Pregnancy outcomes after maternal varenicline use; analysis of surveillance data collected by the European Network of Teratology Information Services

Nicotine Use During Pregnancy: Cessation and Treatment Strategies

Abstract

The use of tobacco and nicotine products during pregnancy is known to increase the risk of adverse effects on the fetus. Increased education and research have resulted in greater rates of smoking cessation during pregnancy, with a decline from 13.2% of pregnant individuals smoking in 2006 to 7.2% in 2016. However, smoking while pregnant still proves to be a prevalent issue that is associated with numerous adverse outcomes, including low birth weight, preterm birth, and developmental delays. Smoking cessation before or during pregnancy can help mitigate these effects, but the appropriate treatment can be challenging to ascertain. Accordingly, clinicians should look to provide individualized care composed of behavioral counseling in conjunction with pharmacotherapies when indicated, combined with ongoing support and education.

Information Needs and Counseling Preferences among Potential Users of the Future Teratology Information Service in Belgium: A Cross-Sectional Study Involving the Public and Healthcare Professionals

A Teratology Information Service (TIS) does not exist in Belgium yet but will hopefully be established soon. To prepare for this, we aimed to provide insight into the information needs and counseling preferences of the Belgian public and healthcare professionals (HCPs) regarding medication use in pregnancy and breastfeeding. A cross-sectional study using two anonymous, online surveys disseminated via social media, websites, and newsletters addressing Dutch and French-speaking individuals (≥18 years) and licensed HCPs was performed between June and September 2020. Ethics approval and informed consent were obtained. In total, 1508 public survey respondents (98% women) and 702 HCPs participated. Information needs on perinatal medication use were ubiquitous among both groups, and for which they often relied on patient information leaflets or the product information and online fora. Conflicting information on this topic regularly occurs and complicates HCPs’ duties. Women and HCPs assigned an important role to a TIS, both in terms of providing evidence-based information (via a website or app) and being accessible to be contacted in case of questions (by phone or via e-mail or chat). In conclusion, a TIS would be warmly welcomed by women and HCPs in Belgium and should ideally be established soon to address current information needs regarding perinatal medication use and to contribute to research in this field.

Explainable multimodal machine learning model for classifying pregnancy drug safety

MOTIVATION

Teratogenic drugs can cause severe fetal malformation and therefore have critical impact on the health of the fetus, yet the teratogenic risks are unknown for most approved drugs. This article proposes an explainable machine learning model for classifying pregnancy drug safety based on multimodal data and suggests an orthogonal ensemble for modeling multimodal data. To train the proposed model, we created a set of labeled drugs by processing over 100 000 textual responses collected by a large teratology information service. Structured textual information is incorporated into the model by applying clustering analysis to textual features.

RESULTS

We report an area under the receiver operating characteristic curve (AUC) of 0.891 using cross-validation and an AUC of 0.904 for cross-expert validation. Our findings suggest the safety of two drugs during pregnancy, Varenicline and Mebeverine, and suggest that Meloxicam, an NSAID, is of higher risk; according to existing data, the safety of these three drugs during pregnancy is unknown. We also present a web-based application that enables physicians to examine a specific drug and its risk factors.

AVAILABILITY AND IMPLEMENTATION

The code and data is available from https://github.com/goolig/drug_safety_pregnancy_prediction.git.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

Tobacco and Nicotine Cessation During Pregnancy: ACOG Committee Opinion, Number 807

Pregnant women should be advised of the significant perinatal risks associated with tobacco use, including orofacial clefts, fetal growth restriction, placenta previa, abruptio placentae, preterm prelabor rupture of membranes, low birth weight, increased perinatal mortality, ectopic pregnancy, and decreased maternal thyroid function. Children born to women who smoke during pregnancy are at an increased risk of respiratory infections, asthma, infantile colic, bone fractures, and childhood obesity. Pregnancy influences many women to stop smoking, and approximately 54% of women who smoke before pregnancy quit smoking directly before or during pregnancy. Smoking cessation at any point in gestation benefits the pregnant woman and her fetus. The greatest benefit is observed with cessation before 15 weeks of gestation. Although cigarettes are the most commonly used tobacco product in pregnancy, alternative forms of tobacco use, such as e-cigarettes or vaping products, hookahs, and cigars, are increasingly common. Clinicians should advise cessation of tobacco products used in any form and provide motivational feedback. Although counseling and pregnancy-specific materials are effective cessation aids for many pregnant women, some women continue to use tobacco products. Clinicians should individualize care by offering psychosocial, behavioral, and pharmacotherapy interventions. Available cessation-aid services and resources, including digital resources, should be discussed and documented regularly at prenatal and postpartum follow-up visits.

