Drug prescribing during pregnancy. A controlled study of Tennessee Medicaid recipients

Risk management and monitoring methods for the future mother, embryo, fetus, and post-natal consequences

Data required to asses the risk of a new drug regarding the normal course of pregnancy as well as embryo, fetal and neonate development, are often missing when a new product is launched. In such a situation, a risk management plan is to be developed by the industrial and validated by regulatory authorities. This risk management plan is to take into account the data benefits on the drug and its potential therapeutic use by women as being of childbearing age. The obtaining of post licence human data is to be built on many players, both private and public, involved in the data collection and evaluation. The setting up of such a network would allow them to join together and optimize their action by standardizing the data collected and their follow up. This should help to generate or rapidly respond to an alert, to conduct collaborative pharmacovigilance pharmacology studies.

National patterns of medication use during pregnancy

PURPOSE

To describe patterns of medication use during pregnancy in ambulatory care settings according to the U.S. Food and Drug Administration (FDA) pregnancy risk classification.

METHODS

A cross-sectional study of two national ambulatory care surveys, sampling all office visits made by pregnant women in 1999 and 2000, was conducted. Using the FDA pregnancy risk classification, patterns of medication use and predictive factors for FDA pregnancy risk D or X (D/X) medications were evaluated.

RESULTS

In 1999 and 2000, about half of all pregnant visits had one or more medications. Among the total visits, FDA Class A was the majority (private = 65.7%; hospital = 79.5%; p < 0.05) followed by Class C (private = 26.5%; hospital = 36.4%; p < 0.05). Class D/X medications accounted for 6.4% and 2.9% of visits in private and hospital, respectively (p < 0.05). Medications with unknown pregnancy categories were predominant in the private setting (12.0% and 3.9%; p < 0.05). Age, insurance type, region, physician specialty, and number of medications were associated with a category D/X prescription. Among hospital visits, those from the West region and with private insurance were more likely to receive category D/X prescriptions. Number of medications was strongly associated with high-risk drugs in both settings.

CONCLUSIONS

This study shows considerable medication use among pregnant women. The prevalence of visits with FDA pregnancy category D/X drugs was moderate, but still indicates exposure to high-risk medications.

Use of Coptidis Rhizoma and foetal growth: a follow-up study of 9895 pregnancies

PURPOSE

To explore the effect of Coptidis Rhizoma on foetal growth in pregnancy.

METHODS

During 1985-1987, each pregnant woman with 26 or more weeks of gestation who came to the Taipei Municipal Maternal and Child Hospital for prenatal care was enrolled and interviewed by three trained interviewers using structured questionnaires to obtain detailed information including the herbal medicines used during pregnancy. Medical histories of diabetes, hypertension, antepartum haemorrhage and medicines used during pregnancy were abstracted from medical records of mothers'. Data of birth weight, gestational duration and characteristics of infants were gathered from the Taiwan national birth registration. A total of 9,895 singleton livebirths were analysed. The variables related to foetal growth included two dichotomous measures: low birth weight (LBW) and small for gestational age (SGA); and one continuous measure: birth weight. Potential risk factors associated with these outcomes were investigated using multiple logistic and linear regression models.

RESULTS

After adjustment, pregnant women taking Coptidis Rhizoma during pregnancy had no significantly adverse effect on foetal growth. There was a non-significantly slightly decreased mean of birth weight and increased risk of LBW and SGA babies if the frequency of using Coptidis Rhizoma was more than 56 times.

CONCLUSIONS

The usual usage of Coptidis Rhizoma during pregnancy seemed not to increase the adverse risk on foetal growth. Future observations for use of longer than 56 times or a higher cumulated dose were needed to clarify the safety.

Antibiotics in pregnancy: analysis of potential risks and determinants in a large German statutory sickness fund population

PURPOSE

Antibiotics are frequently prescribed drugs in pregnancy. The purpose of the study was to analyse the use, the potential risks and the determinants of systemic antibiotic prescriptions during pregnancy.

METHODS

A large, nation-wide acting German statutory sickness fund provided prescription data and personal data of 41,293 pregnant women. For this study, all prescriptions of systemic antibiotics (ATC: J01) dispensed to each woman during a 21-month period were analysed. We used the FDA risk classification system and enrolled a literature search to identify potentially harmful antibiotics. To investigate the impact of geographical and socio-economic determinants in antibiotic prescribing, a multivariate logistic regression model was performed.

RESULTS

Of the 41,293 women, 19.7% received at least one antibiotic drug during pregnancy. There was a shift to relatively safe and reduced antibiotic drug use during pregnancy. Prescribing of contraindicated antibactericals or potentially harmful drugs was seen in 521 women (1.3% of all women). In the logistic regression, being younger than 21 years (adjusted OR 2.14, 95%CI 1.80-2.53) or being welfare recipient (adjusted OR 1.57, CI 1.25-2.00) was strongly associated with higher antibiotic use. Significantly lower antibiotic use was seen in 5 of 16 German federal states (OR 0.74-0.83).

CONCLUSIONS

About 20% of pregnant women received antibiotics, and 1.3% received a harmful drug. To minimise the risks, detailed guidelines are needed for the antibiotic treatment during pregnancy.

