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

Prevalence of polypharmacy in pregnancy: a systematic review

OBJECTIVES

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

DESIGN

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

RESULTS

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

CONCLUSION

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

TWEETABLE ABSTRACT

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

PROSPERO REGISTRATION NUMBER

CRD42021223966.

The use, perceptions and knowledge of safety of over-the-counter medications during pregnancy in a Canadian population

BACKGROUND

The prevalence of prenatal over-the-counter medication use in Canadian women is unknown.

METHODS

A cross-sectional study of prenatal over-the-counter medication use and safety knowledge was conducted among pregnant and post-partum women attending an academic hospital obstetrics clinic.

RESULTS

Seventy-two women participated; 90.3% were Caucasian, 69.4% had a college/university degree, and 61.1% lived in an urban area. Of the 72 women, 87.5% used over-the-counter medications prenatally, first (55.6%), second (65.3%), and third (47.2%) trimesters, with prenatal acetaminophen use most common (72.2%). Women who used over-the-counter medications 1-0onths before conception were more likely to use over-the-counter medications during pregnancy, and 18% of women initiated over-the-counter medications in pregnancy. Women self-reported a medium level of over-the-counter medication safety knowledge (73.6%) and responded that not all over-the-counter medications are safe during pregnancy (95.8%).

CONCLUSION

Despite limited safety profiles of some over-the-counter medications, pre-conception and prenatal over-the-counter medication use was high. Further research on the risk of over-the-counter medications and combinations in pregnancy is needed to help women to make safe choices during pregnancy.

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..

Parental comorbidity and medication use in the USA: a panel study of 785 000 live births

STUDY QUESTION

How prevalent is paternal medication use and comorbidity, and are rates of these rising?

SUMMARY ANSWER

Paternal medication use and comorbidity is common and rising, similar to trends previously described in mothers.

WHAT IS KNOWN ALREADY

Maternal medication use and comorbidity has been rising for the past few decades. These trends have been linked to potential teratogenicity, maternal morbidity and mortality and poorer fetal outcomes.

STUDY DESIGN, SIZE, DURATION

This is a Panel (trend) study of 785 809 live births from 2008 to 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We used the IBM© Marketscan®™ database to gather data on demographic information and International Classification of Diseases codes and Charlson comorbidity index (CCI) during the 12 months prior to the estimated date of conception for mothers and fathers. We similarly examined claims of prescriptions in the 3 months prior to conception. We performed companion analyses of medications used for >90 days in the 12 months prior to conception and of any medication use in the 12 months prior to conception.

MAIN RESULTS AND THE ROLE OF CHANCE

We confirmed that both maternal medication use and comorbidity (e.g. hypertension, diabetes, hyperlipidemia) rose over the study period, consistent with prior studies. We found a concurrent rise in both paternal medication use 3 months prior to conception (overall use, 31.5-34.9% during the study period; P < 0.0001) and comorbidity (CCI of ≥1 and 10.6-18.0% over study period; P < 0.0001). The most common conditions seen in the CCI were chronic obstructive pulmonary disease for mothers (6.6-11.6%) and hyperlipidemia for fathers (8.6-13.7%). Similar trends for individual medication classes and specific comorbidities such as hypertension, diabetes and hyperlipidemia were also seen. All primary result trends were statistically significant, making the role of chance minimal.

LIMITATIONS, REASONS FOR CAUTION

As this is a descriptive study, the clinical impact is uncertain and no causal associations may be made. Though the study uses a large and curated database that includes patients from across the USA, our study population is an insured population and our findings may not be generalizable. Mean parental age was seen to slightly increase over the course of the study (<1 year) and may be associated with increased comorbidity and medication use.

WIDER IMPLICATIONS OF THE FINDINGS

As parental comorbidity and certain medication use may impact fecundability, temporal declines in parental health may impact conception, pregnancy and fetal outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

N/A.

Community pharmacists' services for women during pregnancy and breast feeding in Kuwait: a cross-sectional study

OBJECTIVES

This study was designed to identify the services provided by community pharmacists in Kuwait and their views regarding self-care in pregnancy and lactation. In addition, it determined the pharmacists' recommendations for treatment of pregnancy-related and breast feeding-related ailments.

DESIGN

Cross-sectional questionnaire-based survey.

SETTING

Community pharmacies in Kuwait.