[Pharmacotherapy for Smoking Cessation During Pregnancy - CNGOF-SFT Expert Report and Guidelines for Smoking Management During Pregnancy]

OBJECTIVE

To review and describe available pharmacotherapy interventions for smoking cessation during pregnancy: nicotine replacement therapy (NRT) and non-nicotine replacement therapy.

METHODS

The PubMed, Medline®, and Cochrane databases® (1/01/2003 au 5/04/2019) were accessed to identify relevant studies, using the search terms "tobacco use cessation devices", "nicotine replacement product or therapy", "smoking cessation", "pregnancy", "pregnant women", "varenicline", "bupropion".

RESULTS

There is no data on the impact of NRT on the rate of smoking cessation during pre conception period. According to randomised studies versus placebo, the prescription of NRT during pregnancy (16-hours patches and gums being mainly studied) is not associated with smoking cessation during pregnancy or at the end of pregnancy (LE1). Based on the analysis of all available studies, the prescription of NRT during pregnancy is associated with smoking cessation during pregnancy and at the end of pregnancy (LE2). Coadministration of different galenic forms of pharmacotherapy during pregnancy could improve efficacy subject to tolerance and remains to be studied. The prescription of NRT during pregnancy (patches and gums being mainly studied) is not associated with postpartum smoking cessation (LE1). The prescription of NRT may be associated with the occurrence of non-serious adverse reactions (headache, nausea, vomiting, etc.) (LE2). The risk of adverse effects from NRT is not increased by pregnancy (LE2). The prescription of NRT is not associated with spontaneous abortion (LE2). There is insufficient data to establish an excess risk of congenital malformations in case of the prescription of NRT. The prescription of NRT versus placebo is associated with a reduction in the risk of preterm delivery (LE2). There is insufficient data on the prescription of NRT and neonatal outcomes. The prescription of NRT (by decreasing smoking) could be associated with better development scores at 2 years of age in children born to smoking women who received NRT versus placebo (LE2). The prescription of NRT may be offered to any pregnant woman who has failed a spontaneous smoking cessation without NRT (grade B). The data of the literature do not allow recommending one form more than another (forms of rapid action versus transdermal) nor an optimal duration of treatment (professional consensus). This prescription can be initiated by the professional taking care of the pregnant woman in early pregnancy (professional consensus). It is recommended to refer the pregnant woman to a tobacco specialist to assess and adapt the initial prescription (professional consensus). Maintenance of NRT in case of misstep is associated with a reduction in smoking (LE3). These elements suggest that in the event of a misstep or resumption of smoking, it is recommended to continue nicotine substitution (grade C). In the absence of data, second-line non-nicotinic prescriptions, nortriptyline and clonidine, are not recommended during pregnancy (professional consensus). There is insufficient data and low level of evidence to assess the impact of bupropion during the three trimesters of pregnancy, and in particular the neonatal consequences. Because of its amphetamine properties, bupoprion is not recommended for smoking cessation assistance in pregnant women (grade C). The available data are very inadequate and low level of evidence to assess the impact of varenicline during pregnancy. For this reason, varenicline cannot be recommended for smoking cessation during pregnancy (professional consensus).

CONCLUSIONS

The prescription of NRT may be offered to any pregnant woman who has failed a spontaneous smoking cessation without NRT, taking into account the lower risks of premature birth in the case of NRT (grade B). This prescription can be initiated by the professional taking care of the pregnant woman in early pregnancy (professional consensus).