Correlates of prescription drug use during pregnancy

PURPOSE

To evaluate the extent of prescription drug use and the use of category D or X drugs during pregnancy and examine the maternal characteristics associated with use.

METHODS

Medical record and survey data from an observational cohort of pregnant women from 2001 to 2003 (n=1626) were analyzed to examine the use of prescription drugs and the use of category D or X drugs.

RESULTS

A majority of these pregnant women were prescribed a prescription drug (56%), and 4% of women were prescribed a category D or X drug. The most common classes of medications prescribed were antibiotics (62%), analgesics (18%), asthma medications (18%), and antiemetics (17%). After adjustment for sociodemographic and clinical characteristics, African American women were more likely to use a prescription drug than white women. Lower levels of educational attainment were also associated with greater use of prescription drugs compared with women who had graduated from college. Women with a chronic health condition, gestational diabetes, a prenatal hospitalization, a history of infertility, or symptoms of acid reflux were also more likely to use a prescription drug than women without these conditions. Nulliparous women and women who were married or living with a partner were less likely to use category D or X drugs during pregnancy than women without these characteristics. Women with a history of infertility and those with a chronic health condition were more likely to use a category D or X drugs during pregnancy than those without these conditions.

CONCLUSIONS

The common use of prescription drugs during pregnancy supports the importance of expanding the evidence about the risks and benefits of prescription drug use during pregnancy and suggests the need for systems to safeguard prescribing practices for women of reproductive age.

Evaluation of gestational age and admission date assumptions used to determine prenatal drug exposure from administrative data

OBJECTIVE

Our aim was to evaluate the 270-day gestational age and delivery date assumptions used in an administrative dataset study assessing prenatal drug exposure compared to information contained in a birth registry.

STUDY DESIGN AND SETTING

Kaiser Permanente Colorado (KPCO), a member of the Health Maintenance Organization (HMO) Research Network Center for Education and Research in Therapeutics (CERTs), previously participated in a CERTs study that used claims data to assess prenatal drug exposure. In the current study, gestational age and deliveries information from the CERTs study dataset, the Prescribing Safely during Pregnancy Dataset (PSDPD), was compared to information in the KPCO Birth Registry. Sensitivity and positive predictive value (PPV) of the claims data for deliveries were assessed. The effect of gestational age and delivery date assumptions on classification of prenatal drug exposure was evaluated.

RESULTS

The mean gestational age in the Birth Registry was 273 (median = 275) days. Sensitivity of claims data at identifying deliveries was 97.6%, PPV was 98.2%. Of deliveries identified in only one dataset, 45% were related to the gestational age assumption and 36% were due to claims data issues. The effect on estimates of prevalence of prescribing during pregnancy was an absolute change of 1% or less for all drug exposure categories. For Category X, drug exposures during the first trimester, the relative change in prescribing prevalence was 13.7% (p = 0.014).

CONCLUSION

Administrative databases can be useful for assessing prenatal drug exposure, but gestational age assumptions can result in a small proportion of misclassification.

Prescription drug use in pregnancy

OBJECTIVE

The purpose of this study was to provide information on the prevalence of the use of prescription drugs among pregnant women in the United States.

STUDY DESIGN

A retrospective study was conducted with the use of the automated databases of 8 health maintenance organizations that are involved in the Health Maintenance Research Network Center for Education and Research on Therapeutics. Women who delivered of an infant in a hospital from January 1, 1996, through December 31, 2000, were identified. Prescription drug use according to therapeutic class and the United States Food and Drug Administration risk classification system was evaluated, with the assumption of a gestational duration of 270 days, with three 90-day trimesters of pregnancy, and with a 90-day period before pregnancy. Nonprescription drug use was not assessed.

RESULTS

During the period 1996 through 2000, 152,531 deliveries were identified that met the criteria for study. For 98,182 deliveries (64%), a drug other than a vitamin or mineral supplement was prescribed in the 270 days before delivery: 3595 women (2.4%) received a drug from category A; 76,292 women (50.0%) received a drug from category B; 57,604 women (37.8%) received a drug from category C; 7333 women (4.8%) received a drug from category D, and 6976 women (4.6%) received a drug from category X of the United States Food and Drug Administration risk classification system. Overall, 5157 women (3.4%) received a category D drug, and 1653 women (1.1%) received a category X drug after the initial prenatal care visit.

CONCLUSION

Our finding that almost one half of all pregnant women received prescription drugs from categories C, D, or X of the United States Food and Drug Administration risk classification system highlights the importance of the need to understand the effects of these medications on the developing fetus and on the pregnant woman.

Drugs that affect the fetus and newborn infant via the placenta or breast milk

In general, drugs that are taken by a mother during pregnancy or after birth may be transferred to the fetus or the infant (through breast milk). Many factors are involved that determine the amount of drugs that are transferred and their potential effects on the fetus or infant. A careful assessment of the risk versus benefit is necessary and should be individualized. In the breastfed infant, many measures can be undertaken further so that the amount of drug transferred to the infant is minimized.

