Making Decisions About Medication Use During Pregnancy: Implications for Communication Strategies

Interpersonal Influences on the Choice to Treat Nausea during Pregnancy with Medication or Cannabis

OBJECTIVE

 This study aimed to better understand the interpersonal influences on a pregnant individual's decision of how to treat nausea and vomiting during pregnancy using a qualitative approach.

STUDY DESIGN

 A semistructured interview guide was developed to assess pregnancy symptoms, decision-making regarding treating nausea, and interpersonal influences on treatment decisions. Interviews were conducted with 17 individuals enrolled in a neuroimaging and behavioral study of prenatal exposure to cannabis who used medication and/or cannabis to treat symptoms associated with pregnancy.

RESULTS

 Interviews revealed four groups of stakeholders who influenced participant decision-making: medical providers, partners, family, and friends. Influence was categorized as either positive, negative, neutral, or absent (if not discussed or participant chose not to disclose). Those in the medication group reported only positive or neutral feedback from friends, family, partners, and providers. In contrast, the cannabis group participants reported positive feedback from friends, mixed feedback from family and partners, and negative feedback from providers, which was often felt to be stigmatizing. Many in the cannabis group also reported varying feedback from different medical providers. While the cannabis group frequently reported eliciting feedback from friends, family, and partners, the medication group often did not.

CONCLUSION

 Medication group participants reported entirely positive feedback from providers and often did not mention any feedback at all from partners, family, and friends. Cannabis group participants reported much more varied feedback, both positive and negative, from a variety of interpersonal contacts and sometimes decided to conceal their treatment choice after receiving or fearing negative feedback. We recommend further research into the health outcomes of pregnant patients who chose not to discuss their treatment decisions with providers, family, partners, or friends. We also suggest further study of possible reasons behind a lack of disclosure, including fear of stigma and/or legal consequences.

KEY POINTS

· Providers, partners, family, friends gave feedback.. · Medication group got positive feedback.. · Cannabis group stigmatized by providers.. · Cannabis group got mixed feedback..

Determinants of Non-Acceptance of the COVID-19 Vaccine During Pregnancy in Pregnant and Postpartum Women: A Descriptive Cross-Sectional Study

Objective

The rate of COVID-19 vaccination hesitation among Iranian pregnant women is around 50%. The objective of the present study was to determine the reasons for the refusal of COVID-19 vaccination among pregnant and postpartum women.

Materials and methods

This descriptive cross-sectional study was performed on 304 pregnant and postpartum women in the comprehensive health centers of Yazd, Iran, between October 2022 and April 2023. Researchers collected the data of unvaccinated women through phone calls using a validated questionnaire. Data was collected using a questionnaire consisting of baseline characteristics and reasons for refusing vaccination. Descriptive statistics were used to analyze the data using SPSS version 22.

Results

The mean age of the pregnant and postpartum women participating in this study was 28.31 ± 6.47 years. The most common reasons for refusing the COVID-19 vaccine included fear of harming the fetus (32.2%), fear of side effects in the mother (25.7%), disbelief in COVID-19 disease and vaccine (13.8%), lack of information about the vaccine (12.8%), and negative opinions of the media and society (12.8%). Less common reasons included husband's disagreement (8.2%), history of COVID-19 infection (6.9%), gynecologists' disagreement (6.3%), history of infertility (5.9%), and underlying disease (3.3%). Astonishingly, among participants who did not inject a booster dose of the vaccine, 76% reported they didn't receive any training and recommendation on booster dose injection from health providers.

Conclusion

Findings highlight that the most common reasons for refusing the COVID-19 vaccine were fear of harming the fetus and fear of side effects in the mother.

Detection and evaluation of signals associated with exposure to individual and combination of medications in pregnancy: a signal detection study protocol

INTRODUCTION

Considering the high prevalence of polypharmacy in pregnant women and the knowledge gap in the risk-benefit safety profile of their often-complex treatment plan, more research is needed to optimise prescribing. In this study, we aim to detect adverse and protective effect signals of exposure to individual and pairwise combinations of medications during pregnancy.

METHODS AND ANALYSIS

Using a range of real-world data sources from the UK, we aim to conduct a pharmacovigilance study to assess the safety of medications prescribed during the preconception period (3 months prior to conception) and first trimester of pregnancy. Women aged between 15 and 49 years with a record of pregnancy within the Clinical Practice Research Datalink (CPRD) Pregnancy Register, the Welsh Secure Anonymised Information Linkage (SAIL), the Scottish Morbidity Record (SMR) data sets and the Northern Ireland Maternity System (NIMATS) will be included. A series of case control studies will be conducted to estimate measures of disproportionality, detecting signals of association between a range of pregnancy outcomes and exposure to individual and combinations of medications. A multidisciplinary expert team will be invited to a signal detection workshop. By employing a structured framework, signals will be transparently assessed by each member of the team using a questionnaire appraising the signals on aspects of temporality, selection, time and measurement-related biases and confounding by underlying disease or comedications. Through group discussion, the expert team will reach consensus on each of the medication exposure-outcome signal, thereby excluding spurious signals, leaving signals suggestive of causal associations for further evaluation.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Independent Scientific Advisory Committee, SAIL Information Governance Review Panel, University of St. Andrews Teaching and Research Ethics Committee and Office for Research Ethics Committees Northern Ireland (ORECNI) for access and use of CPRD, SAIL, SMR and NIMATS data, respectively.

Placental drug transport and fetal exposure during pregnancy is determined by drug molecular size, chemistry, and conformation

Pregnant people are unable to take many prescription and over-the-counter medications because of suspected or known risk to the fetus. This undermedication contributes to the high maternal mortality rate in the United States and detracts from the quality of life of pregnant people. As such, there is an urgent need to develop safe pharmaceutical formulations for use during pregnancy. Most drugs are small molecules that easily cross the placenta, which is the biological barrier that separates the maternal and fetal bloodstreams. One potential approach to preventing fetal drug accumulation is to design drug compounds that are excluded by the placenta; however, there is little understanding of how macromolecular drug properties affect transplacental transport. To address this knowledge gap, we examined the transport behavior of fluorescently-labeled polymers with varying size, conformation, and chemistry. We compared these polymers to unconjugated fluorescein, a small molecule model drug that readily crosses biological barriers. We found that molecular size affected transplacental transport in an in vitro model, BeWo b30 monolayers, as well as in pregnant mice, with larger polymers having lower permeability. In addition to size, polymer chemistry altered behavior, with polyethylene glycol (PEG) molecules permeating the placental barrier to a greater extent than dextrans of equivalent molecular weight. PEG molecules were also more readily taken up into placental cells in vivo. These findings will inform the future development of drug conjugates or other macromolecular medicines that can safely be used during pregnancy.

Key outcomes for reporting in studies of pregnant women with multiple long-term conditions: a qualitative study

BACKGROUND

Maternal multiple long-term conditions are associated with adverse outcomes for mother and child. We conducted a qualitative study to inform a core outcome set for studies of pregnant women with multiple long-term conditions.

METHODS

Women with two or more pre-existing long-term physical or mental health conditions, who had been pregnant in the last five years or planning a pregnancy, their partners and health care professionals were eligible. Recruitment was through social media, patients and health care professionals' organisations and personal contacts. Participants who contacted the study team were purposively sampled for maximum variation. Three virtual focus groups were conducted from December 2021 to March 2022 in the United Kingdom: (i) health care professionals (n = 8), (ii) women with multiple long-term conditions (n = 6), and (iii) women with multiple long-term conditions (n = 6) and partners (n = 2). There was representation from women with 20 different physical health conditions and four mental health conditions; health care professionals from obstetrics, obstetric/maternal medicine, midwifery, neonatology, perinatal psychiatry, and general practice. Participants were asked what outcomes should be reported in all studies of pregnant women with multiple long-term conditions. Inductive thematic analysis was conducted. Outcomes identified in the focus groups were mapped to those identified in a systematic literature search in the core outcome set development.