Use of smoking cessation pharmacotherapies during pregnancy is not associated with increased risk of adverse pregnancy outcomes: a population-based cohort study

BACKGROUND

Varenicline, bupropion and nicotine replacement therapy (NRT) are three effective pharmacotherapies for smoking cessation, but data about their safety in pregnancy are limited. We assessed the risk of adverse perinatal outcomes and major congenital anomalies associated with the use of these therapies in pregnancy in Australia.

METHODS

Perinatal data for 1,017,731 deliveries (2004 to 2012) in New South Wales and Western Australia were linked to pharmaceutical dispensing, hospital admission and death records. We identified 97,875 women who smoked during pregnancy; of those, 233, 330 and 1057 were exposed to bupropion, NRT and varenicline in pregnancy, respectively. Propensity scores were used to match exposed women to those who were unexposed to any smoking therapy (1:10 ratio). Propensity scores and gestational age at exposure were used to match varenicline-exposed to NRT-exposed women (1:1 ratio). Time-dependent Cox proportional hazards models estimated hazard ratios (HR) with 95% confidence intervals (95% CI) for any adverse perinatal event (a composite of 10 unfavourable maternal and neonatal outcomes) and any major congenital anomaly.

RESULTS

The risk of any adverse perinatal event was not significantly different between bupropion-exposed and unexposed women (39.2% versus 39.3%, HR 0.93, 95% CI 0.73-1.19) and between NRT-exposed and unexposed women (44.8% vs 46.3%, HR 1.02, 95% CI 0.84-1.23), but it was significantly lower in women exposed to varenicline (36.9% vs 40.1%, HR 0.86, 95% CI 0.77-0.97). Varenicline-exposed infants were less likely than unexposed infants to be born premature (6.5% vs 8.9%, HR 0.72, 95% CI 0.56-0.92), be small for gestational age (11.4% vs 15.4%, HR 0.68, 95% CI 0.56-0.83) and have severe neonatal complications (6.6% vs 8.2%, HR 0.74, 95% CI 0.57-0.96). Among infants exposed to varenicline in the first trimester, 2.9% had a major congenital anomaly (3.5% in unexposed infants, HR 0.91, 95% CI 0.72-1.15). Varenicline-exposed women were less likely than NRT-exposed women to have an adverse perinatal event (38.7% vs 51.4%, HR 0.58, 95% CI 0.33-1.05).

CONCLUSIONS

Pregnancy exposure to smoking cessation pharmacotherapies does not appear to be associated with an increased risk of adverse birth outcomes. Lower risk of adverse birth outcomes in varenicline-exposed pregnancies is inconsistent with recommendations that NRT be used in preference to varenicline.

Health-care providers' concern regarding smoking cessation pharmacotherapies during pregnancy: Calls to a teratology information service

INTRODUCTION AND AIMS

Few smokers use smoking cessation pharmacotherapies during pregnancy. It is hypothesised that health-care providers' reluctance due to safety concerns contributes to their low use. This study examined the extent of providers' concern regarding smoking cessation pharmacotherapies, relative to other medications in the same and other pregnancy risk categories. Calls made to a teratology information service (MotherSafe, Australia) were taken as a proxy indicator of concern regarding safety during pregnancy.

DESIGN AND METHODS

The primary exposure discussed in 66 687 calls made to MotherSafe between 2001 and 2016 was categorised as nicotine replacement therapy (NRT), bupropion, varenicline or category A (low risk), B1, B2, B3, C, D or X (teratogenic). Separate logistic regression models estimated the odds that calls regarding pharmacotherapies were from providers, relative to medications in the same and other risk categories. Models adjusted for caller remoteness and socio-economic status.

RESULTS

Calls regarding bupropion were more likely to be made by providers than calls regarding other medications in its corresponding risk category [B2, adjusted odds ratio (aOR): 2.77, 95% confidence interval (CI) 1.17, 6.59]. Calls about varenicline were also more likely to be from providers than calls regarding other category B3 medications (aOR 95% CI 2.33:1.30, 4.17). Calls regarding NRT were not more or less likely to be from providers than calls regarding other category D medications.