Prescription of drugs to pregnant women in France: the HIMAGE study

The HIMAGE study, conducted in partnership with the principal Public Health Insurance Funds of the Loire region, analysed medicinal prescriptions during pregnancy on the basis of a representative sample of 911 pregnant women resident in this region of France. Altogether 93.5% received at least one prescription, with a mean of 10.9 different drugs per woman. The prescriptions were predominantly for drugs of the following Anatomical Therapeutic Chemical (ATC) classes: "alimentary tract and metabolism" (78%); "genito-urinary system and sex hormones" (62%); "nervous system" (62%); and "blood and blood-forming organs" (57%). Iron supplements, paracetamol, folic acid, magnesium, progesterone, oxaceprol, phloroglucinol, amoxicillin, domperidone and diosmine were the most frequently prescribed drugs. In total, 4.6% of the women were exposed to drugs involving a risk during pregnancy: principally nonsteroidal anti-inflammatory drugs (NSAIDs) prescribed from the sixth month onwards. This study revealed a high frequency of prescription of drugs to pregnant women, largely motivated by non-rational and to some extent culture-specific considerations, and it also highlighted the prescription of drugs known to involve risk during pregnancy. These results provide a basis for advising clinicians on the rational and safe use of drugs during pregnancy.

Racial/ethnic variation in parent expectations for antibiotics: implications for public health campaigns

CONTEXT

Widespread overuse and inappropriate use of antibiotics are a major public health concern. Little is known about racial/ethnic differences in parents seeking antibiotics for their children's upper respiratory illnesses.

OBJECTIVE

To examine racial/ethnic differences in parent expectations about the need for antibiotics and physician perceptions of those expectations.

DESIGN

We conducted a nested, cross-sectional survey of parents who were coming to see their child's pediatrician because of cold symptoms between October 2000 and June 2001. Parents completed a previsit survey that collected information on demographics, their child's illness, and a 15-item previsit expectations inventory that included an item asking how necessary it was for the physician to prescribe antibiotics. Physicians completed a postvisit survey that collected information on diagnosis, treatment, and whether the physician perceived the parent expected an antibiotic. The encounter was the unit of analysis. Multivariate logistic regression analyses were performed to evaluate predictors of dichotomized parental expectations for antibiotics, dichotomized physician perceptions of those expectations, diagnostic patterns, and antibiotic-prescribing patterns.

SETTING

Twenty-seven community pediatric practices in the Los Angeles, Calif, metropolitan area.

PARTICIPANTS

A volunteer sample of 38 pediatricians (participation rate: 64%) and a consecutive sample of 543 parents (participation rate: 83%; approximately 15 participating for each enrolled pediatrician) seeking care for their children's respiratory illnesses. Pediatricians were eligible to participate if they worked in a community-based managed care practice in the Los Angeles area. Parents were eligible to participate if they could speak and read English and presented to participating pediatricians with a child 6 months to 10 years old who had cold symptoms but had not received antibiotics within 2 weeks.

MAIN OUTCOME MEASURES

Parental beliefs about the necessity of antibiotics for their child's illness, physician perceptions of parental expectations for antibiotics, bacterial diagnosis rates, and antibiotic-prescribing rates.

RESULTS

Forty-three percent of parents believed that antibiotics were definitely necessary, and 27% believed that they were probably necessary for their child's illness. Latino and Asian parents were both 17% more likely to report that antibiotics were either definitely or probably necessary than non-Hispanic white parents. Physicians correctly perceived that Asian parents expected antibiotics more often than non-Hispanic white parents but underestimated the greater expectations of Latino parents for antibiotics. Physicians also correctly perceived that parents of children with ear pain or who were very worried about their child's condition were significantly more likely to expect antibiotics. Physicians were 7% more likely to make a bacterial diagnosis and 21% more likely to prescribe antibiotics when they perceived that antibiotics were expected.

CONCLUSIONS

Parent expectations for antibiotics remain high in Los Angeles County. With time, traditional public health messages related to antibiotic use may decrease expectations among non-Hispanic white parents. However, both public health campaigns and physician educational efforts may need to be designed differently to reach other racial/ethnic groups effectively. Despite public health campaigns to reduce antibiotic overprescribing in the pediatric outpatient setting, physicians continue to respond to parental pressure to prescribe them. To effectively intervene to decrease rates of inappropriate antibiotic prescribing further, physicians need culturally appropriate tools to better communicate and negotiate with parents when feeling pressured to prescribe antibiotics.

Safe prescribing practices in pregnancy and lactation

Midwives and other health care providers face a dilemma when a pregnant woman develops a condition that usually is treated with a pharmacologic agent. Understanding of basic teratology associated with drugs as well as the FDA categorization of agents can assist professionals in recognizing which pharmaceuticals should be used or avoided. In addition to reviewing teratology, this article addresses the use of common drugs for the treatment of upper respiratory conditions, minor pain, gastrointestinal problems, psychiatric illnesses, and neurologic disorders. In each category, current evidence is presented pertaining to which agents should be recommended for pregnant women.

Do pregnant women report use of dispensed medications?