RESULTS

The focus groups identified 63 outcomes, including maternal (n = 43), children's (n = 16) and health care utilisation (n = 4) outcomes. Twenty-eight outcomes were new when mapped to the systematic literature search. Outcomes considered important were generally similar across stakeholder groups. Women emphasised outcomes related to care processes, such as information sharing when transitioning between health care teams and stages of pregnancy (continuity of care). Both women and partners wanted to be involved in care decisions and to feel informed of the risks to the pregnancy and baby. Health care professionals additionally prioritised non-clinical outcomes, including quality of life and financial implications for the women; and longer-term outcomes, such as children's developmental outcomes.

CONCLUSIONS

The findings will inform the design of a core outcome set. Participants' experiences provided useful insights of how maternity care for pregnant women with multiple long-term conditions can be improved.

Polysubstance use during pregnancy: The importance of screening, patient education, and integrating a harm reduction perspective

BACKGROUND

Substance use during pregnancy is associated with poor health outcomes. This study assessed substance use, polysubstance use, and use of select prescription medications during pregnancy.

METHODS

We analyzed 2019 data from the Pregnancy Risk Assessment Monitoring System in 25 United States jurisdictions that included questions on prescription medications, tobacco, and illicit substance use during pregnancy. Alcohol and electronic cigarette use were assessed during the last three months of pregnancy, and all other substances and medications were assessed throughout pregnancy. Weighted prevalence estimates and 95% confidence intervals (CIs) were calculated.

RESULTS

Nearly one-fifth of respondents who reported use of any substance reported use of at least one other substance during pregnancy. Cigarettes (8.1%; 95% CI 7.6-8.7%) and alcohol (7.4%; 95% CI 6.7-8.1%) were the most frequently reported substances, followed by cannabis (4.3%; 95% CI 3.9-4.7%). Substance use was higher among individuals who reported having depression or using antidepressants during pregnancy compared with those who did not report depression or antidepressant use. Illicit drug use prevalence was low (0.5%, 95% CI 0.4-0.7%); however, respondents reporting heroin use also frequently reported use of illicit stimulants (amphetamines: 51.7%, 95% CI 32.1-71.3% or cocaine: 26.5%, 95% CI 11.9-41.1%). Although prenatal clinician screening for alcohol and cigarette use was approximately 95%, fewer respondents (82.1%) reported being screened for cannabis or illicit substance use during pregnancy.

CONCLUSIONS

One in five individuals who reported use of any substance during pregnancy engaged in polysubstance use, highlighting the importance of comprehensive screening and evidence-based interventions including harm reduction.

Antibiotic Use in Pregnancy: A Global Survey on Antibiotic Prescription Practices in Antenatal Care

Antibiotic prescription and use practices in the antenatal care setting varies across countries and populations and has the potential to significantly contribute to the global spread of antibiotic resistance. This study aims to explore how healthcare practitioners make decisions about antibiotic prescriptions for pregnant women and what factors play a role in this process. A cross-sectional exploratory survey consisting of 23 questions, including 4 free-text and 19 multiple-choice questions, was distributed online. Quantitative data were collected through multiple-choice questions and was used to identify the most common infections diagnosed and the type of antibiotics prescribed. Qualitative data were gathered through free-text answers to identify gaps, challenges, and suggestions, and the data were analyzed using thematic analysis. A total of 137 complete surveys mostly from gynecologists/obstetricians from 22 different countries were included in the analysis. Overall, national and international clinical guidelines and hospital guidelines/protocols were the most frequently used sources of information. This study highlights the crucial role of laboratory results and guidelines at different levels and emphasizes region-specific challenges and recommendations. These findings underscore the pressing need for tailored interventions to support antibiotic prescribers in their decision-making practice and to address emerging resistance.

COVID‑19 vaccine hesitancy among pregnant women and their reported reasons for vaccine refusal - A prospective study in Tehran, Iran

OBJECTIVE

Evaluation of covid‑19 vaccine hesitancy among pregnant women and their reported reasons for vaccine refusal.

METHODS

This prospective study was performed in Arash women's Hospital, Tehran, Iran, between December 1, 2021 and January 1, 2022. All pregnant women who were attended to prenatal care unit were considered eligible for inclusion. A validated questionnaire was used for data gathering. Written informed consent was obtained from all participants.

RESULTS

Finally, 477 pregnant women were recruited and were divided into two groups according the status of vaccine acceptance (237 accepted and 240 women refused vaccination). The mean age of accepted participants was higher (31.65 ± 5.69 vs 30.39 ± 5.5; P = 0.01). There was a significant statistical difference between the groups regarding education level. Access to internet and social media were also significantly different between the two groups (94.8% in accepted vs 86.6% in refused group; P = 0.002). There was more rate of severe COVID-19 infection in friends or relatives of accepted group (50% vs 38%). we did not find any statistically significant differences in obstetric characteristics and the rate of obstetric complications between the two groups. The most common reasons reported by participants for vaccine refusal, was fear of vaccination side effects on the fetus (86.5%), and the less common reported reasons were husband's disagreement (9.7%), use of traditional medicine (5.6%), religious beliefs (3.7%), and information obtained from social media (2.8%). After advices from medical staff, most of these mothers (86.5%) still refused vaccination.

CONCLUSION

Based on the results of the present study,rate of COVID-19 vaccine hesitancy was about 50% and its most common reported reason was fear of probable side effects of vaccine on the fetus.

Behaviors Related to Medication Safety and Use During Pregnancy

Background: Most women take medication during pregnancy despite limited scientific evidence on safety. We investigated medication use, including changes in and reasons for changes in use during pregnancy, with attention to medication use in pregnant women with chronic conditions. Materials and Methods: We conducted an online survey of pregnant women aged ≥18 years (n = 1,226). We calculated descriptive statistics for aspects of medication use and performed multivariable logistic regression to examine associations between change in use and chronic conditions. Results: Seventy-nine percent of women took at least one medication during pregnancy. Among those, 63.2% made at least one medication change: 42.0% started, 34.9% stopped, 30.0% missed dose(s), and 18.1% lowered dose(s) from that originally prescribed or recommended. More than a third (36.5%) of women who stopped, lowered, or missed medication did so independent of health care provider advice; 54.0% cited concern about birth or developmental defects as reasons for change. Odds of medication change were higher for women with chronic conditions: digestive conditions-starting (adjusted odds ratio [AOR] = 1.8, 95% confidence interval [CI] = 1.1-2.7), stopping (AOR = 2.1, 95% CI = 1.4-3.3), and lowering (AOR = 2.4, 95% CI = 1.7-3.3) medication; mental health conditions-starting (AOR = 1.6, 95% CI = 1.2-2.2), stopping (AOR = 3.0, 95% CI = 2.3-4.0), or missing (AOR = 2.1, 95% CI = 1.6-2.8) medication; pain conditions-stopping (AOR = 2.9, 95% CI = 2.0-4.2); and respiratory conditions-starting (AOR = 2.0, 95% CI = 1.3-3.1), stopping (AOR = 1.7, 95% CI = 1.1-2.6), and missing (AOR = 2.2, 95% CI = 1.4-3.4) medication. Conclusions: Most pregnant women take medication and many, including those with chronic conditions, change their medication use during pregnancy. Medication change may occur independent of health care provider advice and due to women's safety concerns.