DISCUSSION AND CONCLUSIONS

Providers were more concerned about bupropion and varenicline than other medications within the same pregnancy risk categories. As this overestimation of risk may limit cessation pharmacotherapy use during pregnancy, research investigating strategies for correcting this imbalance is warranted.

Guideline for the management of pre-, intra-, and postpartum care of women with a spinal cord injury

The German Association of the Scientific Medical Societies guideline for pregnancy, childbirth, and puerperium in women with a spinal cord injury (SCI) addresses a range of topics from the desire to have a child to different stages of pregnancy and birth. Given that a generally accessible and evidence-based presentation of this complex issue does not yet exist, this new guideline contributes to the standardization of gynecological, obstetric, and maternal care of women with SCI. This guideline aims to provide practice-oriented support for the care and counseling of women in the pre-, intra-, and postpartum periods; to close identified gaps in medical care; foster collaboration among clinicians of relevant disciplines; and inspire research.

Risk of adverse birth outcomes after maternal varenicline use: A population-based observational study in Denmark and Sweden

PURPOSE

To examine risks of adverse birth outcomes in women exposed to varenicline during pregnancy.

METHODS

Population-based cohort study including live-born and stillborn infants from 1 May 2007 to 31 December 2012. Data from health and administrative registries in Denmark and Sweden, two Nordic countries with universal health care and routine registration of major life and health events. Infants were allocated to three cohorts on the basis of their in utero exposure: the exposed cohort consisting of infants whose mothers were dispensed varenicline during pregnancy; the unexposed cohort comprised infants unexposed to varenicline, but exposed to maternal smoking in utero; and the reference cohort of infants unexposed to varenicline and maternal smoking in utero. The primary outcome was major congenital malformations diagnosed from birth to the first year of life. Secondary outcomes included stillbirth, fetal growth restriction (measured as small for gestational age), preterm delivery, preterm premature rupture of membranes, and sudden infant death syndrome. We estimated the prevalence of the primary outcome and secondary outcomes in the exposed, unexposed, and reference cohorts. Prevalence odds ratios with 95% confidence intervals (CIs) were computed using logistic regression with propensity score adjustment to control for potential confounders.

RESULTS

The combined cohort included 885 185 infants. Of these, 335 infants were exposed, 78 412 were unexposed, and the remaining 806 438 comprised the reference cohort. Major congenital malformations were detected among 3.6% of exposed infants, 4.3% of unexposed infants, and 4.2% of infants in the reference cohort. The propensity score-adjusted prevalence odds ratio for major congenital malformations was 0.80 (95% CI, 0.45-1.42) for exposed vs unexposed infants. All analyses of primary and secondary outcomes comparing exposed with unexposed infants yielded odds ratio estimates below or close to unity. Use of varenicline during pregnancy does not appear to increase the risk of major congenital malformations or other adverse birth outcomes.

Smoking cessation in pregnancy: An update for maternity care practitioners

INTRODUCTION

This paper provides an up-to-date summary of the effects of smoking in pregnancy as well as challenges and best practices for supporting smoking cessation in maternity care settings.

METHODS

We conducted a qualitative review of published peer reviewed and grey literature.

RESULTS

There is strong evidence of the effects of maternal tobacco use and secondhand smoke exposure on adverse pregnancy outcomes. Tobacco use is the leading preventable cause of miscarriage, stillbirth and neonatal deaths, and evidence has shown that health effects extend into childhood. Women who smoke should be supported with quitting as early as possible in pregnancy and there are benefits of quitting before the 15th week of pregnancy. There are a variety of factors that are associated with tobacco use in pregnancy (socioeconomic status, nicotine addiction, unsupportive partner, stress, mental health illness etc.). Clinical-trial evidence has found counseling, when delivered in sufficient intensity, significantly increases cessation rates among pregnant women. There is evidence that the use of nicotine replacement therapy (NRT) may increase cessation rates, and, relative to continued smoking, the use of NRT is considered safer than continued smoking. The majority of women who smoke during pregnancy will require support throughout their pregnancy, delivered either by a trained maternity care provider or via referral to a specialized hospital or community quit-smoking service. The 5As (Ask, Advise, Assess, Assist, Arrange) approach is recommended for organizing screening and treatment in maternity care settings. Additionally, supporting smoking cessation in the postpartum period should also be a priority as relapse rates are high.