PARTICIPANTS

207 pharmacies were randomly selected from the Ministry of Health database. One registered pharmacist was approached from each pharmacy. One hundred and ninety-two (92.8%) pharmacists agreed to participate and completed a self-administered questionnaire.

OUTCOMES

The proportions of pharmacists offering particular advice for health conditions in pregnancy and lactation, pharmacists' recommendations for common and specific ailments during pregnancy and breast feeding, and pharmacists' views about self-care in pregnancy and breast feeding.

RESULTS

The top services provided to pregnant and lactating women were recommending vitamins and food supplements (89.8%) and contraception advice (83.4%), respectively. More than half of participants indicated that they would recommend medications for headache, constipation, cough, runny nose, sore throat, nausea/vomiting, indigestion, sore or cracked nipple and insufficient milk. Diarrhoea, haemorrhoids, insomnia, varicose vein, swelling of the feet and legs, vaginal itching, back pain, fever, mastitis and engorgement were frequently referred to the physician. Recommendations on medication use were occasionally inappropriate in terms of unneeded drug therapy, off-label use and safety. In relation to offering advice and solving medication and health problems of pregnant and lactating women, more than half of pharmacists indicated that they have sufficient knowledge (61.5%; 50.5%) and confidence (58.3%; 53.1%), respectively. Most of the respondents (88.5%) agreed that a continuing education programme on this topic would be of value for their practice.

CONCLUSION

The present findings show that respondents had different recommendations for treatment of pregnancy-related and lactation-related ailments; and also highlight the need for interventions, including continuing professional development and revision of the undergraduate pharmacy curriculum.

Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE): Proposed DSM-5 Diagnosis

Over the past 40 years, a significant body of animal and human research has documented the teratogenic effects of prenatal alcohol exposure (PAE). Neurobehavioral Disorder associated with PAE is proposed as a new clarifying term, intended to encompass the neurodevelopmental and mental health symptoms associated with PAE. Defining this disorder is a necessary step to adequately characterize these symptoms and allow clinical assessment not possible using existing physically-based diagnostic schemes. Without appropriate diagnostic guidelines, affected individuals are frequently misdiagnosed and treated inappropriately (often to their considerable detriment) by mental health, educational, and criminal justice systems. Three core areas of deficits identified from the available research, including neurocognitive, self-regulation, and adaptive functioning impairments, are discussed and information regarding associated features and disorders, prevalence, course, familial patterns, differential diagnosis, and treatment of the proposed disorder are also provided.

Predictors of the use of medications before and during pregnancy

BACKGROUND

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

OBJECTIVES

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

SETTING

Six maternity care units and five community pharmacies.

METHOD

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

MAIN OUTCOME MEASURE

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

RESULTS

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

CONCLUSION

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

Effects of personality on use of medications, alcohol, and cigarettes during pregnancy

PURPOSE

The aim of the study was to examine the role of personality in a pregnant woman's consumption of medications, cigarettes, and alcohol.

METHODS

The study included 835 pregnant women in Norway who responded to an electronic questionnaire posted on websites for pregnant women. On the questionnaire, the women reported their use of medications, cigarettes, and alcohol during pregnancy. They also filled out a personality assessment questionnaire, the Big Five Inventory.

RESULTS

Use of medications, alcohol, and cigarettes was significantly associated with different personality traits. Women with high scores for conscientiousness were less likely to use an over-the-counter medication such as paracetamol than other women (odds ratio (OR) 0.74; 95% confidence interval (CI) 0.55-0.99). Women who scored high for neuroticism were four- to sixfold more likely to use prescription medications such as sedatives/anxiolytics (OR 4.07; 95% CI 1.48-11.20) or antidepressants (OR 5.73, 95% CI 2.33-14.09). Women with high scores for openness to experience were more likely to use herbal remedies (OR 1.59; 95% CI 1.00-2.52). Women who continued consuming alcohol during pregnancy were more likely to score high on extraversion and low on conscientiousness than women who quit alcohol use. Scoring high on neuroticism increased the likelihood of quitting smoking during pregnancy.

CONCLUSIONS

This study shows that a woman's personality traits are associated with use of medications, cigarettes, and alcohol during pregnancy. This knowledge could be of clinical importance to health care personnel providing prenatal care.

