A historical argument for regulatory failure in the case of Primodos and other hormone pregnancy tests

Teratogenicity and Reactive Oxygen Species after transient embryonic hypoxia: Experimental and clinical evidence with focus on drugs causing failed abortion in humans

Teratogenicity and Reactive Oxygen Species after transient embryonic hypoxia: Experimental and clinical evidence with focus on drugs with human abortive potential. Reactive Oxygen Species (ROS) can be harmful to embryonic tissues. The adverse embryonic effects are dependent on the severity and duration of the hypoxic event and when during organongenesis hypoxia occurs. The vascular endothelium of recently formed arteries in the embryo is highly susceptible to ROS damage. Endothelial damage results in vascular disruption, hemorrhage and maldevelopment of organs, which normally should have been supplied by the artery. ROS can also induce irregular heart rhythm in the embryo resulting in alterations in blood flow and pressure from when the tubular heart starts beating. Such alterations in blood flow and pressure during cardiogenesis can result in a variety of cardiovascular defects, for example transpositions and ventricular septal defects. One aim of this article is to review and compare the pattern of malformations produced by transient embryonic hypoxia of various origins in animal studies with malformations associated with transient embryonic hypoxia in human pregnancy due to a failed abortion process. The results show that transient hypoxia and compounds with potential to cause failed abortion in humans, such as misoprostol and hormone pregnancy tests (HPTs) like Primodos, have been associated with a similar spectrum of teratogenicity. The spectrum includes limb reduction-, cardiovascular- and central nervous system defects. The hypoxia-ROS related teratogenicity of misoprostol and HPTs, is likely to be secondary to uterine contractions and compression of uterinoplacental/embryonic vessels during organogenesis.

Detecting the unknown in a sea of knowns: Health surveillance, knowledge infrastructures, and the quest for classification egress

The sociological study of knowledge infrastructures and classification has traditionally focused on the politics and practices of classifying things or people. However, actors' work to escape dominant infrastructures and pre-established classification systems has received little attention. In response to this, this article argues that it is crucial to analyze, not only the practices and politics of classification, but also actors' work to escape dominant classification systems. The article has two aims: First, to make a theoretical contribution to the study of classification by proposing to pay analytical attention to practices of escaping classification, what the article dubs classification egress. This concept directs our attention not only to the practices and politics of classifying things, but also to how actors work to escape or resist classification systems in practice. Second, the article aims to increase our understanding of the history of quantified and statistical health surveillance. In this, the article investigates how actors in health surveillance assembled a knowledge infrastructure for surveilling, quantifying, and detecting unknown patterns of congenital malformations in the wake of the thalidomide disaster in the early 1960s. The empirical account centers on the actors' work to detect congenital malformations and escape the dominant nosological classification of diseases, the International Classification of Diseases (ICD), by replacing it with a procedural standard for reporting of symptoms. Thus, the article investigates how actors deal with the tension between the-already-known-and-classified and the unknown-unclassified-phenomenon in health surveillance practice.

The Duogynon controversy and ignorance production in post-thalidomide West Germany

This article examines the West German controversy over Duogynon, a 'hormone pregnancy test' and the drug at the centre of the first major, international debate over iatrogenic birth defects in the post-thalidomide era. It recovers an asymmetrical power struggle over the uneven distribution of biomedical knowledge and ignorance (about teratogenic risk) that pitted parent-activists, whistleblowers and investigative journalists against industrialists, scientific experts and government officials. It sheds new light on the nexus of reproduction, disability, epidemiology and health activism in West Germany. In addition, it begins to recover an internationally influential discourse that, in the post-thalidomide world, seems to have resuscitated antenatal drug use as safe until proven harmful.

Silences, omissions and oversimplification? The UK debate on mitochondrial donation

Drawing on scholarship from ignorance studies, this paper uses the case of the UK debates on mitochondrial donation (2012-2015) to emphasize the importance of deploying an analysis of ignorance that goes beyond medical and safety concerns when scrutinizing debates or campaigns around new reproductive technologies. In contrast to what happened with previous reproductive health treatments or drugs, the potential medical risks of mitochondrial donation were explicitly acknowledged and examined during its public and parliamentary discussions. However, I show, using the concepts of 'acknowledged unknowns' and 'ignored knowns', how the attention drawn to the medical risks contributed to obscuring the assessment of its economic and social impacts by silencing key knowledge regarding the limitations of mitochondrial donation in relation to the potential beneficiaries, the scope of the techniques, their alternatives and their costs. This article therefore calls for more systematic use of an integrated analytical framework of ignorance to be applied in the field of reproductive public policies, paying particular attention not only to the ways that medical risks are addressed, but also to the type of knowledge and disciplines this allows to silence or side-line in the framing and assessment of new biotechnologies.