Obstetrician-gynecologists' perspectives towards medication use during pregnancy: A cross-sectional study

A vast majority of studies evaluated pregnant women's knowledge and attitudes towards using medications during their pregnancy, with few global and lack of regional studies conducted to spot obstetrician-gynecologists practices in this regard. This study aims to assess Obstetrician-gynecologists' knowledge of medication teratogenicity potential, their frequently used resources, and their residency training contribution to medication use during pregnancy. This is a cross-sectional, survey-based study targeting licensed Obstetrician-gynecologists who are practicing in Saudi Arabia using a validated self-administered web-based questionnaire developed by the American College of Obstetricians and Gynecologists. A total of 60 obstetrician-gynecologists were included in the study. Most participants were female (72%) with median age and clinical experience of 42 and 13 years, respectively. The majority (87%) agreed that Isotretinoin is contraindicated, while around 60% of respondents were unsure about the safety of herbal remedies use. Online databases (e.g., Lexi-Comp and Micromedex) were chosen as the top utilized medication resources (45%). Around 48% strongly agreed that liability is a concern if there were adverse pregnancy outcomes following the use of medications. Regarding their training assessment, obstetrician-gynecologists who had been in practice for more than 15 years were significantly more likely to rate themselves as well qualified (P value < .05). The majority adequately and significantly rated their training on prescribed medications (58.3%), OTC medications (45%) and dietary supplements or herbal remedies (32%) (P value < .05). Obstetrician-gynecologists showed a different level of knowledge about the risks and safety of medications when used during pregnancy. More efforts are needed to optimize medication selection, herbal avoidance, and training performance.

Risk of pre-eclampsia and impact of disease activity and antirheumatic treatment in women with rheumatoid arthritis, axial spondylarthritis and psoriatic arthritis: a collaborative matched cohort study from Sweden and Denmark

Objective

To explore the risk of pre-eclampsia in rheumatoid arthritis (RA), axial spondyloarthritis (AxSpA) and psoriatic arthritis (PsA), focusing on the impact of treatment and disease activity.

Methods

We identified RA, AxSpA and PsA singleton pregnancies (2006–2018) by linking medical birth registers to Swedish (SRQ) and Danish (DANBIO) rheumatology registers. Control pregnancies from the medical birth registers were matched 1:10 on maternal age, parity and birth year.

We obtained information on antirheumatic treatment before and during pregnancy and disease activity during pregnancy. Risks of pre-eclampsia in RA, AxSpA and PsA pregnancies, compared with control pregnancies, were estimated overall and by antirheumatic treatment (conventional synthetic disease-modifying antirheumatic drug (DMARD)/biological DMARD/corticosteroids, as monotherapy or combination therapy) and disease load (Health Assessment Questionnaire≥1/C-reactive protein≥10/Disease Activity Score in 28 joints≥3.2) through logistic regression (adjusted ORs (aORs) with 95% CI).

Results

We observed 69, 34, and 26 pre-eclampsia events among RA (n=1739), AxSpA (n=819) and PsA (n=489), resulting in a risk of pre-eclampsia of, respectively, aOR 1.27 (95% CI 0.96 to 1.67), 1.17 (0.76 to 1.78) and 1.85 (1.10 to 3.12), compared with controls.

For RA, maternal combination therapy before and during pregnancy was associated with increased risk (1.59; 1.07 to 2.37 and 1.53; 0.97 to 2.39, respectively). For PsA, maternal monotherapy before pregnancy was associated with pre-eclampsia (2.72; 1.4 to 5.13). In RA pregnancies with available information (43%), high disease load was associated with doubled risk of pre-eclampsia (aOR 1.96; 1.26 to 3.04).

Conclusion

PsA pregnancies, but not AxSpA pregnancies, were at increased risk of pre-eclampsia. For RA, combination therapy (potentially a surrogate for high disease activity both before and during pregnancy) and high disease load during pregnancy might be a risk factor for pre-eclampsia.

Neonatal outcomes associated with in utero exposure to oxycodone, overall and by trimester of exposure: A retrospective cohort study

Oxycodone is commonly used by pregnant women for the treatment of pain. However, the potential risk associated with its use in pregnancy have not been robustly evaluated. The objective of this study was to examine neonatal outcomes associated with prenatal oxycodone exposure. State dispensing records were matched with midwives records to identify women who had been dispensed oxycodone during pregnancy (n=302). A matched comparison group of women who had been prescribed oxycodone prior to pregnancy was also identified (n=604). Hospital, mortality and congenital abnormality data were obtained for each mother-child dyad. Neonatal outcomes were examined for association with any exposure during pregnancy and trimester specific exposure, using generalized linear models. First trimester exposure was not associated with a significant increased risk of congenital anomalies (OR: 1.74 95%CI: 0.78, 3.87). Second trimester exposure to oxycodone was associated with reduction in average length of gestation (aCoef:-0.83, 95%CI: -1.26, -0.41) and birth weight (aCoef:-188, 95%CI: -299, -76). Second trimester exposure was also associated with an increased risk of very preterm birth (<32 weeks) (OR: 5.03, 95%CI: 1.95, 12.98) and admission to the special care nursery (aOR:1.99, 95%CI: 1.30, 3.03). Third trimester exposure to oxycodone was associated with a reduction in average length of gestation (aCoef:-0.33, 95%CI: -0.63, -0.02) compared with the comparison group. The use of oxycodone in pregnancy was not associated with an increased risk of congenital anomalies. However, oxycodone exposure was associated with a short period of gestation, preterm birth, and NAS, which likely contributed to a longer period of hospitalization following birth. PERSPECTIVE: This article assesses the neonatal risks associated with prenatal exposure to oxycodone, providing clinicians and patients with important information on the safety of oxycodone in the treatment of pain in pregnancy.

How women with obsessive compulsive disorder experience maternity care and mental health care during pregnancy and postpartum: A systematic literature review

INTRODUCTION

Obsessive Compulsive Disorder has a higher prevalence in pregnancy and postpartum than in the general population. Experiences of maternity care and mental health care can impact the health and wellbeing of perinatal women. The aim of this review was to synthesize evidence on the experiences of maternity care and mental health care for women with OCD during pregnancy and postpartum.

METHODS

Studies were systematically reviewed by two independent reviewers after identification in MEDLINE, Embase, PsycINFO, Global Health, CINAHL, the Cochrane Library, Web of Science and grey literature searches (last searched October 2021). Papers meeting pre-specified inclusion criteria were extracted using a pre-determined extraction sheet and were quality assessed. Thematic synthesis was conducted.

RESULTS

19 papers reporting 18 studies describing 33 participants were included. Three descriptive themes were found: experiences of barriers to treatment and care, experiences of treatment/care decision making and experiences of treatment and care. Three analytic themes were found demonstrating tensions: keeping baby healthy vs keeping mother healthy, keeping baby safe vs keeping mother safe, and normal perinatal experience vs not normal perinatal experience.

LIMITATIONS

Despite an inclusive search strategy, available data was limited. 17 of the studies were case studies that were poor in quality. Synthesis and subsequent findings were limited.

CONCLUSIONS

There were significant literature gaps for all aspects of care but particularly around experiences of maternity and pharmacological care. Tensions that could impact the experience of care need to be carefully balanced to ensure that women with OCD get the care that they need.