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

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

Medication use during pregnancy, with particular focus on prescription drugs: 1976-2008

OBJECTIVE

The objective of the study was to provide information on overall medication use throughout pregnancy, with particular focus on the first trimester and specific prescription medications.

STUDY DESIGN

The study design included the Slone Epidemiology Center Birth Defects Study, 1976-2008, and the National Birth Defects Prevention Study, 1997-2003, which together interviewed more than 30,000 women about their antenatal medication use.

RESULTS

Over the last 3 decades, first-trimester use of prescription medication increased by more than 60%, and the use of 4 or more medications more than tripled. By 2008, approximately 50% of women reported taking at least 1 medication. Use of some specific medications markedly decreased or increased. Prescription medication use increased with maternal age and education, was highest for non-Hispanic whites, and varied by state.

CONCLUSION

These data reflect the widespread and growing use of medications by pregnant women and reinforce the need to study their respective fetal risks and safety.

Community pharmacists' views and experiences of counter-prescribing in pregnancy

Objective

To ascertain the sources of community pharmacists' knowledge base for counter-prescribing in pregnancy, whether sufficient additional information was readily accessible and, if not, to discover pharmacists' areas of concern.

Method

A structured telephone interview of community pharmacists by a single researcher using a pre-piloted questionnaire to obtain both quantitative and qualitative data. Questions covered previous education about counter-prescribing in pregnancy, reference sources used, and satisfaction with available reference sources. Respondents were also asked to cite examples where they would or would not recommend a medicine in pregnancy.

Setting

A random sample of 50 community pharmacies in Scotland.

Key findings

From the high response rate (43 pharmacists, 86 per cent) the topic was demonstrably important to community pharmacists, most of whom perceived their knowledge base for counter-prescribing in pregnancy to be experience-gained. Thirty-four pharmacists (79 per cent) agreed there was a need for more information to be available. Ten pharmacists (23 per cent) highlighted complementary therapies as an area where they found available information inadequate. Examples of requests from pregnant women and the action taken by the pharmacist are reported.

Conclusion

There is a need for an accurate, current and comprehensive data source for counter-prescribing in pregnancy. The field of complementary medicines and therapies is of particular concern to many community pharmacists. More research is required into GP referrals.

The use during pregnancy of prescription, over-the-counter, and alternative medications among Hispanic women

BACKGROUND

Despite lack of scientific evidence about the safety of complementary and alternative medicines, the reported use of such remedies during pregnancies has increased. This study was undertaken to investigate the use of herbs, vitamins, and over-the-counter and prescription medications among pregnant Hispanic women and reasons for use, and to assess physician-patient level of communication about women's use.

METHODS

A total of 485 Hispanic women were surveyed by means of a self-administered questionnaire immediately postpartum in a public hospital in Houston, Texas. The primary outcome was use of alternative therapies during the prenatal period.

RESULTS

During their pregnancies, 19 percent of the participants took herbs and 47 percent took vitamin supplements, other than prenatal vitamins. The most common reason for using herbs and vitamins was to improve the woman's general health and energy level (59%); a few women (12%) had used them for specific pregnancy-related problems. Overall, 77 percent took prenatal vitamins and 21 percent supplemented with folic acid. The rates of use of over-the-counter and prescription medications were 23 and 29 percent, respectively. The use of prescription medication was two-and-a-half times higher among women with history of medical problems (adjusted OR = 2.59, 95% CI = 1.59-4.25, p = 0.0001). No other factor studied was independently associated with supplement or medication use. One in five women (20%) believed that herbs and vitamins were safer to use than prescription medication or were better at treating medical problems than prescription medicine, and one-third had not disclosed information about supplement use to their physicians.

CONCLUSIONS

Use of herbal remedies does not appear to be a replacement for conventional medicine among most pregnant Hispanic women. Patient education about the risks of alternative therapies may lead to a reduction in intake of alternative medicines and greater disclosure to medical practitioners among this ethnic group.

Post natal use of analgesics: comparisons between conventional postnatal wards and a maternity hotel

AIM

To investigate factors related to analgesic use after delivery, and especially whether rates of analgesic use were different in a midwife-managed maternity hotel as compared to conventional postnatal wards.

SETTING

One maternity hotel and two conventional postnatal wards at Ullevål University Hospital in Oslo, Norway.

METHOD

Data were obtained from hospital records for 804 women with vaginal deliveries.