Surveillance of drug safety in pregnancy often draws on administrative prescription registries. Noncompliance in the use of prescribed medication may be frequent among pregnant women owing to their fear of fetotoxic side effects. To estimate compliance in the use of prescription drugs dispensed during pregnancy, we compared prescription data from the North Jutland Prescription Database with information on drug use provided by pregnant women to the Danish National Birth Cohort (DNBC), which is a health interview survey. We used the North Jutland Prescription Database to identify all prescription drugs dispensed during pregnancy for the 2,041 women who were enrolled in the DNBC in the County of North Jutland, Denmark. Compliance was defined as the probability of reporting drug use in DNBC after purchasing a dispensed prescription drug. The overall compliance to drugs purchased within 120 days before the interview was 43% (95% confidence interval = 40-46). Drugs used for treating chronic diseases, for example, beta-blockers, insulin, thyroid hormones, and diuretic and antiepileptic drugs, were always reported to be used, but compliance was low for drugs used for local or short-term treatment such as antihistamines, antibiotics, antacids, nonsteroid anti-inflammatory drugs, and gynecologic drugs. Thus, for the latter drug groups the prescription database may provide an incomplete identification of exposure. Neither data source is unbiased regarding actual drug intake. Nevertheless, our results indicate that for some drug groups risk assessment studies based on prescription data may produce false negative results as a result of noncompliance.

Patterns of medication use during and prior to pregnancy: the MAP study

We interviewed 140 pregnant women of any gestational age attending antenatal clinics at the Women's and Children's Hospital in Adelaide during September-October 1999 to elicit information about their patterns of medication use during and in the 3 months prior to their current pregnancy. Demographic information, information on women's prescribed, non-prescribed, and non-medicinal drug use during and in the 3 months prior to pregnancy, and information about both their general sources of information on medication use and their specific reasons for medication uptake/cessation during pregnancy were obtained. The women used an average of 0.7 0.8 prescribed and 2.3-2.6 non-prescribed medications (total 3.1-3.3) in the 3 pregnancy trimesters, compared with 1.0 prescribed and 2.2 non-prescribed prior to pregnancy. Use of a prescribed or non-prescribed medication was 96-97% across trimesters. Simple analgesics, vitamin/mineral supplements, and antacids were the most commonly taken medications. Antibiotics were the most commonly prescribed medication. Use of class A medications increased during pregnancy while use of non-class A medications decreased. Peri-conceptional folate supplementation was 31%. Alcohol consumption and cigarette smoking decreased after diagnosis of pregnancy. Both prescribed and non-prescribed medication use is common during all trimesters of pregnancy. However, overall use changes little compared with pre-pregnancy values. Rates of peri-conceptional folate supplementation are low.

[Prevalence of use of medicines during pregnancy and its relationship to maternal factors]

INTRODUCTION

There is in Brazil a growing use of industrially produced medicines even during the female reprodutive cycle. During pregnancy two organisms are exposed to the effects of medicines but in the foetus this may result in toxicities with possible irreversible lesions. The present study aims at verifying the prevalence of the use of medicines during pregnancy in the studied population and its relationship with maternal characteristics, the pharmacological groups used and the source of prescription.

METHODS

The use of medication was evaluated among 1,620 women that gave birth in five public, private and contracted hospitals in the city of S. Paulo between July and September 1993.

RESULTS AND CONCLUSIONS

The relation between maternal schooling and kind of assistance in hospitals has revealed social inequality in the access to the several kinds of delivery assistance services. The prevalence of use of at least one medicine was 97.6% with an average of 4.2 drugs per woman. The prevalence of use of drugs by medical prescription and self-medication were 94.9% and 33.5%, respectively. The most used medications, excluding vitamins, mineral salts and vaccines, were analgesics, antacids, antispasmodics and antemetics. Users of the largest number of medicines were, characteristically, over 29, married, of university level, salaried workers and had access to private health services. Medical assistance had a facilitating role in access to the use of drugs during the gestational period of the population studied. Women need to be made aware of the potential risks they expose their foetuses to when using so many medicines. Physicians should reflect on their role in contributing to the solution to this problem.

Spectrum of gestational exposure to illicit drugs and other xenobiotic agents in newborn infants by meconium analysis

OBJECTIVE

To detect the spectrum of gestational exposure to illicit drugs and other xenobiotic agents in neonates by meconium analysis.

METHOD

Meconium was collected from 98 neonates and analyzed for illicit drugs and other xenobiotic agents by high-performance liquid chromatography and gas chromatography/mass spectrometry.

RESULTS

Eighty-one (82.7%) infants tested positive for xenobiotic agents, and each infant had from 1 to 9 drugs present. These included local anesthetics (30%) such as lidocaine and mepivacaine; food additives (25%) such as ionol (butylated hydroxytoluene); illicit drugs (11%), especially cocaine and morphine; analgesics (10%) such as meperidine; and fewer (< 10%) other drugs such as antihistamines, antidepressants, adrenergics, anticonvulsants, cough medications, analeptics, hypnosedatives, and cardiotonics.

CONCLUSION

We demonstrated substantial exposure of neonates to xenobiotic agents, ranging from exposure to food additives, prescribed or over-the-counter medications, and drugs of abuse.