Like mother, like daughter, like granddaughter… Transgenerational ignorance engendered by a defective reproductive health technology

From 1941, the synthetic oestrogen diethylstilbestrol (DES) was administered to millions of women around the world to prevent miscarriages. In 1971, a clear and direct link was shown between taking DES during pregnancy and its subsequent long-term morbid effects on offspring. In the last 50 years, the list of side effects of in-utero exposure to DES has grown to include cancer, infertility, significant prematurity and urogenital malformation, amongst others. Based on qualitative sociological research conducted between 2010 and 2013, compiling archives, judicial documents and 108 interviews, this article illustrates a continuous production of ignorance in France. By focusing on DES as a reproductive health technology, three aspects are stressed. First, in terms of recognition of adverse effects, despite DES being identified as a prototype for other technologies such as the contraceptive pill or hormone replacement therapy, there remained a strong reluctance to import knowledge from the USA on its dangers and risks. Second, there was indifference to transgenerational side effects: even when the most visible effects of DES were finally acknowledged, there was a lack of consideration of the health of descendants; an inability to deem the knowledge of these repercussions as emancipatory or potentially empowering for the offspring. Third, regarding the health care of DES daughters, an important propensity to undone science is highlighted, with notable indifference to the risks of hormonalization of the female body, even on the part of activists. Thus, decades after it was last given to pregnant women, the shadow of DES still lingers as a failed reproductive health technology.

Learning from the report of the independent medicines and medical devices safety review: "first do no harm"

This is a review of the learning points from the Independent Medicines and Medical Devices Safety Review,¹ chaired by Baroness Julia Cumberlege CBE DL. This system-wide review was initiated by the then Secretary of State for Health and Social Care, following patient-led campaigns. It looked at how the "healthcare system reacted as a whole, and how that response can be made more robust, speedy and appropriate".We aim to highlight the learning points for doctors in Obstetrics and Gynaecology as these are relevant to our current practice and future changes in our healthcare system. These are: Aims of the review: why it was initiated and how it was conductedOverarching themes and missed opportunities to prevent avoidable harmThree clinical scenarios: their histories, issues and adverse events associated with their use and the current response in Scotland The hormone pregnancy test - PrimodosThe anti-epileptic drug - sodium valproateSurgical mesh for prolapse & incontinenceThe recommendations made by the review and implementation guidanceResponses to the review, such as apologies issued by BSUG²/BAUS³/RCOG,⁴ and compensations schemes such as the Scottish scheme as recommended by the review.

Early pregnancy maternal progesterone administration alters pituitary and testis function and steroid profile in male fetuses

Maternal exposure to increased steroid hormones, including estrogens, androgens or glucocorticoids during pregnancy results in chronic conditions in offspring that manifest in adulthood. Little is known about effects of progesterone administration in early pregnancy on fetal development. We hypothesised that maternal early pregnancy progesterone supplementation would increase fetal progesterone, affect progesterone target tissues in the developing fetal reproductive system and be metabolised to other bioactive steroids in the fetus. We investigated the effects of progesterone treatment during early pregnancy on maternal and fetal plasma progesterone concentrations, transcript abundance in the fetal pituitary and testes and circulating steroids, at day 75 gestation, using a clinically realistic ovine model. Endogenous progesterone concentrations were lower in male than female fetuses. Maternal progesterone administration increased male, but not female, fetal progesterone concentrations, also increasing circulating 11-dehydrocorticosterone in male fetuses. Maternal progesterone administration altered fetal pituitary and testicular function in ovine male fetuses. This suggests that there may be fetal sex specific effects of the use of progesterone in early pregnancy, and highlights that progesterone supplementation should be used only when there is clear evidence of efficacy and for as limited time as necessary.

Oral hormone pregnancy tests and the risks of congenital malformations: a systematic review and meta-analysis

Background: Oral hormone pregnancy tests (HPTs), such as Primodos, containing ethinylestradiol and high doses of norethisterone, were given to over a million women from 1958 to 1978, when Primodos was withdrawn from the market because of concerns about possible teratogenicity. We aimed to study the association between maternal exposure to oral HPTs and congenital malformations.

Methods: We have performed a systematic review and meta-analysis of case-control and cohort studies that included data from pregnant women and were exposed to oral HPTs within the estimated first three months of pregnancy, if compared with a relevant control group. We used random-effects meta-analysis and assessed the quality of each study using the Newcastle–Ottawa Scale for non-randomized studies.

Results: We found 16 case control studies and 10 prospective cohort studies, together including 71 330 women, of whom 4,209 were exposed to HPTs. Exposure to oral HPTs was associated with a 40% increased risk of all congenital malformations: pooled odds ratio (OR) = 1.40 (95% CI 1.18 to 1.66; P<0.0001; I ² = 0%). Exposure to HPTs was associated with an increased risk of congenital heart malformations: pooled OR = 1.89 (95% CI 1.32 to 2.72; P = 0.0006; I ²=0%); nervous system malformations  OR = 2.98 (95% CI 1.32 to 6.76; P = 0.0109 I ² = 78%); gastrointestinal malformations, OR = 4.50 (95% CI 0.63 to 32.20; P = 0.13; I ² = 54%); musculoskeletal malformations, OR = 2.24 (95% CI 1.23 to 4.08; P= 0.009; I ² = 0%); the VACTERL syndrome (Vertebral defects, Anal atresia, Cardiovascular anomalies, Tracheoesophageal fistula, Esophageal atresia, Renal anomalies, and Limb defects), OR = 7.47 (95% CI 2.92 to 19.07; P < 0.0001; I ² = 0%).

Conclusions: This systematic review and meta-analysis shows that use of oral HPTs in pregnancy is associated with increased risks of congenital malformations.