MAIN OUTCOME MEASURE

Postnatal analgesic use.

RESULTS

Overall, approximately half the women used analgesics after vaginal delivery in both conventional postnatal wards and maternity hotel. The factors that were significantly associated with use of analgesics postnatally in multivariate analysis were multiparity, having a non-Western ethnicity, smoking in pregnancy, younger age, instrumental delivery, analgesic use during labour, maternal complications post partum, and duration of postnatal stay 4 days or more.

CONCLUSION

The use of analgesics is determined by socio-demographic and obstetric factors rather than the organisation of the ward.

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

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

Socioeconomic status as a modifier of the relationship between antibiotic use during pregnancy and birthweight

BACKGROUND

Antibiotics taken during pregnancy treat underlying maternal infections that may otherwise contribute to poor birth outcomes, including decreased birthweight. This study investigated whether antibiotics taken by a diverse sample of North American women were associated with increased mean infant birthweight and whether this relationship was modified by socioeconomic status. The study hypothesized that women of low socioeconomic status, whose babies are at highest risk of low birthweight perhaps due to long-standing undiagnosed infections, might benefit from antibiotic use more than women of higher socioeconomic status.

METHODS

The sample was 868 control women from a case-control study of hemifacial microsomia, a craniofacial birth defect. Participants reported information on antibiotic use during pregnancy (type, indication, and timing) and baby's birthweight in telephone interviews.

RESULTS

Nineteen percent of women reported taking at least one antibiotic in the first half of pregnancy, but average birthweights were similar among users and nonusers. However, low-socioeconomic status women who reported taking antibiotics to treat genitourinary infections had babies that were 286 g heavier than those who did not (p = 0.01). No association was seen among higher socioeconomic status women. Differences by socioeconomic status were also seen in treatment for respiratory conditions and use of penicillin antibiotics.

CONCLUSIONS

These findings suggest that socioeconomic status might modify the association between antibiotics taken during pregnancy and infant birthweight. They emphasize the need to consider socioeconomic status in studies of antibiotic use and birth outcomes and extend previous studies of socioeconomic disparities in birth outcomes.

[Prevalence and determinants of medication during pregnancy by risk class among mothers of liveborn infants]

In order to identify the maternal determinants of the consumption of medication during pregnancy according to risk class, we conducted a population cohort baseline cross-sectional study with 2,262 mothers of liveborn infants in Passo Fundo, Rio Grande do Sul, Brazil. Data were collected from the Information System on Live Births and through home interviews (an instrument adapted from the Maternity Advice Survey). The drugs were classified according to criteria. We conducted bivariate analyses and logistic regression according to the hierarchical model of determination. 80% of the mothers consumed at least one medicine during the pregnancy, distributed in risk classes as follows: A (53.4%), B (18.1%), C (24.46%), D (1.47%), X (0.06%), and V (various) (2.1%). Incomplete prenatal care and maternal age < 20 years determined the consumption of medication in class A and pregnancy complications in classes B, C, and D. In class C, cesarean section and previous abortion also determined consumption, which in class V was independent of the variables analyzed. Maternal factors, especially health complications, determine the consumption of medicines during pregnancy, suggesting that the prescribing physician should orient the safe and proper use of such medication.

Principles and practice of teratology for the obstetrician

Common clinical problems of counseling patients about potential teratogenic risks in pregnancy are presented and principles of teratogenicity assessment.

Drug utilization and teratogenicity risk categories during pregnancy

A limited number of studies have investigated in detail the use of drugs during pregnancy. Researchers in the present study investigated the details of drug utilization in pregnant women during the month before pregnancy, at the time that they became aware of the pregnancy, and during the first trimester. Face-to-face interviews were conducted with 359 pregnant women who were admitted to the fetal medicine unit at a university hospital for diagnosis and follow-up. A questionnaire was used to document sociodemographic characteristics and details of drug use. Drugs were categorized according to the US Food and Drug Administration fetal risk classification. Mean maternal age was 29.9+/-5.1 y, and mean gestational age was 19.6+/-9.5 wk. Many of the pregnant women studied (46.6%) were university graduates, and most (61.9%) had a relatively high annual income. Mean gestational age when participants first learned of their pregnancy was 39.8+/-16.4 d. One hundred seventeen participants (32.6%) used drugs during the month before conception, 54 (15%) at the time when they learned of their pregnancy, 180 (50.1%) at the time of the interview, and 289 (80.5%) during the first trimester. The percentages of drugs in categories D and X used by these subjects were 14%, 13.5%, 2.9%, and 5.9%, respectively. Most of the drugs were hormones. The total rate of drug utilization was not high before and during the first trimester of pregnancy. A considerable number of women were using drugs from the D and X categories; however, these numbers decreased significantly when women learned of their pregnancies. Intake of folic acid, vitamins, and iron was very low during the preconception period and was not high enough during the first trimester; this suggests that particular attention should be paid to the use of beneficial "safe" drugs during the preconception and early pregnancy periods.