Impact of a Mobile Application for Tracking Nausea and Vomiting During Pregnancy (NVP) on NVP Symptoms, Quality of Life, and Decisional Conflict Regarding NVP Treatments: MinSafeStart Randomized Controlled Trial

Background

Pregnant women are active users of mobile apps for health purposes. These apps may improve self-management of health-related conditions. Up to 70% of pregnant women experience nausea and vomiting (NVP). Even mild NVP can significantly reduce quality of life (QoL), and it can become an economic burden for both the woman and society. NVP often occurs before the first maternal care visit; therefore, apps can potentially play an important role in empowering pregnant women to recognize, manage, and seek appropriate treatment for NVP, when required.

Objective

This study investigated whether the MinSafeStart (MSS) mobile app could impact NVP-related symptoms, QoL, and decisional conflict regarding NVP treatment.

Methods

This randomized controlled trial enrolled 268 pregnant women with NVP in Norway from 2019 to 2020. The intervention group had access to the MSS app, which could be used to track NVP symptoms and access tailored advice. NVP severity was rated with the Pregnancy Unique Quantification of Emesis (PUQE) score. The control group followed standard maternal care. We collected data on maternal baseline characteristics, NVP severity, QoL, and decisional conflict using 2 sets of online questionnaires. One set of questionnaires was completed at enrollment, and the other was completed after 2 weeks. We performed linear regression analyses to explore whether the use of the MSS app was associated with NVP severity, QoL, or decisional conflict.

Results

Among the 268 women enrolled in the study, 192 (86.5%) completed the baseline questionnaires and were randomized to either the intervention (n=89) or control group (n=103). In the intervention group, 88 women downloaded the app, and 468 logs were recorded. In both groups, women were enrolled at a median of 8 gestational weeks. At baseline, the average PUQE scores were 4.9 and 4.7; the average QoL scores were 146 and 149; and the average DCS scores were 40 and 43 in the intervention and control groups, respectively. The app had no impact on NVP severity (aβ 0.6, 95% Cl −0.1 to 1.2), QoL (aβ −5.3, 95% Cl −12.5 to 1.9), or decisional conflict regarding NVP treatment (aβ −1.1, 95% Cl −6.2 to 4.2), compared with standard care.

Conclusions

Tracking NVP symptoms with the MSS app was not associated with improvements in NVP symptoms, QoL, or decisional conflict after 2 weeks, compared with standard care. Future studies should include a process evaluation to improve our understanding of how pregnant women use the app and how to optimize its utility within maternity care. Specifically, studies should focus on how digital tools might facilitate counseling and communication between pregnant women and health care providers regarding NVP management during pregnancy.

Trial Registration

ClinicalTrails.gov (NCT04719286): https://www.clinicaltrials.gov/ct2/show/NCT04719286

Assessment of adherence to aspirin for preeclampsia prophylaxis and reasons for nonadherence

BACKGROUND

Preeclampsia is a hypertensive disease unique to pregnancy and has a significant impact on maternal and neonatal morbidity and mortality. Daily aspirin has been demonstrated to reduce the risk of preeclampsia. The American College of Obstetricians and Gynecologists recommends daily low-dose aspirin, ideally before 16 weeks' gestation, in at-risk patients for preeclampsia risk reduction. This study examined whether patients at-risk for preeclampsia by the American College of Obstetricians and Gynecologists criteria recalled aspirin recommendation and factors associated with treatment adherence.

OBJECTIVE

This study examined whether patients at-risk for preeclampsia by the American College of Obstetricians and Gynecologists criteria recalled aspirin recommendation and factors associated with treatment adherence.

STUDY DESIGN

This study used an anonymous written survey. Pregnant patients were asked to record self-reported risk factors and to recall recommendation to take aspirin for preeclampsia prophylaxis. Participants were then determined to be high-, moderate-, or low-risk on the basis of the American College of Obstetricians and Gynecologists guidelines. Self-reported adherence to recommendations and factors contributing to the patients' decisions to take or decline aspirin were assessed. Secondary outcomes included demographic characteristics of adherent patients and patients who did not recall aspirin recommendation.

RESULTS

A total of 544 surveys were distributed and 500 were returned (91.9% response rate). Of the 104 high-risk pregnancies identified, aspirin was recommended in 60 (57.7%; 95% confidence interval, 0.48-0.67). Of the 269 patients with 2 or more moderate-risk factors, aspirin was recommended for 13 (4.8%; 95% confidence interval, 0.03-0.08). Among the participants who recalled aspirin recommendation, adherence was similar between high-risk (81.7%) and moderate-risk (76.9%) groups (P=.69). Patients with chronic hypertension, a history of preeclampsia or gestational hypertension in a previous pregnancy, and pregestational diabetes mellitus were most likely to report receiving aspirin recommendation (78.8%, 76.5%, 63.8%, and 53.3%, respectively). No high-risk factor was associated with a decreased likelihood of adherence. Nonadherent patients rarely discussed their decision with their medical provider (5.9%). In the 42.3% of high-risk participants who did not recall aspirin recommendation, autoimmune disease, multiple gestation, and kidney disease were the most prevalent risk factors (42.9%, 35.7%, and 25.0%, respectively).

CONCLUSION

In the population studied, many at-risk patients, as defined by the American College of Obstetricians and Gynecologists criteria, did not recall recommendations to take aspirin for preeclampsia prophylaxis. This raises concerns for absent or ineffective counseling. Of the patients who recalled aspirin recommendation, most reported adherence, and a history of hypertensive disorders or preeclampsia, autoimmune disease, and pregestational diabetes mellitus were most often associated with adherence. There was no single factor most strongly associated with intentional nonadherence.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

GOV IDENTIFIER

NCT00912132.

KEY POINTS

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

Supportive Home Remedies for Orofacial Pain during the Coronavirus Disease 2019 Pandemic: Their Value and Limitations

Background

The coronavirus disease 2019 (COVID-19) pandemic has impeded access to timely dental care, and there is an urgent need for adjuvant therapies that can reduce orofacial pain in emergencies.

Aims

To provide information on the benefits and limitations of eight representative home remedies as palliative care for orofacial pain during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

PubMed and Medline were electronically searched for eight home remedies for orofacial pain that can be used in COVID-19. Papers published in English in the past 30 years were considered. Among the published studies suitable for the research purpose, those in which the abstract and body text were confirmed were targeted, and duplicate studies were excluded. Finally, 86 studies were included.

Results

There is extensive and high-level scientific evidence for the application of tooth brushing and flossing, mouth rinsing with chlorhexidine, use of over-the-counter pain medication, and application of cryotherapy in emergencies. Gargling with salt water, brushing with bamboo salt, gargling with garlic juice, and oil pulling are traditional methods used for centuries. The use of natural products for orofacial pain has a significant empirical effect but has weak scientific evidence.

Conclusions

Knowing the correct application method, effects, and side effects is desirable to use these methods appropriately in emergencies. However, scientific evidence is unclear and generally lacking for home remedies to be the main treatment strategy, and there are clear limitations to their use as a single main treatment.