Pharmacokinetic changes during pregnancy and their clinical relevance

The dynamic physiological changes that occur in the maternal-placental-fetal unit during pregnancy influence the pharmacokinetic processes of drug absorption, distribution and elimination. Pregnancy-induced maternal physiological changes may affect gastrointestinal function and hence drug absorption rates. Ventilatory changes may influence the pulmonary absorption of inhaled drugs. As the glomerular filtration rate usually increases during pregnancy, renal drug elimination is generally enhanced, whereas hepatic drug metabolism may increase, decrease or remain unchanged. A mean increase of 8 L in total body water alters drug distribution and results in decreased peak serum concentrations of many drugs. Decreased steady-state concentrations have been documented for many agents as a result of their increased clearance. Pregnancy-related hypoalbuminaemia, leading to decreased protein binding, results in increased free drug fraction. However, as more free drug is available for either hepatic biotransformation or renal excretion, the overall effect is an unaltered free drug concentration. Since the free drug concentration is responsible for drug effects, the above mentioned changes are probably of no clinical relevance. The placental and fetal capacity to metabolise drugs together with physiological factors, such as differences acid-base equilibrium of the mother versus the fetus, determine the fetal exposure to the drugs taken by the mother. As most drugs are excreted into the milk by passive diffusion, the drug concentration in milk is directly proportional to the corresponding concentration in maternal plasma. The milk to plasma (M:P) ratio, which compares milk with maternal plasma drug concentrations, serves as an index of the extent of drug excretion in the milk. For most drugs the amount ingested by the infant rarely attains therapeutic levels.

Use of psychotropic drugs and pregnancy outcome

This study reports the use of psychotropic drugs and pregnancy outcome in a prospective survey carried out in northern Finland in 1985-1986, consisting of 7933 pregnant women and their 8030 births. Of the mothers, 120 (1.5%) used psychotropic drugs during pregnancy and of them 26 (0.3% of the total) used these drugs before and during the pregnancy. According to the logistic regression analysis, the biological and social background variables associating significantly with the use of these drugs were maternal advanced age and multiparity (> 35 years and > 4 parous), overweight (body mass index > the 90th percentile), smoking, alcohol use, belonging to social class IV, and failure to ensure contraception. The users needed hospital observation significantly more often during pregnancy (regular users, 80.8%; occasional users, 38.3; nonusers, 27.4%) and the adjustment of the background variables did not change this result. Of the pregnancy complications bleeding was significantly more common among users than nonusers (23.3 vs. 13.2%) and this difference was not explained by difference in background variables. The mean birth weight of infants of the regular users was significantly lower (255 g) when background variables were standardized by linear regression analysis. No association of increased number of birth defects was found with usage of psychotropic drugs.

Use of psychotropic drugs during pregnancy. A report of the international co-operative drug use in pregnancy (DUP) study. Collaborative Group on Drug Use in Pregnancy (CGDUP)

Drug Use in Pregnancy (DUP) is an international epidemiological survey of drug use in pregnancy conducted from 1988 to 1990 in 148 maternity wards, representing the general delivery practices of 22 countries. Data on exposure of pregnant women to psychotropic drugs, the indications for their use and their correlation with maternal characteristics are reported. Of the 14,778 women interviewed, 520 (3.5%) reported 562 courses of psychotropic drugs. Benzodiazepines (BDZ) accounted for the greatest number of the exposures (444/520 women); neuroleptics and antidepressants were prescribed to tiny minorities of women (83 and 17 respectively), mostly in those few countries were the overall prevalence of use of those drugs was highest. Throughout the majority of the other countries, overall rates were in the low range and were rather heterogeneous. With the exception of small clusters of "unexpected" indications, prescriptions of BDZ were found to be consistent with the target symptoms of anxiety and insomnia; chronic use was reported in 31/444 women. The study was not targeted to the detection of malformations; no suspected clustering was found, however, among the 130 women exposed during the first trimester of pregnancy. The collaborative network now established provides a framework for periodically replicated surveillance to monitor the evolution of this field of knowledge and care in order to provide reliable information for women and society.

Drug use in pregnancy: a comparative appraisal of data collecting methods

We have compared the reliability of the information about drug therapy and pregnancy retrieved by interviewing patients with that distilled from pharmacy records. In the initial phase of each interview we used the internationally accepted open-ended technique, and extended this with an indication-oriented set of questions and then a set of specific drug-oriented questions. These data were then compared with those from pharmacy records on dispensing for the same patients during their pregnancy. The results suggest that if drug consumption during pregnancy is evaluated by interview, one should not restrict oneself to open-ended questions but should include indication-oriented and, when appropriate, drug-oriented questions. Such specific questions offer the opportunity of detecting the use of over-the-counter medication and of constructing drug use/complaint profiles. By contrast, pharmacy records will give better information in case of long recall periods and in patients with multiple and/or repeated drug use. Investigators should use the complementary elements of both techniques where appropriate.