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.

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.

Use of over-the-counter medications during pregnancy

OBJECTIVE

The most common medications used in pregnancy are nonprescription or over-the-counter medications, although there has been little research on their risks or safety. We describe the patterns of over-the-counter medication use among pregnant women.

STUDY DESIGN

Data were collected in 2 case-control studies of birth defects: the Slone Epidemiology Center Birth Defects Study (BDS) and the National Birth Defects Prevention Study (NBDPS).

RESULTS

Among 7563 mothers of malformed and nonmalformed offspring in the Slone Epidemiology Center Birth Defects Study and 2970 mothers of nonmalformed offspring in the National Birth Defects Prevention Study, acetaminophen, ibuprofen, and pseudoephedrine were used by at least 65%, 18%, and 15%, respectively. Among women in the Slone Epidemiology Center Birth Defects Study, the use in pregnancy of aspirin and chlorpheniramine decreased from 1976 to 2004 and of ibuprofen, pseudoephedrine, diphenhydramine, dextromethorphan, and guaifenesin increased. Among women in the National Birth Defects Prevention Study, the use of acetaminophen, pseudoephedrine, diphenhydramine, and guaifenesin was higher during pregnancy than before pregnancy.

CONCLUSION

Findings show that over-the-counter medications are used by most pregnant women. Studies that examine specific over-the-counter medications in relation to specific birth defects are necessary to better inform pregnant women about risks and safety.

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.

O uso de medicamentos na gravidez

O uso de medicamentos na gravidez é cada vez mais intenso, enquanto a prática médica volta-se para a incorporação do conceito de risco. Embora a tragédia da talidomida tenha marcado o início da reflexão sobre a ocorrência de efeitos adversos de medicamentos usados durante a gestação, as percepções dos prescritores, no âmbito da terapêutica medicamentosa na gravidez, ainda oscilam entre a certeza de que tudo é nocivo e a relativa crença de que tudo é seguro até que se prove o contrário. Faz-se necessária a produção de evidências que substanciem as condutas clínicas. O ensaio clínico randomizado é considerado a pedra angular do paradigma da medicina baseada em evidências. Sugerem-se os contextos nos quais a aplicação dos diversos tipos de pesquisa clínica seriam apropriados na gestação e ainda o emprego ampliado da farmacoepidemiologia para a construção de evidências nessa população, por meio de estudos analíticos, em especial a coorte. Entende-se que estes estudos, desde que executados com rigor metodológico, possam oferecer informação balizada, geradora de hipóteses, essenciais para a prática clínica.

Fatores associados ao uso de medicamentos durante a gestação em seis cidades brasileiras

O objetivo deste estudo foi comparar o uso de medicamentos durante a gravidez, segundo variáveis sócio-demográficas, em gestantes que fizeram o pré-natal em serviços do SUS em seis grandes cidades brasileiras. Utilizando-se um questionário estruturado, foram entrevistadas 5.564 gestantes que se apresentaram para consulta em serviço de pré-natal do SUS, participantes do Estudo Brasileiro de Diabetes Gestacional, entre 1991 e 1995. O uso de qualquer medicamento mostrou uma associação positiva com o aumento da escolaridade, da idade e com o fato de ter companheiro, e uma associação negativa com maior número de filhos. O uso de medicamentos multivitamínicos e medicamentos que atuam sobre o aparelho digestivo mostrou aumento da associação com maior escolaridade e idade e uma associação negativa com o aumento do número de filhos. O uso de medicamentos antianêmicos mostrou uma associação negativa com o aumento da escolaridade e com o aumento da idade. O uso de multivitamínicos e medicamentos que atuam sobre o aparelho digestivo mostrou uma associação com variáveis que caracterizam gestantes de melhor nível sócio-econômico, sugerindo que o uso de medicamentos é uma expressão de cuidado com a gestação.