Medication effects on developmental sterol biosynthesis

Cholesterol is essential for normal brain function and development. Genetic disruptions of sterol biosynthesis result in intellectual and developmental disabilities. Developing neurons synthesize their own cholesterol, and disruption of this process can occur by both genetic and chemical mechanisms. Many commonly prescribed medications interfere with sterol biosynthesis, including haloperidol, aripiprazole, cariprazine, fluoxetine, trazodone and amiodarone. When used during pregnancy, these compounds might have detrimental effects on the developing brain of the offspring. In particular, inhibition of dehydrocholesterol-reductase 7 (DHCR7), the last enzyme in the biosynthesis pathway, results in accumulation of the immediate cholesterol precursor, 7-dehydrocholesterol (7-DHC). 7-DHC is highly unstable, giving rise to toxic oxysterols; this is particularly pronounced in a mouse model when both the mother and the offspring carry the Dhcr7^+/- genotype. Studies of human dermal fibroblasts from individuals who carry DCHR7^+/- single allele mutations suggest that the same gene*medication interaction also occurs in humans. The public health relevance of these findings is high, as DHCR7-inhibitors can be considered teratogens, and are commonly used by pregnant women. In addition, sterol biosynthesis inhibiting medications should be used with caution in individuals with mutations in sterol biosynthesis genes. In an age of precision medicine, further research in this area could open opportunities to improve patient and fetal/infant safety by tailoring medication prescriptions according to patient genotype and life stage.

Pregnancy outcomes in relation to disease activity and anti-rheumatic treatment strategies in women with rheumatoid arthritis

OBJECTIVES

To explore the association of maternal rheumatoid arthritis (RA) to pregnancy outcomes, especially preterm birth (PTB) and small for gestational age (SGA), in relation to disease activity and anti-rheumatic treatment before and during pregnancy.

METHODS

By linking prospective clinical rheumatology registers (CRR) in Sweden (SRQ) and Denmark (DANBIO) with medical birth registers, we identified 1,739 RA-pregnancies and 17 390 control-pregnancies (matched 1:10 on maternal age, birth year, parity) with delivery 2006-2018. Disease activity (DAS28, CRP, HAQ-score) and anti-rheumatic treatment nine months before and during pregnancy were identified through CRR and prescribed drug registers. Using logistic regression, we estimated adjusted odds ratios (aOR) with 95% confidence intervals (CI) for PTB and SGA overall and stratified by disease activity and anti-rheumatic treatment before and during pregnancy, adjusting for maternal characteristics.

RESULTS

We found increased aOR of PTB (1.92, 1.56-2.35) and SGA (1.93, 1.45-2.57) in RA-pregnancies vs control-pregnancies. For RA-pregnancies with DAS28-CRP ≥ 4.1 vs < 3.2 during pregnancy, aOR was 3.38 (1.52-7.55) for PTB and 3.90 (1.46-10.4) for SGA. Use of oral corticosteroids (yes/no) during pregnancy resulted in an aOR of 2.11 (0.94-4.74) for PTB. Corresponding figure for biologics was 1.38 (0.66-2.89). Combination therapy, including biologics before pregnancy, was a marker of increased risk of both PTB and SGA.

CONCLUSION

During pregnancy, disease activity rather than treatment seems to be the most important risk factor for PTB and SGA in RA. Women with RA should be carefully monitored during pregnancy, especially if they have moderate to high disease activity or/and are treated with extensive anti-rheumatic treatment.

Identification of At-risk Pregnant Population for Over-the-Counter Drug Usage in Low-Resource Settings

OBJECTIVE

Nearly 1.5 billion people of an Asian country are living their lives without a country-specific over-the-counter (OTC) drug list. A study was planned to assess the understanding and practice of OTC medication consumption in the pregnant population.

METHODS

A questionnaire-based cross-sectional study evaluating different perspectives on OTC drug consumption was planned in around 500 pregnant women attending tertiary care outpatient antenatal clinics. The association of knowledge, attitude and practice versus indications, knowledge regarding harmful effects possible, reasons for choosing OTC medication, the practice of consulting nonmedical persons and drug interactions with the disease or prescription medications was determined. Regression analysis was performed in statistical software R.

RESULTS

Seven percent (36/516) of pregnant women were found to consume oral antimicrobials without prescription. Local chemist consultation was the most common channel (72.48%) to procure the OTC medicines. Participants with good knowledge score showed an odds ratio (OR) of 1.87 (95% C.I.; 1.28-2.73), 1.6 (95% C.I.; 0.99-2.63), 1.66 (95% C.I.; 1.14-2.42) and 2.66 (95% C.I.; 1.49-4.89) for self-medication encouragement tendency possible, restricting sale of OTC medications, the habit of reading drug leaflets and understanding the potentially harmful effects, with OTC drugs, respectively. Right-attitude participants showed an OR of 1.89 (95% C.I.; 1.29-2.80) and 1.8 (95% C.I.; 1.19-2.76) for identifying knowledge of acetaminophen overdose and liver damage link as well as the disease symptom masking possibility with OTC, respectively. Participants with insufficient knowledge and attitude scores showed an association with more OTC antacid-antiemetics and analgesic use, respectively.

CONCLUSION

Antenatal pregnant women need to be guided on avoiding OTC antimicrobial usage. Both obstetricians and regulators have to play an active role in educating pregnant women and contributing to developing country-specific OTC drug lists with the guidelines.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13224-021-01481-2.

Agreement and Disparities between Women and Stop-Smoking Specialists about How to Promote Adherence to Nicotine Replacement Therapy in Pregnancy

Evidence for the effectiveness of nicotine replacement therapy (NRT) for smoking-cessation in pregnancy is weak. This has been attributed to insufficient dosing and low adherence. This study investigated the acceptability of key messages and delivery modes for a behavioral intervention to increase NRT adherence in pregnancy. Semi-structured telephone interviews were carried out with pregnant or postpartum women aged ≥16 from across England, who had been offered NRT during pregnancy as part of a quit attempt and who struggled to quit (n = 10), and a focus group with stop-smoking specialists from across England (n = 6). The two data sources were coded separately using a thematic approach and then integrated to compare perspectives. Women and specialists agreed on message tone and delivery modes. However, views diverged on the most influential sources for certain messages and whether some information should be given proactively or reactively. There was also disagreement over which messages were novel and which were routinely delivered. This study demonstrates the value of capturing and integrating different perspectives and informational requirements when developing behavior-change interventions. The findings provide useful insights for designing a pregnancy-specific NRT adherence intervention that is acceptable to both those who will deliver and receive it.

Sterol Biosynthesis Inhibition in Pregnant Women Taking Prescription Medications

Sterol biosynthesis is a critical homeostatic mechanism of the body. Sterol biosynthesis begins during early embryonic life and continues throughout life. Many commonly used medications, prescribed >200 million times in the United States annually, have a sterol biosynthesis inhibition side effect. Using our high-throughput LC-MS/MS method, we assessed the levels of post-lanosterol sterol intermediates (lanosterol, desmosterol, and 7-dehydrocholesterol (7-DHC)) and cholesterol in 1312 deidentified serum samples from pregnant women. 302 samples showing elevated 7-DHC were analyzed for the presence of 14 medications known to inhibit the 7-dehydrocholesterol reductase enzyme (DHCR7) and increase 7-DHC. Of the 302 samples showing 7-DHC elevation, 43 had detectable levels of prescription medications with a DHCR7-inhibiting side effect. Taking more than one 7-DHC-elevating medication in specific combinations (polypharmacy) might exacerbate the effect on 7-DHC levels in pregnant women, suggesting a potentially additive or synergistic effect. As 7-DHC and 7-DHC-derived oxysterols are toxic, and as DHCR7-inhibiting medications are considered teratogens, our findings raise potential concerns regarding the use of prescription medication with a DHCR7-inhibiting side effect during pregnancy. The use of prescription medications during pregnancy is sometimes unavoidable, but choosing a medication without a DHCR7-inhibiting side effect might lead to a heathier pregnancy and prevent putatively adverse outcomes for the developing offspring.

"I know my body better than you:" patient focus groups to inform a decision aid on oral corticosteroid use during pregnancy

PURPOSE

There is unmet need for decision support regarding medication use during pregnancy. We aimed to inform the development of a decision aid on oral corticosteroid (OCS) use during pregnancy through focus groups.