Use of prescription and non-prescription drugs in pregnancy. The Baltimore-Washington Infant Study Group

We analyzed use of therapeutic drugs during pregnancy by 2752 mothers of infants without major congenital malformations. During pregnancy, 68% of the women used at least one prescription or non-prescription drug. Drug use in pregnancy was significantly more common for women who were white, older, married, better educated, of higher income and occupational status, receiving private prenatal care and not living in urban areas. Number of maternal illnesses, higher socioeconomic status, white race, multiparity and use of recreational drugs explained 26% of reported drug use. The mean number of drugs reported (1.2) underestimates total drug exposure due to exclusion of some drug categories including multivitamins and illicit drugs. Since the majority of women giving birth to normal infants report use of at least one pharmacologic agent during pregnancy, attribution of adverse outcome to drug use in an individual case is rarely justified.

A national study to monitor the safety of IUCD use

OBJECTIVE

To determine whether the known adverse effects of IUD use were being kept to a minimum in a population of women.

DESIGN

A national survey of all doctors purchasing IUDs in a three-month period. Information was sought on the doctors' training, experience and usual insertion practice, and also on characteristics of each woman receiving an IUD in the study period.

MAIN OUTCOME MEASURES

Published national and international guidelines on selection of users for IUDs and on training for IUD insertion were compared with our findings on these measures.

RESULTS

Not all IUD insertions were in accordance with published guidelines. Very few IUD insertions (0.9%) were carried out in the face of absolute contraindications to this type of contraception. However, 126 insertions (27%) were for women who had a relative contraindication, excluding an incomplete family. Gynaecologists were significantly less likely to fit an IUD in the presence of contraindications than other doctors. Few doctors reported training to the standard recommended.

CONCLUSIONS

That the known adverse effects of IUD use are not being kept to a minimum for New Zealand women. The study design could be used to estimate the potential for adverse effects in populations for other types of contraceptives.

Handling of risk-bearing drugs during pregnancy. Do we choose less risky alternatives?

The drug use of nearly 2,000 pregnant women was evaluated at the level of the individual patient for the drugs belonging to the Australian risk categories B3, C and D. The pattern of changes in the use of these drugs is studied in terms of women who discontinue (d), continue (c) or begin (b) using the drug during pregnancy. The ratios d/(c+b) and d/b were the highest for the drugs belonging to the high-risk groups and the lowest for drugs from the low-risk categories. This suggests a congruence between theoretical knowledge and daily practice. Patients who had already been using a drug for a long time before pregnancy, more frequently continued using that drug than patients who had been using the drug only incidentally before. The described daily dose for the riskful drugs was approximately 20% lower in patients who started to use a drug during pregnancy compared to those who continued drug use. The data from this analysis indicate that the prescribing physician is generally aware of the possible risks of drug use during pregnancy. The d/(b+c) and d/b ratios are shown to be a good measure of prescribing behaviour in relation to pregnancy and can be used to compare knowledge of theory and daily practice.

Medication during low-risk pregnancy

The use of medication during low-risk pregnancy was studied prospectively in a cohort of women supervised by specialist obstetricians at a university hospital (n = 332) and a cohort of women supervised by midwives in private practice (n = 250). More women under supervision of obstetricians/gynaecologists used medication (87.7%) than women supervised by midwives (59.8%). The top-five of medication were analgesics, antacids, vitamins, antibiotics and dermatologic preparations. More research is needed to establish the risks of these medications to the offspring.

Prenatal exposure to prescribed drugs in Tennessee Medicaid, 1983-1988

This report describes the prenatal exposure histories of 107,804 women to prescribed drugs other than vitamins, iron and other minerals. The data were obtained from Tennessee Medicaid pharmacy files linked to birth and fetal death certificates for 1983-1988. The utility of these data to other investigators in predicting power or estimating sample size for studies of drug exposure in pregnancy associated with adverse birth outcomes is discussed.

Medication in early pregnancy: prevalence of use and relationship to maternal characteristics

Medication use was assessed in a population of 4186 women who were delivered of infants at Yale-New Haven Hospital, New Haven, Connecticut, between 1980 and 1982. The frequency of over-the-counter and prescription drug use, and the association of such use with maternal characteristics was studied. Of all women, 66% used at least one drug. The mean number of drugs used by all subjects was 1.3 and, among drug users, 2.9. Of all drugs used, 68% were over-the-counter and 32% were prescription preparations. Internal analgesics, autonomic drugs, antiinfective agents, and antacids were most frequently used. Women who used prescription drugs were also more likely to use over-the-counter medications. Maternal characteristics that were associated with an increase in both over-the-counter and prescription drug use were being white, smoking more than 20 cigarettes a day, using alcohol, using caffeine, and smoking marijuana. These findings suggest that women who engage in "risk-taking behavior" during pregnancy are also more likely to use medications while pregnant.