Maternal use of acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), and muscular ventricular septal defects

BACKGROUND

Muscular ventricular septal defects (mVSDs) are the most common congenital heart defects. Previous studies have suggested maternal use of acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), and/or fever as risk factors. We evaluated the association between mVSDs and maternal use of acetaminophen or NSAIDs adjusting for fever.

METHODS

Infants with nonsyndromic mVSDs (cases) and without birth defects (controls), with gestational age > or =37 weeks and their mothers were enrolled in the National Birth Defects Prevention Study. Two exposure periods were defined: the first trimester of pregnancy, and one month before pregnancy through delivery. Mothers reporting fever or medication use at least once during either period were considered exposed. Adjusted odds ratios and 95% confidence intervals were estimated independently for each exposure period.

RESULTS

The analysis included 168 cases and 692 controls. Two case groups were evaluated: all mVSD infants (n = 168) (including those with associated minor cardiac defects or noncardiac defects), and infants with isolated mVSDs (n = 133). Mothers of cases were less likely to be African-American than Caucasian (OR, 0.36; 95% CI, 0.18, 0.73). Approximately equal numbers of case mothers and control mothers (10.4 versus 9.7%, respectively) reported at least one febrile episode during the first trimester. Neither acetaminophen nor NSAID exposure was significantly associated with mVSDs. This was true for both case groups and both exposure periods.

CONCLUSIONS

Significant associations were not detected between the occurrence of mVSDs and maternal use of NSAIDs or acetaminophen adjusting for maternal fever, nor were they detected between maternal fever and mVSDs.

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.

Drug use by pregnant women and comparable non-pregnant women in The Netherlands with reference to the Australian classification system

OBJECTIVE

To describe drug use in pregnancy, and compare drug use of pregnant women with non-pregnant women with respect to possible teratogenicity.

STUDY DESIGN

A cross-sectional study based on pharmacy records from 1997 to 2001 was performed. Pregnant women and matched non-pregnant women (same physician and age) were identified. Prescriptions were set against the Australian risk classification.

RESULTS

Thirty-five percent of all prescriptions for non-pregnant women were safe in pregnancy (Australian classification A), in 14% the risk was unknown (B1, B2), 49% were potentially harmful drugs (B3, C, D, X), and in 3% no classification was available. For pregnant women these figures were 86, 3, 10 and 2%, respectively. In non-pregnant women the highest percentages of prescriptions for unsafe drugs were for psycholeptics (99% not classified as safe), psychoanaleptics (100%), anti-inflammatory/antirheumetic products (100%), antihistamines (94%), antacids/anti-ulcer drugs (81%), antiepileptics (100%), beta-blockers (100%), systemic antimycotics (100%), antiprotozoals (97%), diuretics (100%) and immunosuppressives (100%). In pregnant women this pattern was comparable, except for antihistamines (22%) and antacids/anti-ulcer drugs (3%).

CONCLUSION

We conclude that many drugs used by non-pregnant women should be avoided in pregnancy, and that pregnant women indeed do so. However, for some drug groups the available safe alternatives are limited.

[Prescribed and reported drug use during pregnancy]

Few studies describe drug utilization in pregnancy focusing on prescribing practices. This study is part of a larger survey on perinatal care in the City of Rio de Janeiro, Brazil. The type of hospital (public, contracted out by the Unified National Health System, or private) determined the stratification of 10,072 hospitalized post-partum women, who were asked about medication used during pregnancy. Hospital records supplied information on drugs prescribed during labor. Drugs were classified according to the Anatomical Therapeutic Chemical (ATC) system. Another system was used for specific cases of referred use. A mean of 2.08 drugs was prescribed during labor, and a mean of 2.3 was reported during pregnancy. Anesthetics, antibiotics, oxytocin, and analgesics were the most frequently prescribed during labor, with significant differences between strata. Ferrous sulfate, vitamins, scopolamine, and acetaminophen were the main drugs reported during pregnancy. Women who had attempted abortion referred use of various kinds of tea (49.7%) and misoprostol (9.2%). The drug utilization pattern was consistent with the literature. This study offers knowledge on prescribing patterns during labor and self-reported use during pregnancy in both the public and private sectors.

