Weighing the risks and the benefits: a call for the empirical assessment of perceived teratogenic risk

A descriptive analysis of calls to the NSW Teratogen Information Service regarding use of anti-infectives during pregnancy

BACKGROUND

MotherSafe is a free telephone-based counseling service for Australian consumers and health-care providers concerned about drug exposures during pregnancy and breastfeeding. Anti-infectives are the most commonly prescribed drugs for pregnant women. This study aims to provide a descriptive analysis of prospectively collected calls received by MotherSafe regarding anti-infective exposures during pregnancy between 2000 and 2020. Aggregate data were examined by type of caller, reason for call, pregnancy category and exposure type. Inductive thematic analysis of the comments recorded by MotherSafe counsellors at the time of call was undertaken.

RESULTS

Over the study period, 25,890 calls related to exposure to anti-infectives during pregnancy (antibiotic, antiviral, and antifungal medications). Calls from patients were dominated by low-risk exposures (pregnancy category A) to drugs while calls from health care professionals related to drugs with limited human information (pregnancy category B3). Analysis of MotherSafe counsellor comments revealed over 200 instances of concerns relating to health care professional advice to the patient. Three themes emerged: incorrect or conflicting advice, poor counselling, and refusal to treat, prescribe or dispense. It is likely that these comments are biased to the negative as patients would not call MotherSafe if they were happy with HCP advice. However, the findings are concerning as they reveal an underlying lack of knowledge in some health care professionals which may have led to undertreatment of patients. This study reinforced the importance of Teratogen Information Services such as MotherSafe in providing counselling and clear communication of evidence-based information to guide decision-making, reducing potential emotional distress in pregnant women, and optimizing maternal, pregnancy and infant outcomes.

Surveillance of Drug Safety During Pregnancy: Insight in Current International Activities, Future Intentions and Need for Support of National Pharmacovigilance Centres

INTRODUCTION

Surveillance of drug safety during pregnancy is a special interest of pharmacovigilance (PV). The role that national PV centres take in this field is, however, unclear.

AIM

The aim of this study was to provide insight into current activities, future intentions and need for support of national PV centres in the field of drug safety during pregnancy.

METHOD

A web-based questionnaire was used to ask PV centres about their current activities concerning the surveillance of drug safety during pregnancy, their intentions to implement or improve activities and need for support. For these three main topics, questions were posed about spontaneous adverse drug reaction (ADR) reporting, additional activities to obtain information, signal detection and informing healthcare professionals and the public.

RESULTS

The questionnaire was sent to PV centres of 172 countries. Response was 40%. In general, the PV centres received limited numbers of reports of ADRs in the (unborn) child, related to drug exposure during pregnancy. Signal detection in pregnancy cases is carried out by 8 out of 58 PV centres (13.5%). Most PV centres mention they have intentions to implement or improve activities, mainly for spontaneous reporting (69.4%) and methods for signal detection (67.2%). Support was needed for all topics of the questionnaire.

CONCLUSION

Current activities of national PV centres concerning drug safety during pregnancy are limited. The majority of PV centres are, however, willing to improve or implement activities. Programmes should be set up in order to support and stimulate PV centres with these activities. The aim of all these activities is to increase knowledge about the safety of drugs during pregnancy.

Risk perception regarding drug use in pregnancy

Pregnant women, but also physicians, have unrealistically high perceptions of teratogenic drug effects. This may result in suboptimal treatment of disease and even influence decisions of whether to continue pregnancy. To attain more realistic teratogenic risk perceptions, several factors that influence this issue should be considered, and these are further discussed in this Clinical Opinion. Importantly, drug use may have several benefits, both for the pregnant woman's health and to avoid negative fetal effects of untreated maternal disease. A greater focus on this aspect may act to balance risk perceptions. Furthermore, both pregnant women and physicians need access to drug information sources that provide realistic risk estimates to increase confidence in appropriate drug use and prescribing. We suggest that access to decision support and individually tailored information provided by drug information centers may contribute to this goal.

Analysis of agreement between Visual Analogue Scales (VAS) and numerical questions to assess perception of teratogenic risks in treatment with drugs and radiotherapy in women

Objectives: to evaluate the agreement between Visual Analogue Scales (VAS) and numerical questions as a way of assessing the perception of teratogenic risk of treatment with drugs and radiotherapy. Methods: the sample comprised 144 pregnant and 143 non-pregnant women consecutively recruited at public health centers in Porto Alegre, in the State of Rio Grande do Sul, from February to August 2011. The perception of risk for congenital malformations in the general population and the perceptions of teratogenic risk for exposure to acetaminophen, meto-clopramide, misoprostol and radiotherapy were measured using VAS and numerical questions. The agreement between the results of the two techniques was tested using a Bland-Altman plot. Results: the medians for the perceptions measured using VAS were higher than those obtained using numerical questions for all variables. The perception of risk for acetaminophen showed the lower bias of the two techniques (bias=13.17; p<0.001) and exposure to radiotherapy, the higher (bias=25.02; p<0.001). Conclusion: there was no agreement between the measurements obtained using the two techniques for any of the risk perceptions under study. Risk perceptions were higher using VAS, for all kinds of exposure. Studies should be conducted to assess whether there is overestimation in other situations and social contexts owing to the use of VAS.