CONCLUSIONS

There have been several recent updates to clinical practice regarding the treatment of tobacco use in pregnancy. It is important for the latest guidance to be put into practice, in all maternity care settings, in order to decrease rates of smoking in pregnancy and improve pregnancy outcomes.

Pharmaceutical strategies for smoking cessation during pregnancy

Introduction: Tobacco use is the most preventable cause of death worldwide, with over 7 million deaths per year. Smoking during pregnancy causes harm to the mother, fetus, and can result in problems for the infant from childhood into adulthood. Practitioners should ask all expectant mothers about tobacco use. For expectant mothers who smoke or recently quit, practitioners should advice to quit and provide psychosocial interventions. Rates of smoking during pregnancy differ between geographical locations, with estimates of 10.8% in the UK and 7.2% in the US. Practitioners should provide expectant mothers unable to quit smoking with information about the risks and benefits of pharmacotherapy and use a patient-centered approach to determine the use. Although there is no definitive evidence on birth outcomes, nicotine replacement therapy and bupropion are adequate pharmacotherapies to help those unable to quit. Areas covered: Herein, this author looks at the various pharmaceutical strategies to help patients cease smoking and provides expert perspectives on the subject. Expert opinion: Additional research on pharmacotherapy is warranted, especially with varenicline. Practitioners working with pregnant patients should be familiar with the evidence for pharmacotherapy in smoking cessation during pregnancy. This evidence can be difficult to navigate due to conflicting results and limitations with the trials.

Immediate release tablet formulation of varenicline salicylate and comparative pharmacokinetic study in human volunteers

PURPOSE

To develop an immediate release-type tablet containing varenicline salicylate (VRC-S), a smoking cessation agent, formulation and stability studies were performed. The in vitro dissolution and in vivo pharmacokinetic (PK) behavior of the tablets were compared with those of the commercial product (Champix) as a reference.

MATERIALS AND METHODS

The characteristics of the powder were investigated by particle morphology, size distribution, solubility, hygroscopicity, differential scanning calorimetry, and powder X-ray diffraction. Based on the drug-excipient compatibility test, different VRC-S tablets were prepared with the selected excipients through direct compression or wet granulation method and subjected to a dissolution test. The stability of the most promising VRC-S tablet (F4) was evaluated under accelerated conditions (40°C and 75% relative humidity). Further, the dissolution and human pharmacokinetic profiles of the F4 tablet and Champix were compared.

RESULTS

VRC-S showed a positively skewed unimodal size distribution with a specific surface area of 2.02 m2/g, single endothermic peak of 225.2°C in differential scanning calorimetry, crystalline internal structure in powder X-ray diffraction, aqueous solubility of 244.7 mg/mL, and hygroscopicity of 0.256 mg/g. The wet granulation method was preferred for tablet preparation and employed the following excipients: microcrystalline cellulose and anhydrous dibasic calcium phosphate as diluents, croscarmellose sodium as a disintegrant, and colloidal silicon dioxide and magnesium stearate as lubricants. The F4 tablet was stable for 6 months under accelerated conditions. The dissolution of VRC was pH independent, revealing f 2 values of 76.49 and 68.38 at pH 1.2 and pH 6.8, respectively. After the oral administration of F4 tablet and Champix to healthy human volunteers, pharmacokinetic parameters, including time to reach the maximum plasma concentration (Tmax), maximum plasma concentration (Cmax), and area under the curve from 0 to infinity (AUCinf), were compared. The values of 90% CI were 0.972-1.035 for Cmax and 0.982-1.075 for AUCinf, which was indicative of the bioequivalence of both products.

CONCLUSION

VRC-S-containing F4 tablet might be a good candidate for smoking cessation treatment.