METHODS

We invited patients from one health system who had a recent live birth and a condition for which OCSs may be prescribed (ie, asthma or other autoimmune disease) to participate in focus groups. We conducted conventional qualitative content analysis of verbatim transcripts of the focus groups using inductive coding.

RESULTS

There were 30 participants across five focus groups from May to June 2019. Women endorsed the need for patient-provider discussions about OCS use during pregnancy in which the provider shares risks and benefits and the patient makes her decision. Furthermore, women generally expressed support for patient-centered handouts about OCS use during pregnancy that the provider discusses with the patient. When considering whether to take OCSs in pregnancy, women had concerns about: the medication's impact on their baby (eg, miscarriage, birth defects, long-term effects), themselves (eg, effects on mood, sleep, weight gain), pregnancy complications (eg, preterm birth, increased blood pressure), and lactation. Women wanted information on OCSs (eg, indications, length of treatment, and cost), alternative treatments, and risks of not taking OCSs.

CONCLUSIONS

We established patient need for a decision aid on OCS use during pregnancy that providers can discuss with patients. To address patient concerns, the aid should at a minimum describe the medication's impact on baby, including long-term effects, maternal health, pregnancy complications, and lactation.

A Qualitative Study of Pregnant Women's Perspectives on Antibiotic Use for Mom and Child: Implications for Developing Tailored Health Education Interventions

The overutilization of antibiotics during pregnancy and early life are associated with adverse health outcomes for mothers and infants. In this study, we explored pregnant women’s opinions and concerns of antibiotics and how perceptions may affect their health-related decision-making. We conducted 18 in-depth, semi-structured interviews with pregnant women and used the Health Belief Model (HBM) as a framework to analyze the data. We found that mothers generally understood the benefits of antibiotics and were aware that antibiotics are clinically effective for treating bacterial infections. Importantly, perceived barriers related to antibiotic use included concerns regarding the impact of antibiotics on breastfeeding efficacy, microbial health, and societal factors such as antimicrobial resistance. The prescription of antibiotics by a healthcare provider was a cue to action for women, as they trusted providers to recommend medications that were safe for them and their infants. Overall, mothers shared that receiving education on the effects of antibiotics would improve their self-efficacy and decision-making surrounding the use of antibiotics for treating illness. Implications for tailored perinatal health education interventions to enhance antibiotic use, knowledge, and decision-making are discussed.

Patterns and determinants of prescribed drug use among pregnant women in Adigrat general hospital, northern Ethiopia: a cross-sectional study

Background

A vigilant prescription of drugs during pregnancy can potentially safeguard the growing fetus from the deleterious effect of the drug while attempting to manage the mother’s health problems. There is a paucity of information about the drug utilization pattern in the area of investigation. Hence, this study was implemented to investigate the pattern of drug utilization and its associated factors among pregnant women in Adigrat general hospital, Northern Ethiopia.

Methods

An institution-based cross-sectional study was conducted among randomly selected 314 pregnant women who attended obstetrics-gynecology and antenatal care units of the hospital. Relevant data were retrieved from the pregnant women’s medical records and registration logbook. The drugs prescribed were categorized based on the United States Food and Drug Administration (US-FDA) fetal harm classification system. Data analysis was done using SPSS version 20 statistical software. Multivariate logistic regression was employed to analyze the association of the explanatory variables with the medication use, and p < 0.05 was declared statistically significant.

Results

The overall prescribed drug use in this study was found to be 87.7%. A considerable percentage of the study participants (41.4%) were prescribed with supplemental drugs (iron folate being the most prescribed drug) followed by antibiotics (23.4%) and analgesics (9.2%). According to the US-FDA drug’s risk classification, 42.5, 37, 13, and 7% of the drugs prescribed were from categories A, B, C, and D or X respectively. Prescribed drug use was more likely among pregnant women who completed primary [AOR = 5.34, 95% CI (1.53–18.6)] and secondary education [AOR = 4.1, 95% CI (1.16–14)], who had a history of chronic illness [AOR = 7.9, 95% CI (3.14–19.94)] and among multigravida women [AOR = 2.9, 95% CI (1.57 5.45)].

Conclusions

The finding of this study revealed that a substantial proportion of pregnant women received drugs with potential harm to the mother and fetus. Reasonably, notifying health practitioners to rely on up-to-date treatment guidelines strictly is highly demanded. Moreover, counseling and educating pregnant women on the safe and appropriate use of medications during pregnancy are crucial to mitigate the burden that the mother and the growing fetus could face.

Use of Decision Support Tools to Empower Pregnant Women: Systematic Review

Background

Women face many health-related decisions during pregnancy. Digitalization, new technology, and a greater focus on empowering patients have driven the development of patient-centered decision support tools.

Objective

This systematic review provides an overview of studies investigating the effect of patient-centered decision support tools for pregnant women.

Methods

We searched 5 online databases, MEDLINE, EMBASE, Web of Science, PsycINFO, and Scopus, from inception to December 1, 2019. Two independent researchers screened titles, abstracts, and full-texts against the inclusion criteria. All studies investigating the effect of patient-centered decision support tools for health-related issues among pregnant women were included. Study characteristics and results were extracted using the review management tool Rayyan and analyzed according to topic, type of decision support tools, control group, outcome measurements, and results.

Results

The 25 eligible studies covered a range of health topics, including prenatal screening (n=10), gestational diabetes and weight gain (n=7), lifestyle (n=3), blood pressure and preeclampsia (n=2), depression (n=1), asthma (n=1), and psychological well-being (n=1). In general, the use of decision support tools increased women's knowledge, and recording symptoms enhanced satisfaction with maternity care.

Conclusions

The opportunities created by digitalization and technology should be used to develop innovative patient-centered decision support tools tailored to support pregnant women. Effect on clinical outcomes should be documented.

Obstetrician-Gynecologist Views of Pregnancy-Related Medication Safety

Background: Medication use among pregnant women is widespread, despite limited evidence about the teratogenicity of most medications. Improved physician-patient communication about pregnancy-related medication safety has been identified as a strategy to address this critical issue; however, little is known about physicians' knowledge, attitudes, and practices that could inform tools for information access and sharing to support such communication. The primary objective of this study is to address gaps in what is known about obstetrician-gynecologist views, practices, and needs related to accessing and sharing pregnancy-related medication safety information with patients. Materials and Methods: The basis for this study is a nationally representative, randomized survey of 506 practicing obstetrician-gynecologists. The survey was completed by mail or online between October 26, 2015 and May 8, 2016 with a 52% response rate. Data were weighted to population parameters to reduce the risk of potential nonresponse biases. Analyses included univariate distributions and comparisons between physicians in different residency cohorts using all-pairs dependent t-tests. Results: Findings point to critical features of obstetrician-gynecologist access and sharing of medication safety information. Obstetrician-gynecologists often retrieve medication safety information during a clinical visit. There is widespread provision of potentially problematic "safe lists" to patients, particularly by younger cohorts, and limited counseling for reproductive-aged patients not actively planning a pregnancy. Conclusions: To improve clinical care, physician-patient communication may be enhanced with technical and policy solutions, including improved digital information tools for retrieving and discussing information in the clinical setting; evidence-based, written information for physicians to share with patients; and encouragement for counseling all women of reproductive age receiving teratogenic medications.