Investigating drug use in pregnancy. Methodological problems and perspectives

In this study the use of prescribed drugs before, during and after pregnancy is described. The study is based on data obtained from pharmacy records of 1,948 women who delivered a live-born infant. Different measures to evaluate drug exposure are used. During the nine months of pregnancy 86% of the women used on average 4.2 prescriptions. During the course of pregnancy the use of gastro-intestinal and blood-forming drugs increased, whereas the use of cardiovascular, antiphlogistic and central nervous system drugs decreased. Anti-emetics were predominantly used in the first trimester, and antacids in the last trimester, whereas laxatives were especially used after delivery. The percentage of women who used a treatment for vaginal infections increased from 2 to 7 during pregnancy. Most of the women (73%) received one or more iron prescriptions during the course of pregnancy, however, the prescribed daily dose was low (prescribed daily dose/defined daily dose = 0.6). At least 1% of the women filled a new prescription for anticonceptives in the first trimester of pregnancy. Most likely, our data reflect the general prescribing pattern for Dutch pregnant women who delivered a live-born baby. Therefore, they form a good and detailed base for further studies, for instance, on the exposure to drugs with known or suspected risks or on the use of drugs in patients with chronic concomitant diseases. Such studies may lead to recommendations that may improve prescribing behaviour.

Effects of drug administration in pregnancy on children's school behaviour

Files with prescription data were used to assess possible behavioural changes in children, whose mothers used benzodiazepines or neuroleptic drugs during the second half of their pregnancy. Prescriptions, bearing the identification number of women resident in one district of Prague, filed in pharmacies during 1974 and the first three months of 1975 represent the first part of the data. During 1984, children born in the appropriate earlier period were searched and linked with the earlier prescription data. A group of 68 children with possible exposure to neuroleptics and a group of 15 children possibly exposed to diazepam during the second half of their intrauterine development were found. Two groups of 55 and 7 children, respectively, born of mothers without exposure to these drugs, were chosen as controls. The teachers of classes attended by these children were addressed by a letter and asked to evaluate their behaviour at school. This was done by means of a form containing analogue scales evaluating different features of behaviour. Each child was compared with its control. The statistical evaluation with Student's t-test, regression analysis and analysis of variance did not reveal any significant difference between both groups and their controls.

Drug use in pregnancy: an overview of epidemiological (drug utilization) studies

The need for further information on drug utilization patterns during pregnancy in different countries was assessed by reviewing literature obtained by hand and computer searches for the years 1960-1988. The 13 identified studies showed that pregnant women used an average of 4.7 drugs. The most commonly ingested medications were vitamins and iron preparations (almost all women), analgesics, antiemetics and antacids. However, the important variables taken into account differently in each study, such as date of surveillance, country, size of population, personal habits, and physiopathological and demographic characteristics, may it impossible to construct a comprehensive, detailed, up-to-date picture of drug utilization during pregnancy. The evaluation confirmed the need for systematic permanent surveillance of drug utilization in pregnancy, so as to avoid the use of data based on widely differing contexts, times and methods, in a field where knowledge is often derived from scanty information.

Information on drug use in pregnancy from the Viewpoint Regional Drug Information Centre

The need for information on drug use during pregnancy was assessed by reviewing the requests for information arriving at a drug information centre in the past nine years. Of all the queries received 24% concerned this aspect, of which the majority were focused on drug use during pregnancy. Mothers received an average of 2.6 prescriptions, most frequently for antiinfectives, psychotropics, hormones and non-narcotic analgesics. Questions were answered personally after a literature search. A profile of questions and a summary of model cases registered in the archives of the centre are reported. The evaluation confirmed the need for and value of a drug information service in relation to pregnancy, so as to avoid alarmist and falsely reassuring attitudes in a field where knowledge is often based on scanty information.

Drug accumulation in lung fluid of the fetal lamb after maternal or fetal administration

The pharmacokinetic characteristics of the antiemetic drug metoclopramide and the antihistamine diphenhydramine have been determined in a chronically catheterized pregnant sheep preparation. Metoclopramide and diphenhydramine were administered by separate maternal and fetal intravenous infusions to a steady state as well as by maternal intravenous bolus dosing. Drug concentrations in the maternal and fetal plasma and the amniotic and tracheal fluids were measured by means of capillary gas-liquid chromatographic assay techniques. Both metoclopramide and diphenhydramine were excreted into tracheal fluid in substantial quantities. Tracheal metoclopramide concentrations were found to exceed fetal plasma levels by about fifteen-fold while diphenhydramine attained maximal excretion in tracheal fluid of about five times that seen in fetal plasma. Drug levels were observed to accumulate slowly in amniotic fluid and eventually to exceed tracheal concentrations. The markedly elevated concentrations of these drugs in fetal lung fluid suggests that the fetal lung may be an important route of drug distribution, elimination, and excretion.

Prescription drug use before and during pregnancy in a Medicaid population

This study describes prescription drug use before and during pregnancy and is based on data obtained from the paid Medicaid claims of 18,886 Michigan women aged 15 to 44 years who were delivered of a live infant. Rates of exposure to drugs within 15 therapeutic categories are presented for each of five 90-day periods preceding delivery. Overall dispensed drug use (excluding vitamins) decreased during pregnancy; however, there was still substantial exposure to drugs including drugs that are contraindicated during pregnancy. During the gestational period, study mothers received an average of 3.1 prescriptions for nonvitamin drugs. Black mothers received more exposure to drugs other than vitamins than did white mothers. Black mothers had higher rates of exposure to analgesics, ampicillin, codeine, and vaginal preparations. Similarities between black and white mothers in the use of vitamins with and without other drugs suggest there is no racial difference in attaining prenatal care within the Medicaid system, but that black mothers may have more medical problems that warrant the use of other medications in addition to vitamins during pregnancy.