Calcium intake during pregnancy among white and African-American pregnant women in the United States

OBJECTIVE

To characterize the calcium intake in a racially mixed cohort of pregnant women, including the contribution of supplementation and antacids.

METHODS

A cohort of women was interviewed twice during their pregnancies. The interviews included a food frequency questionnaire and questions on calcium supplementation and antacid intake. Pregnant women seeking prenatal care at a Pittsburgh hospital in the first trimester were enrolled. 454 women were enrolled and did not miscarry; 385 completed two interviews and were of white or African-American race.

RESULTS

Mean and median intakes of calcium were 1671 mg/day and 1482 mg/day. 36% of the women were under the former RDA level (1200 mg/day) for calcium, while 26% were under the current AI (1000 mg/day). Six percent were taking in less than 600 mg/day, and 15% over 2500 mg/day, the tolerable upper limit. Young women were particularly likely to have low intakes (12% of those less than 21 years of age had less than 600 mg/day). Black women were slightly overrepresented among those with low intake (8% vs. 5% of whites), but, overall, their intake was quite similar to whites. Milk and cheese provided more calcium than other food items. Many women took antacids, especially during the second half of pregnancy, and these were a major source of calcium for some members of the cohort.

CONCLUSIONS

Although mean and median calcium intake in the cohort were above the AI, many women had calcium intakes that were too high or low. Dairy products provided the most calcium for most pregnant women, and antacids were an important source for many.

Herbal agents and over-the-counter medications in pregnancy

Exposures to over-the-counter and herbal products are frequent in pregnant women. Limited information exists on the effects of many of these agents during pregnancy; it is not safe to assume that because these products are available without a prescription that they are without danger to the pregnant woman and her fetus. The basic principles utilized in deciding whether to employ prescription medications such as dose, embryological timing and potential toxic fetal effects also apply to herbal medications and over-the-counter agents. Conventional reasoning indicates that maternal exposure to poorly studied medications should be limited; therefore, many of these agents should be used sparingly or not at all by pregnant women. This chapter includes a review of selected herbal and over-the-counter agents, including those which are considered to be acceptable for use in pregnancy.

Prescription drugs during pregnancy and lactation--a Finnish register-based study

OBJECTIVE

To examine the use of prescription drugs in Finnish women before and during pregnancy and lactation.

METHODS

A register-based study linking four nation-wide registers in Finland: the Maternal Grants Register, the Drug Prescription Register, and the Special Refund Register (all maintained by the Social Insurance Institution in Finland; KELA), and the Finnish Population Register. The study included all women applying for maternity support (maternal grants) during the year 1999, and non-pregnant control women matched by age and hospital district. Data collection included the number and type of prescription drugs purchased by the two cohorts during preconception (3 months before pregnancy), each trimester, and lactation.

RESULTS

Of the 43,470 pregnant women, 46.2% purchased at least one drug and 12.7% three or more different drugs during pregnancy. Corresponding proportions for the control cohort were 55.2% (OR 0.7, 95% CI 0.6-0.7) and 23.0% (OR 0.5, 95% CI 0.5-0.5). The drugs most frequently purchased during pregnancy were systemic antibiotics (24.1% of pregnant women vs 27.3% controls; OR 0.8, 95% CI 0.8-0.9) and gynaecological anti-infective agents (8.3% vs 1.5%; OR 5.5, 95% CI 5.5-6.5). For pregnant women, purchases of most drug groups had already declined during the first trimester, but no reduction was apparent in drugs for chronic illnesses (epilepsy, asthma, diabetes).

CONCLUSIONS

Although drugs were purchased abundantly during pregnancy, a significant decline occurred for most drug groups. The medication pattern for chronic illnesses remained unchanged. The purchase of several different drugs was relatively common and raises concerns.