Population-Based Birth Cohort Studies in Epidemiology

Birth cohort studies are the most appropriate type of design to determine the causal relationship between potential risk factors during the prenatal or postnatal period and the health status of the newborn up to childhood and potentially adulthood. To date, there has been a growth in interest regarding observational population-based studies which are performed to provide answers to specific research questions for defined populations, for instance, assessing the exposure to environmental pollutants or drugs on the risk of developing a disease. Birth cohorts based on the recruitment and active follow-up of mothers and children allow the collection of biological material, and specific clinical and genetic information. However, they require a considerable amount of time and resources and, besides being usually of limited size, they are exposed to the risk of the loss of subjects to follow-up, with decreased statistical power and possible selection bias. For these reasons, linking the medical birth register with administrative health records for mothers and babies is increasingly being used in countries with a universal healthcare system, allowing researchers to identify large and unselected populations from birth, and to reconstruct relevant traits and care pathways of mothers and newborns. This Special Issue of the International Journal of Environmental Research and Public Health focuses on the current state of knowledge on perinatal and postnatal exposures and adverse pregnancy, maternal, fetal and neonatal outcomes through population-based birth cohort studies, with a specific focus on real-word data. The 12 accepted articles covered a wide range of themes that can be addressed specifically through birth cohort study design; however, only three were based on real word data with record-linkage to health administrative databases. In particular, two papers have addressed the topic of socioeconomic status considering several indicators both at the individual and contextual level. Two papers focused on inflammatory bowel diseases, both as an outcome of perinatal and antibiotic exposure in early life and as a condition associated with asthma, among children identified in a birth cohort based on a Regional Medical Birth Register. Three articles focused on medication use during pregnancy and its impact on maternal and fetal health. The effect of exposure to prenatal environmental risk factors on perinatal and childhood outcomes has been considered in two papers. Two papers analyzed ad hoc nationwide prospective birth cohorts set in Japan and UK. Finally, we included a systematic review with meta-analysis to evaluate the relation between growth restriction at birth and congenital heart defects. We think that this Special Issue may contribute to enriching the discussion of future challenges, opportunities, strengths and limitations for all research topics that can be investigated using a population-based birth cohort study design.

Treatment and Management of Depression Symptoms in Pregnant Veterans: Varying Experiences of Mental Health Care in the Prenatal Period

Depression screening is recommended for all pregnant veterans; however, little is known on how often symptomatic women receive care, how depression treatment presents in practice, and whether women veterans are utilizing treatment during the appreciable perinatal period. Our sample included 142 pregnant veterans from 15 Veterans Health Administration (VA) medical facilities with Edinburgh Postnatal Depression Scale (EPDS) scores ≥10. Sociodemographic characteristics, military service, health utilization, and pregnancy related factors were collected as part of a telephone survey. A majority of our sample (70%) had 1 or more mental health visits or antidepressant prescriptions during pregnancy. Women with a history of depression had more mental health visits and a higher percentage of antidepressant use before and during pregnancy than women without a history of depression. Pregnant women veterans without a history of depression may be less likely to receive care for depression during pregnancy. However, the majority of our veterans showing depression symptoms prenatally had at least one mental health visit or an antidepressant medication fill during their pregnancy window, suggesting that mental health care is readily available for women veterans.

SafeMotherMedicine: Aiming to Increase Women's Empowerment in Use of Medications During Pregnancy and Breastfeeding

Purpose

Approximately 80% of pregnant women use medications. There is a need for evidence based medicines information that provide realistic risk estimates as pregnant and breastfeeding women tend to overestimate the risk of medications. The purpose of this paper is to describe the development and future perspectives of an innovative medicines information service aiming to increase empowerment among pregnant and breastfeeding women.

Description

SafeMotherMedicine (SMM) (www.tryggmammamedisin.no) is a Norwegian medicines information service for pregnant and breastfeeding women. Established in 2011, the service was initially web-based only, in contrast to most teratology information services that at the time mainly operated using telephone and/or e-mail.

Assessment

During the last eight years, SMM has provided close to 30,000 answers promoting appropriate medication use among pregnant and breastfeeding women. SMM launched a telephone-service in 2016, however, the annual number of questions received through the web-based service continues to increase.

Conclusion

The service seems to have fulfilled a previously unmet need of evidence-based, individually tailored information about medications to pregnant and breastfeeding women in Norway. SMM empowers the women to make informed decisions regarding medication use in pregnancy and breastfeeding, thus contributing to person-centred medicine. The web-based design of the service may represent the pregnant and breastfeeding women’s preferred way of communication.

Information needs across the family planning continuum: A survey of women with chronic autoimmune inflammatory conditions

OBJECTIVE

This study assessed the information needs of women with chronic autoimmune inflammatory conditions across the pregnancy continuum.

METHODS

We conducted a web-based survey with women about information needs related to family planning. Eligible participants were female, aged 18-44, had a diagnosis of a chronic inflammatory condition, and were at one of three pregnancy stages (planning, currently pregnant, or postpartum).

RESULTS

The survey yielded 209 responses. Respondents had high levels of information needs and were active information seekers. Many respondents reported difficulty finding the information they need. Over half (56.9%) reported receiving conflicting information from different doctors, and a majority of those respondents reported doing their own research. Respondents expressed the greatest interest in resources that facilitated connections to other women and their experiences (87.4%). Pregnancy stage was significantly associated with information needs and preferences; respondents in the planning stage of pregnancy had higher information needs, reported more dissatisfaction with communication with doctors, and were less connected to pregnancy resources.

PRACTICE IMPLICATIONS

Both providers and health/advocacy organizations have a role in improving information around this topic, such as developing and disseminating resources tailored to pregnancy status and supporting patient-centered communication around family planning.

Risk of adverse perinatal outcomes among women with pharmacologically treated and untreated depression during pregnancy: A retrospective cohort study

BACKGROUND

The association between antidepressant use during pregnancy and adverse perinatal outcomes is unclear. The association without taking into consideration the independent effect of depression leads to a confounding of the effects of antidepressants with those of the underlying reason for the use of those medications. Additionally, a history of depression and antidepressant use may also influence this association.

OBJECTIVE

This study examined the risks of adverse perinatal outcomes associated with antidepressant use during pregnancy.

METHODS

This retrospective cohort study used population-based data in Alberta, Canada, for women who delivered between 2012 and 2015 (n = 158486). Women with depression were identified using a validated case definition, and the receipt of antidepressants was identified using Anatomical Therapeutic Chemical codes. Adverse perinatal outcomes such as severe maternal/neonatal morbidity, preterm birth, and neonatal intensive care unit admission were assessed. Multivariable log-binomial regression was used to estimate the risk of adverse perinatal outcomes associated with antidepressants, adjusting for age and parity.

RESULTS

In total, 9.1% women had depression and 2.5% women received antidepressants during pregnancy. The relative risk of severe neonatal morbidity/mortality was 1.25 (95% confidence interval 1.17, 1.33) times higher for women with depression alone compared to women without depression. The risk of severe neonatal morbidity/mortality was 1.51 (95% confidence interval 1.36, 1.66) times higher for women who used antidepressants compared to women with depression alone-however, the risk differed between the women with and without a history of antidepressant use. A similar risk pattern was observed for preterm birth and neonatal intensive care unit admission.

CONCLUSIONS

Both depression and antidepressant use were independently associated with the risk of adverse perinatal outcomes; however, the risk associated with antidepressants was higher over and above the risk associated with depression. This may reflect the biological effects of antidepressants, greater severity of depression in those treated, or both.

Social media monitoring on the perceived safety of medication use during pregnancy: A case study from the Netherlands

Aims

An increasing number of women trust the Internet for information about medication safety during pregnancy. This study aimed to evaluate the availability and accuracy of social media content on the perceived safety of medication use in pregnancy.