Smoking cessation strategies in pregnancy: Current concepts and controversies

Smoking during pregnancy is a risk factor associated with adverse pregnancy outcomes. Despite the fact that these outcomes are well known, a considerable proportion of pregnant women continue to smoke during this critical period. This paper evaluates critically smoking cessation interventions targeting pregnant women. We describe the findings of key published studies, review papers and expert statements to report the efficacy and safety of strategies for smoking cessation in pregnancy, including counselling and pharmacotherapy. Counselling appears to improve quit rates but mainly when used in combination with pharmacological therapy. Pharmacotherapy is recommended for women who are heavy smokers and are unable to quit smoking on their own. Nicotine replacement therapy is a reasonable first-line drug option. It is recommended that women who are pregnant, or planning to become pregnant, should be informed of potential risks for the foetus before considering smoking cessation therapy with bupropion or varenicline. Pregnant women view electronic nicotine delivery systems as being safer than combustible cigarettes, and this indeed may be the case; however, further evidence is required to assess their effectiveness as a smoking cessation aid and their safety for the mother and the child. Postpartum relapse is a significant problem, with approximately one out of two quitters relapsing in the first 2 months after delivery. These women should be considered 'at risk' and provided with ongoing support.

Algorithm for resolving discrepancies between claims for smoking cessation pharmacotherapies during pregnancy and smoking status in delivery records: The impact on estimates of utilisation

BACKGROUND

The linkage of routine data collections are valuable for population-based evaluation of smoking cessation pharmacotherapy in pregnancy where little is known about the utilisation or safety of these pharmacotherapies antenatally. The use of routine data collections to study smoking cessation pharmacotherapy is limited by disparities among data sources. This study developed an algorithm to resolve disparity between the evidence of pharmacotherapy utilisation for smoking cessation and the recording of smoking in pregnancy, examined its face validity and assessed the implications on estimates of smoking cessation pharmacotherapy utilisation.

METHODS

Perinatal records (n = 1,098,203) of women who gave birth in the Australian States of Western Australia and New South Wales (2004-2012) were linked to hospital admissions and pharmaceutical dispensing data. An algorithm, based on dispensing information about the type of smoking therapy, timing and quantity of supply reclassified certain groups of women as smoking during pregnancy. Face validity of the algorithm was tested by examining the distribution of factors associated with inaccurate recording of smoking status among women that the algorithm classified as misreporting smoking in pregnancy. Rate of utilisation among smokers, according to original and reclassified smoking status, was measured, to demonstrate the utility of the algorithm.

RESULTS

Smoking cessation pharmacotherapy were dispensed to 2184 women during pregnancy, of those 1013 women were originally recorded as non-smoking as per perinatal and hospital data. Application of the algorithm reclassified 730 women as smoking during pregnancy. The algorithm satisfied the test of face validity-the expected demographic factors of marriage, private hospital delivery and higher socioeconomic status, were more common in women whom the algorithm identified as misreporting their smoking status. Application of the algorithm resulted in smoking cessation pharmacotherapy utilisation estimates ranging from 2.3-3.6% of all pregnancies.

CONCLUSION

Researchers can use the algorithm presented herein to improve the identification of smoking among women who use cessation pharmacotherapies during pregnancy. Improved identification can improve the validity of safety analyses of smoking cessation pharmacotherapy-providing clinicians with valuable evidence to use when counselling women on the role of pharmacotherapy for smoking cessation during pregnancy.

Prenatal Primary Prevention of Mental Illness by Micronutrient Supplements in Pregnancy