Principles of irrational drug therapy

Drugs are extensively used in medicine when they are unlikely to produce a benefit to the patient. In most instances this does no apparent harm to the patient but sometimes (for example, the extensive use of thorotrast) the results are tragic. Even when the patient is not injured, overuse of medicines is an undesirable and money-wasting behavioral pattern. Several factors relating to the social process of drug use which encourage overprescribing are discussed and the Principles of Irrational Drug Therapy are derived. These principles are presented as negative role models for the use of medicines in developing countries.

Placental transfer of diphenhydramine in chronically instrumented pregnant sheep

To study the placental transfer and pharmacokinetics of the H1 receptor blocker, diphenhydramine [2-(diphenylmethoxy)-N,N-dimethylethylamine], 100 mg of the drug was administered to four pregnant sheep (122-129 d gestation) by intravenous injection through catheters chronically implanted in the ewe and fetus. Rapid placental transfer occurred, with peak fetal plasma concentrations occurring within 5 min after injection. The fetal-maternal ratio of the area under the plasma concentration versus time curves averaged 0.85, indicating significant fetal exposure to the drug. The average apparent terminal elimination half-life in the ewe (52 min) was not significantly different from that obtained in the fetus (46 min). The maternal total body clearance was 3.6 L X h-1 X kg-1, and the volume of distribution at steady state was 3.2 L/kg. In summary, this study demonstrates rapid and extensive placental transfer of diphenhydramine after maternal drug administration. Since placental permeability to lipid-soluble compounds does not differ greatly in different species, it is likely that a similar situation exists in humans.

Prospective survey of use of therapeutic drugs, alcohol, and cigarettes during pregnancy

Use of drugs during pregnancy was recorded prospectively in 2765 women attending the antenatal clinics of a general hospital from October 1982 to March 1984. Of these women, 2588 (93.6%) avoided exposure to drugs during the first trimester, 1802 (65.2%) took no drugs at any stage, 963 (34.8%) took a total of 154 different drugs from 35 groups of drugs, and 243 (8.8%) took a self administered drug. The most commonly used drugs were non-narcotic analgesics, usually self administered, and antibacterials. The last survey of use of drugs in pregnancy in the United Kingdom 20 years ago showed fewer women avoiding drugs throughout pregnancy (195 of 911 (21.4%), p less than 0.001) and in taking a self administered drug (586 (64.4%), p less than 0.001) than at present. Most women nowadays abstain totally from alcohol (1786 (64.6%) v 109 (12.0%) previously, p less than 0.001), but while more women are non-smokers compared with previously (1811 (65.5%) v 392 (43%), p less than 0.001) the trend has been far less dramatic than that for use of alcohol.

Effects of drugs and chemicals on the fetus and newborn (1)

Drug teratogenicity has been demonstrated experimentally for more than 30 years. After the discovery of the thalidomide-induced embryopathies, the fetal dangers of maternal drug ingestion were overemphasized. Accumulation of additional information during the past 15 years has led to a more balanced viewpoint concerning drug teratogenicity. A complex set of circumstances must prevail for a specific teratogenic effect to result. Not only the drug or environmental pollutant in question but also its dose, timing, and frequency of administration as well as the genetic and individual susceptibility of the embryo are important factors. Herein we review the currently available information on drug and environmental effects on the fetus and neonate.

Opiates, endorphins and the developing organism: a comprehensive bibliography

A comprehensive bibliography of the literature concerned with opiates, endorphins, and the developing organism is presented. A total of 1378 clinical and laboratory references, with citations beginning in 1875, are recorded. A series of indexed accompanies the citations in order to make the literature more accessible. These indexes are divided into clinical and laboratory topics. The clinical section is subdivided into: age of subject examined; maternal aspects; effects on the fetus; pharmacology, physiology, and the withdrawal syndrome; and "other" effects on the offspring. The laboratory section is subdivided into: type of opiate/endorphin studied; species utilized; and major subject areas explored.

Effects of phenylephrine and sodium salicylate on maternal and fetal cardiovascular indices and blood oxygenation in sheep

Phenylephrine and sodium salicylate, separately and in combination, in doses equivalent to the phenylephrine in one "cold" tablet and the sodium salicylate in three aspirins, were infused into conscious, chronically cannulated ewes in the third trimester of pregnancy. Maternal and fetal indices were recorded before (control), during, and after infusion. Phenylephrine depressed uterine blood flow and maternal heart rate (both, 40% below control) and increased maternal mean arterial blood pressure 50%; in the fetus, it depressed arterial blood Po2 (30%) and blood pH, but increased Paco2 and had little effect on mean arterial blood pressure and heart rate. Salicylate alone had no significant effect on maternal and fetal indices, and sodium salicylate plus phenylephrine produced changes similar to those with phenylephrine alone. We conclude that phenylephrine in the maternal circulation could have detrimental effects on the fetus, particularly when fetal Pao2 is depressed as by cord compression during delivery.