Methods

We performed a systematic search of posts related to medication safety during pregnancy in the Dutch language published on social media, blogs and forums between May 2011 and April 2016 using Coosto, a tool for social media monitoring. The perceived safety in the posts was compared with the Dutch Teratology Information Service (TIS) safety classifications.

Results

We included 1224 online posts, which described 1441 scenarios about medication safety in pregnancy. A total of 820 (57%) scenarios were in line with the TIS classification. Incorrect perception was higher for prescription medication compared to medication available over‐the‐counter (60 vs 25%). Furthermore, the safety classification of medications with a TIS classification on strict indication or second‐line drugs (93%) and medications with insufficient knowledge on their safety during pregnancy (76%) was more likely to be incorrectly perceived by the public compared to medications with the TIS classification safe (24%).

Conclusions

Social media monitoring may be useful for surveillance of potentially unsafe use of medications in pregnancy. Many social posts related to medication safety during pregnancy provide inaccurate information. As this information may affect women's perceptions and decisions, accurate communication between healthcare providers and pregnant women regarding the benefits and risks of medications is vital.

Community pharmacist counseling in early pregnancy-Results from the SafeStart feasibility study

Background

Community pharmacists are available to counsel women in early pregnancy, but no studies have assessed the feasibility of such a service.

Objective

To test the feasibility of a pharmacist consultation in early pregnancy and to inform the design of a definitive trial.

Setting

Six community pharmacies in Norway from Oct. to Dec. 2017.

Method

We evaluated recruitment approaches and an automatic data preprocessing system (ADPS) to enroll, assign participants, and distribute questionnaires. Women (≥18 years) in early pregnancy were eligible for inclusion. Participants were assigned to a pharmacist consultation (intervention group) or standard care (control group). The intervention aimed to address each woman’s concerns and needs regarding medications and ailments in pregnancy, and was documented on a standard form. The women’s acceptability of the intervention was measured by a questionnaire.

Main outcome measures

Appropriate recruitment approaches, workflow of the ADPS, and women’s acceptability of the intervention.

Results

Of the 35 participants recruited, 19 were recruited through Facebook. The ADPS worked well. Treatment of nausea and vomiting (NVP) (10/11) and general information about medications (8/11) were frequently discussed during the consultations (n = 11). The women reported high satisfaction with the consultation. Having the option of telephone and follow-up consultations was important to the women.

Conclusion

It is feasible to provide community pharmacist consultations in early pregnancy. In a definitive study, the consultations should focus on NVP and general medication use and further explore social media as a recruiting tool. Both in-pharmacy and telephone consultations should be offered to deliver the intervention.

Adherence to and Persistence with Antidepressant Medication during Pregnancy: Does It Differ by the Class of Antidepressant Medication Prescribed?

OBJECTIVE

Pregnant women are often concerned about the impact of medication use on their pregnancy, such as congenital abnormalities. This study examined the rate of adherence to and persistence with antidepressant medications during pregnancy based on the class of antidepressants prescribed.

METHODS

Women who gave birth between 2012 and 2015 in Alberta, Canada; had ≥1 diagnosis of depression within 1 year of preconception in outpatient physician claims, emergency department, or hospitalization administrative data; and were adherent (medication possession ratio ≥80%) to ≥2 consecutive antidepressant prescriptions during the preconception year ( n = 1865) were included in this retrospective cohort study. The rates of adherence and persistence (prescription refill gap ≤30 days) were calculated by antidepressant class and were compared using chi-square tests.

RESULTS

During pregnancy, 834 (44.7%; 95% CI, 42.4% to 47.0%) women discontinued antidepressants. Among those continuing antidepressants, the overall rate of adherence was 62.6% (95% CI, 59.4% to 65.7%). The rate differed significantly by medication class ( P < 0.0001), with a rate of 75.1% (95% CI, 68.3% to 80.9%) for serotonin-norepinephrine inhibitors, 60.9% (95% CI, 57.2% to 64.5%) for selective serotonin reuptake inhibitors, 42.8% (95% CI, 19.9% to 69.3%) for nonselective monoamine reuptake inhibitors, and 37.5% (95% CI, 22.5% to 55.4%) for atypical antidepressants. Only, 40.7% (95% CI, 37.5 to 44.1) of women were persistent with antidepressants for the full pregnancy period-the rate differed significantly by medication class ( P < 0.0001).

CONCLUSIONS

Adherence to and persistence with antidepressants is low during pregnancy and varies by medication class. Low adherence and persistence can interfere with a therapeutic effect of antidepressants, which may contribute to the worsening of depression symptoms.

Risk perception, beliefs about medicines and medical adherence among pregnant and breastfeeding women with migraine: findings from a cross-sectional study in Norway

OBJECTIVES

To examine risk perception, beliefs about migraine medications and medical adherence among pregnant and breastfeeding women with migraine.

DESIGN AND SETTING

Cross-sectional study conducted in Norway from October 2013 to February 2014. Data were collected via an anonymous, electronic questionnaire.

PARTICIPANTS

Women with migraine, either pregnant or having delivered within the previous 18 months.

MAIN OUTCOMES

Women's perception of teratogenic risk (numeric rating scale 0-10) was obtained for 14 different drugs/substances, including medications commonly used in the acute treatment of migraine. Women's perspectives on migraine drug therapy were assessed by 10 statements from the Beliefs about Medicines Questionnaire (BMQ-Specific) and six pregnancy/breastfeeding-specific statements. Adherence to migraine treatment during pregnancy and breastfeeding period was assessed by maternal self-report.

RESULTS

The study population included 401 women with migraine, of which 140 were pregnant and 261 were new mothers. More than 70% of the women reported use of migraine medications during pregnancy. Still, the majority severely overestimated the risk associated with migraine medications and were concerned about using medications to manage their migraine during pregnancy and breastfeeding. Almost 9 out of 10 women had at some point deliberately avoided using migraine medications during their pregnancy. Women reporting use of migraine medications, however, were more positive and overestimated to a lesser extent the risks of using such medications in pregnancy compared with their counterparts.

CONCLUSIONS

Women with migraine severely overestimated the risk associated with migraine pharmacotherapy in pregnancy. The majority of women were concerned about use of migraine medications during pregnancy and breastfeeding and reported non-adherence to needed treatment. More attention should be focused on women's beliefs and concerns regarding migraine pharmacotherapy during pregnancy and breastfeeding in order to improve management of disease, reduce unfounded concerns and enhance adherence to needed treatment.

Enhancing uptake of influenza maternal vaccine

INTRODUCTION

Influenza vaccination during pregnancy can offer many benefits to both mother and infant. Despite recommendations from the Advisory Committee on Immunization Practices, vaccine coverage rates among pregnant women during pregnancy are below 40% in the United States. There is a need for a greater understanding of what interventions can improve vaccine uptake among pregnant women.

AREAS COVERED

This review synthesizes the existing evidence on the effectiveness of interventions to improve maternal influenza vaccine uptake. These interventions are examined within the framework of the three psychological propositions: thoughts and feelings, social processes and changing behavior directly.

EXPERT COMMENTARY

A number of promising and effective interventions were identified in this review. Nudge-based interventions that build on favorable intentions to vaccinate such as provider prompts and standing orders have demonstrated significant success in improving influenza vaccine uptake. However, substantial gaps in the literature still exist. Provider recommendations are the most important predictor of vaccine receipt among pregnant women, yet few studies evaluated intervening to improve the dialogue between patient and provider. With the potential for even more vaccines to be added to the maternal immunization schedule, it is vitally important to understand how to improve uptake.