Genes, infection, malnutrition, and other factors affecting fetal brain development are a major component of risk for a child's emotional development and later mental illnesses, including schizophrenia, bipolar disorder, and autism. Prenatal interventions to ameliorate that risk have yet to be established for clinical use. A systematic review of prenatal nutrients and childhood emotional development and later mental illness was performed. Randomized trials of folic acid, phosphatidylcholine, and omega-3 fatty acid supplements assess effects of doses beyond those adequate to remedy deficiencies to promote normal fetal development despite genetic and environmental risks. Folic acid to prevent neural tube defects is an example. Vitamins A and D are currently recommended at maximum levels, but women's incomplete compliance permits observational studies of their effects. Folic acid and phosphatidylcholine supplements have shown evidence for improving childhood emotional development associated with later mental illnesses. Vitamins A and D decreased the risk for schizophrenia and autism in retrospective observations. Omega-3 fatty acid supplementation during early pregnancy increased the risk for schizophrenia and increased symptoms of attention deficit hyperactivity disorder, but in later pregnancy it decreased childhood wheezing and premature birth. Studies are complicated by the length of time between birth and the emergence of mental illnesses like schizophrenia, compared with anomalies like facial clefts identified at birth. As part of comprehensive maternal and fetal care, prenatal nutrient interventions should be further considered as uniquely effective first steps in decreasing risk for future psychiatric and other illnesses in newborn children. [AJP at 175: Remembering Our Past As We Envision Our Future July 1959: Longitudinal Observations of Biological Deviations in a Schizophrenic Infant Barbara Fish described the course of an infant born with fluctuating motor problems who developed schizophrenia. (Am J Psychiatry 1959; 116:25-31 )].

Ethical approval for multicenter cohort studies on drug exposure during pregnancy: A survey among members of the European Network of Teratology Information Services (ENTIS)

The European Network of Teratology Information Services (ENTIS) is in a privileged position to perform independent post-marketing surveillance of drugs in pregnancy. The aim of this survey was to describe the legal requirements and procedures involved in obtaining ethical approval for collaborative cohort studies. We sent a survey questionnaire to all 28 Teratology Information Services (TIS), of which 25 (89%) in 18 countries completed our questionnaire. For 15 TIS, specific research ethical approval was mandatory. The review process was estimated to last from 2 up to 16 weeks. Procedures for patients' information and consent were oral (12), written (5) or both (3). Five TIS had no requirement to inform patients and seek consent. Since data on drug exposure during pregnancy are scarce, ENTIS research efforts should be further encouraged, and procedures optimized so that legitimate ethical and legal requirements do not translate into deterrent administrative constraints and costs.

Substance use in pregnancy: The medical challenge

Substance use contributes significantly to the global burden of disease. Growing numbers of women use nicotine, alcohol, and illicit substances. Women are the most vulnerable to problematic substance use in their reproductive years. The first 1000 days of life, starting at conception, have been established as a critical window of time for long-term health and development. Substance use in pregnancy is associated with negative pregnancy and child health outcomes. The impact of antenatal substance use on these outcomes needs to be considered within a challenging and complex context. This review provides an overview of the current literature on the impact of substances on pregnancy and child outcomes as well as the evidence and guidelines on screening and interventions for women using substances during pregnancy.

Systematic Review and Meta-Analysis to Assess the Safety of Bupropion and Varenicline in Pregnancy

Introduction

Smoking in pregnancy is a substantial public health issue, but, apart from nicotine replacement therapy (NRT), pharmacological therapies are not generally used to promote cessation. Bupropion and varenicline are effective cessation methods in nonpregnant smokers and this systematic review investigates their safety in pregnancy.

Methods

We searched MEDLINE, EMBASE, CINAHL, and PsychINFO databases for studies of any design reporting pregnancy outcomes after bupropion or varenicline exposure. We included studies of bupropion used for smoking cessation, depression, or where the indication was unspecified. Depending on study design, quality was assessed using the Newcastle-Ottawa Scale or Cochrane Risk of Bias Tool. Most findings are reported narratively but meta-analyses were used to produce pooled estimates for the proportion of live births with congenital malformations and of the mean birthweight and gestational age at delivery following bupropion exposure.

Results

In total, 18 studies were included: 2 randomized controlled trials, 11 cohorts, 2 case– control studies, and 3 case reports. Study quality was variable. Gestational safety outcomes were reported in 14 bupropion and 4 varenicline studies. Meaningful meta-analysis was only possible for bupropion exposure, for which the pooled estimated proportion of congenital malformations amongst live-born infants was 1.0% (95% CI = 0.0%–3.0%, I2 = 80.9%, 4 studies) and the mean birthweight and mean gestational age at delivery was 3305.9 g (95% CI = 3173.2–3438.7 g, I2 = 77.6%, 5 studies) and 39.2 weeks (95% CI = 38.8–39.6 weeks, I2 = 69.9%, 5 studies), respectively.