Perceptions by pregnant and childbearing-age women in southern Brazil towards teratogenic risk from medicines and radiotherapy

Mistaken perception of teratogenic risk can keep pregnant women from using safe medicines. The current study analyzed women’s concepts and perceptions towards teratogenic risk from medicines and exposure to radiotherapy during pregnancy. The quantitative data resulted from interviews with 287 pregnant and non-pregnant women. Two qualitative focus groups were conducted. No significant differences were observed between the two groups in terms of perceptions of teratogenic risk. Median perceptions of non-teratogenic exposures (paracetamol and metoclopramide) were close to the expected values, while higher values were found for teratogenic exposures (misoprostol and radiotherapy). The logic women used to estimate risk was classification of medicines as “strong” or “weak”. Medicines perceived as “weak” by the women do not pose any teratogenic risk, as shown by the median perceptions close to the true values. Meanwhile, “strong” medicines were viewed as dangerous, thus explaining the high median perceptions of teratogenic exposures.

Teratogenic risk perception and confidence in use of medicines in pairs of pregnant women and general practitioners based on patient information leaflets

OBJECTIVE

The aim of this study was to examine teratogenic risk perceptions and confidence in the use of medicines in pairs of pregnant women and general practitioners (GPs) through assessments of medicines information texts from patient information leaflets (PILs).

METHODS

A questionnaire was handed out to women attending regular ultrasound examination in week 17-19 of pregnancy. The women stated name and address of their GP and questionnaires were sent to the GPs' clinic. The questionnaires contained texts regarding pregnancy from PILs for pivmecillinam, metoclopramide, paracetamol, escitalopram, Valeriana officinalis and dexchlorpheniramine. For each PIL, teratogenic risk (scale from 0: never teratogenic to 10: always teratogenic), confidence in use of medicines (yes or no) and clarity of the text (scale from 0: exceptionally clear to 3: exceptionally unclear) were assessed.

RESULTS

In total, 171 pregnant women and 74 GPs participated, of which 98 pairs were identified. Pregnant women had significantly higher perceptions of teratogenic risks and lower confidence in use of medicines compared to GPs. Differences in teratogenic risk perceptions and confidence in use were highest for escitalopram and lowest for dexchlorpheniramine, representing texts with different phrasing and length. Neither pregnant women nor GPs were confident in using Valeriana officinalis.

CONCLUSIONS

Perceptions of teratogenic risks and confidence in use of medicines during pregnancy differ within pairs of pregnant women and their GP when they assess PILs. Phrasing of medicines information texts can influence teratogenic risk perceptions and thereby prescribing of medicines and adherence.

Funding for teratology information services: up, down, and all around

Funding for Teratology Information Services has been an ongoing struggle over the 25 years of its existence. Traditional and novel funding mechanisms have been explored with varying success. The importance of providing teratology risk assessment and counseling to all women of reproductive age is now an established health care objective. Sufficient and stable funding for these services is essential.

Perception of teratogenic and foetotoxic risk by health professionals: a survey in Midi-Pyrenees area

Counselling or prescribing drugs during pregnancy requires health professionals to assess risk/benefit ratio for women and their baby. A misperception of the risk may lead to inappropriate decisions for pregnancy outcomes. The aim of the present study was to assess teratogenic and/or foetotoxic risk perception of common medications by general practitioners (GPs) and community pharmacists (CPs) from the Midi-Pyrenees area.

METHODS

103 GPs and 104 CPs were interviewed. For 21 given drugs, a visual-analogue scale was used to evaluate the risk to give birth to a malformed infant if the mother had taken the drug during first trimester of pregnancy. For 9 drugs, health professionals had to say if they thought there was a potential foetotoxic and/or neonatal risk when drugs were administered during late pregnancy.

RESULTS

97% and 91% of GPs and CPs respectively thought that isotretinoin and thalidomide are teratogenic and more than 80% thought that amoxicillin and acetaminophen are safe in early pregnancy. However, 19% of the GPs and 33% of CPs answered there were no teratogenic risk for valproate. Around 11% of both GPs and CPs said that warfarin was safe during pregnancy. For 22% of GPs and for 13% and 27% of CPs respectively, ibuprofen and enalapril were safe on late pregnancy. For each drug, mean value of perceived teratogenic risk by health professionals was higher than values that can be found in scientific references. Concerning isotretinoin, thalidomide and metoclopramide, perceived teratogenic risk was higher for CPs.

CONCLUSION

These data show that the potential teratogenic and foetotoxic risk of several commonly used drugs is unknown by health professionals. Conversely, GPs and CPs who think that a risk exists, overestimate it. This misperception can lead to inappropriate decisions for pregnancy outcomes.

Developmental toxicity: web resources for evaluating risk in humans

This review presents a brief overview of Internet resources that provides information on developmental toxicity. The advantages and limitations of these resources for evaluating human risk and where each one is useful for informing various stages of the risk assessment process (i.e. hazard characterization, dose-response assessment, exposure assessment and risk characterization) are reviewed. How these Internet resources can be utilized to obtain information on and evaluate the developmental risk associated with exposures during pregnancy will be illustrated using toluene. Translating information derived from laboratory and human population studies into clinical management prescriptions for individual patients is difficult. With the increasing availability of Internet resources that provide information relevant for developmental risk assessments, health care professionals will be better equipped to make more accurate estimations of potential risk for their patients.