A study of drug use during pregnancy in a teaching hospital in western Nepal

Information on the use of drugs during pregnancy is scarce and rather anecdotal. Careful consideration of the benefit to the mother and the risk to the fetus is required when prescribing drugs during pregnancy. The aim of this study was to gain knowledge on this issue in western Nepal. 2156 prescriptions of pregnant women were collected at random from the antenatal care (ANC) in obstetrics out-patient department (OPD) at Manipal Teaching Hospital (MTH), Nepal and analyzed for this study. The mean maternal age and hemoglobin concentration were 25 years and 12.21 g/dl, respectively. Twenty-three percent women attended obstetric OPD due to maternal disorders other than routine ANC (77%). Problem oriented drug use was due to nausea/vomiting (4.7%), dyspepsia (3.1%), and per vaginal spotting/bleeding (3.4%), mainly. Most of the women got 2-3 drugs and commonly included nutritional supplementation and tetanus toxoid. The average number of drugs/prescription was 2.00, 15.37% and 64.8% drugs were prescribed by generic name and as fixed dose combinations, respectively. The most commonly prescribed drugs were nutritional supplements like iron, folate, calcium, vitamins (72.8%), followed by tetanus toxoid (12.4%), gastrointestinals (5%), antimicrobials (4.6%), etc. Though, the selection of drugs was rational in most of the cases, some anomalies were observed and discussed with the clinicians. Our data reflect the general extent and prescribing pattern for those Nepalese pregnant women attending hospital in western Nepal.

Use of over-the-counter medications during pregnancy

The use of over-the-counter medications by pregnant women is common. Over-the-counter medications are widely assumed to be harmless because they may be purchased without prescription. Some consumers do not consider them to be drugs. Women may not realize that over-the-counter medications have the potential to harm them or their fetuses. This article reviews selected over-the-counter medications commonly used by pregnant women, including pharmacology, risks, Food and Drug Administration risk classifications, and strategies for counseling clients.

Parental medication use and risk of childhood acute lymphoblastic leukemia

BACKGROUND

Few studies have examined the risk of childhood acute lymphoblastic leukemia (ALL) associated with parental medication use. As part of a large case-control study conducted by the Children's Cancer Group, we evaluated the association between maternal and paternal medication use and the risk of ALL in offspring.

METHODS

Information on selected medication use in the year before and during the index pregnancy was obtained by telephone interview. Participants included 1842 children of 14 years or younger with newly diagnosed and immunophenotypically defined ALL and 1986 individually matched controls. Data were analyzed using logistic regression models and stratified by immunophenotypes of ALL and age at diagnosis of cases.

RESULTS

After adjusting for potential confounders and other medication use, we found that maternal use of vitamins (odds ratio [OR] = 0.7, 99% confidence interval [CI]: 0.5-1.0) and iron supplements (OR = 0.8, 99% CI: 0.7-1.0) only during the index pregnancy was associated with a decreased risk of ALL. Parental use of amphetamines or diet pills and mind-altering drugs before and during the index pregnancy was related to an increased risk of childhood ALL, particularly among children where both parents reported using these drugs (OR = 2.8, 99% CI: 0.5-15.6 for amphetamines or diet pills, OR = 1.8, 99% CI: 1.1-3.0 for mind-altering drugs). Stratified analyses showed that maternal use of antihistamines or allergic remedies and parental use of mind-altering drugs were strongly associated with infant ALL, whereas patterns of association between childhood ALL and parental medication use did not influence markedly the immunophenotypic subgroup of ALL.

CONCLUSIONS

The findings of this study suggest that certain parental medication use immediately before and during the index pregnancy may influence risk of ALL in offspring.

Drugs in pregnancy. Drugs to avoid

Drugs given in pregnancy can adversely affect the fetus in many ways. Anxiety about birth defects is a major parental concern during pregnancy. Doctors, midwives and their patients often seek information about the potential teratogenicity of drugs that are taken by, or prescribed for, the pregnant woman. Because no drug is entirely without side-effects, great caution should be taken when prescribing in pregnancy. The development of knowledge in understanding the use of drugs during pregnancy has been in stalemate in comparison to other areas of therapeutics, due mainly to difficulties in testing new products in pregnant women and lack of good quality research. In this chapter, we review current knowledge of the epidemiology of drug use among pregnant women, drug metabolism in pregnancy, adverse fetal and neonatal effects of drugs and specific effects of drugs that are relatively or absolutely contraindicated in pregnancy.

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.

Mini-review: history of organized teratology information services in North America

A history of the Organization of Teratology Information Services (OTIS) is presented in context of the history of teratology information services. During the late 1970s, teratology information services grew out of the need for current and accurate information about fetal effects of environmental exposures in pregnancy. Over the next decade, teratology information services networked and collaborated, developing their own professional organization. A description of the activities of OTIS is described.

[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.

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.