Conclusions

There was no strong evidence that either major positive or negative outcomes were associated with gestational use of bupropion or varenicline. PROSPERO registration number CRD42017067064.

Implications

We believe this to be the first systematic review investigating the safety of bupropion and varenicline in pregnancy. Meta-analysis of outcomes following bupropion exposure in pregnancy suggests that there are no major positive or negative impacts on the rate of congenital abnormalities, birthweight, or premature birth. Overall, we found no evidence that either of these treatments might be harmful in pregnancy, and no strong evidence to suggest safety, but available evidence is of poor quality.

Bupropion promotes alterations in the spermatogenesis of mice and congenital malformations in the offspring

Bupropion hydrochloride (BUP) has been associated with male sexual dysfunction. The aim of this study was to evaluate the effects of BUP on the reproductive function of male mice and to evaluate offspring development. The mice were distributed into BUP group (40 mg kg−1) and control group (saline). On Day 35 of treatment the males were placed to mate with females and then killed on Day 46 for evaluation of reproductive function. On Day 18 of pregnancy, pregnant females were killed for evaluation of congenital malformations in the offspring. The BUP group showed a decrease in the Johnsen score (Control, 9.354 ± 0.092; BUP, 7.615 ± 0.147), Sertoli (Control, 5.623 ± 0.184; BUP, 4.215 ± 0.097) and Leydig (Control, 11.430 ± 0.817; BUP, 7.531 ± 0.213) cell counts, testosterone levels (Control, 783.5 ± 154.2 ng dL−1; BUP, 201.4 ± 54.8 ng dL−1) and sperm production (Control, 2.852 ± 0.211; BUP, 1.988 ± 0.116) and increased morphological alterations of the sperm head (Control, 8.134%; BUP, 10.423%) and tail (Control, 4.96%; BUP, 16.211%). The congenital malformations observed in BUP-derived offspring were: kyphosis (Control, 0.00%; BUP, 5.26%), retroverted rear legs (Control, 14.43%; BUP, 53.68%), incomplete ossification of the supraoccipital and exoccipital (Control, 21.82%; BUP, 86.00%) and sternum (Control, 25.45%; BUP, 82.00%). BUP had toxic effects on testicular function and teratogenic potential.

Committee Opinion No. 721: Smoking Cessation During Pregnancy

Smoking is the one of the most important modifiable causes of poor pregnancy outcomes in the United States, and is associated with maternal, fetal, and infant morbidity and mortality. The physical and psychologic addiction to cigarettes is powerful; however, the compassionate intervention of the obstetrician-gynecologist can be the critical element in prenatal smoking cessation. An office-based protocol that systematically identifies pregnant women who smoke and offers treatment or referral has been proved to increase quit rates. A short counseling session with pregnancy-specific educational materials and a referral to the smokers' quit line is an effective smoking cessation strategy. The 5A's is an office-based intervention developed to be used under the guidance of trained practitioners to help pregnant women quit smoking. Knowledge of the use of the 5A's, health care support systems, and pharmacotherapy add to the techniques providers can use to support perinatal smoking cessation. The use of alternative forms of nicotine, such as e-cigarettes and vaping, have increased substantially in recent years, but there are little data regarding the health effects of these agents, either in the general population or in pregnant women specifically.

British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017

Decisions about the use of psychotropic medication in pregnancy are an ongoing challenge for clinicians and women with mental health problems, owing to the uncertainties around risks of the illness itself to mother and fetus/infant, effectiveness of medications in pregnancy and risks to the fetus/infant from in utero exposure or via breast milk. These consensus guidelines aim to provide pragmatic advice regarding these issues. They are divided into sections on risks of untreated illness in pregnancy; general principles of using drugs in the perinatal period; benefits and harms associated with individual drugs; and recommendations for the management of specific disorders.