant women has lagged behind. We outline resulting knowledge gaps and their costs and then highlight four reasons why ethically we are obliged to confront the challenges of including pregnant women in clinical research. These are: the need for effective treatment for women during pregnancy, fetal safety, harm from the reticence to prescribe potentially beneficial medication, and the broader issues of justice and access to benefits of research participation. Going forward requires shifting the burden of justification from inclusion to exclusion and developing an adequate ethical framework that specifies suitable justifications for excluding pregnant women from research.