Editorial: Can the pill cause birth defects?

Side effects of steroid contraception

Side effects of steroid contraception during lactation are discussed and followed by a review of the relevant literature. It appears that oestrogen has an inhibiting effect on lactation performance, but progestogen alone does not. Most of the undesirable systemic side effects of oral contraceptives on the mother are connected with the relative excess or deficiency of the oestrogen and/or the progestogen component. It is likely that a low oestrogen content preparation causes no dangerous side effects. There are few data about the appearance of contraceptive steroids in breast milk. Probably only a small proportion of the steroids are excreted into the milk. Any adverse effects, on the infant, such as slow weight gain, neonatal breast hypertrophy and breast milk jaundice, are dependent on the two preceding factors. It is doubtful whether the small amount of contraceptive steroids contained in modern pills exert any influence on the fetus. Although further examinations are necessary, the low dosage of progestogen and oestrogen combined contraceptives given at fully established lactation under close control seems to be advantageous to both mothers and their infants.

Medications in pregnancy and lactation: part 1. Teratology

One of the least-developed areas of clinical pharmacology and drug research is the use of medication during pregnancy and lactation. This article is the first in a two-part series designed to familiarize physicians with many aspects of the drugs they commonly prescribe for pregnant and breast-feeding women. Almost every pregnant woman is exposed to some type of medication during pregnancy. Although the majority of pregnant and breast-feeding women consume clinically indicated or over-the-counter drug preparation regularly, only few medications have specifically been tested for safety and efficacy during pregnancy. There is scant information on the effect of common pregnancy complications on drug clearance and efficacy. Often, the safety of a drug for mothers, their fetuses, and nursing infants cannot be determined until it has been widely used. Absent this crucial information, many women are either refused medically important agents or experience potentially harmful delays in receiving drug treatment. Conversely, many drugs deemed "safe" are prescribed despite evidence of possible teratogenicity. Novel research and diagnostic applications evolving from the opportunities presented by the advances in genomics and proteomics are now beginning to affect clinical diagnosis, vaccine development, drug discovery, and unique therapies in a modern diagnostic-therapeutic framework-part of the new scientific field of theranostics. This review critically explores a number of recently raised issues in regard to the use of several classes of medications during gestation and seeks to provide a general and concise resource on drugs commonly used during pregnancy and lactation. It also seeks to make clinicians more aware of the controversies surrounding some drugs in an effort to encourage safer prescribing practices through consultation with a maternal-fetal medicine specialist and through references and Web sites that list up-to-date information.

Noninherited risk factors and congenital cardiovascular defects: current knowledge: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young: endorsed by the American Academy of Pediatrics

Prevention of congenital cardiovascular defects has been hampered by a lack of information about modifiable risk factors for abnormalities in cardiac development. Over the past decade, there have been major breakthroughs in the understanding of inherited causes of congenital heart disease, including the identification of specific genetic abnormalities for some types of malformations. Although relatively less information has been available on noninherited modifiable factors that may have an adverse effect on the fetal heart, there is a growing body of epidemiological literature on this topic. This statement summarizes the currently available literature on potential fetal exposures that might alter risk for cardiovascular defects. Information is summarized for periconceptional multivitamin or folic acid intake, which may reduce the risk of cardiac disease in the fetus, and for additional types of potential exposures that may increase the risk, including maternal illnesses, maternal therapeutic and nontherapeutic drug exposures, environmental exposures, and paternal exposures. Information is highlighted regarding definitive risk factors such as maternal rubella; phenylketonuria; pregestational diabetes; exposure to thalidomide, vitamin A cogeners, or retinoids; and indomethacin tocolysis. Caveats regarding interpretation of possible exposure-outcome relationships from case-control studies are given because this type of study has provided most of the available information. Guidelines for prospective parents that could reduce the likelihood that their child will have a major cardiac malformation are given. Issues related to pregnancy monitoring are discussed. Knowledge gaps and future sources of new information on risk factors are described.

Prescribing and managing oral contraceptive pills and emergency contraception for adolescents

Combination OCPs are safe and effective ways to prevent unintended adolescent pregnancy if they are used properly. Numerous noncontraceptive benefits of OCPs can bolster continued combination OCP use. Progestin-only OCPs are an option, particularly for young women with medical contraindications to taking estrogens; however, because of their lower efficacy, progestin-only pills are not the first choice for oral contraception for adolescents. Health care providers can give young women a second chance to prevent unintended pregnancy by improving their access to emergency contraception through educating and counseling about emergency contraception at all office visits, by prescribing emergency contraceptive pills in advance, or by prescribing emergency contraceptive pills over the telephone.

Drug administration to the pregnant or lactating woman: a reference guide for dermatologists

Dermatologists are occasionally faced with the problem of appropriate systemic drug administration to the lactating or pregnant woman. The physician's responsibility is to be aware of the potential risk of prescribing a specific therapeutic agent, to inform the mother of this risk, and to administer an alternate, less deleterious drug, if available. The purpose of this review is to provide guidelines for dermatologists who must consider the risks to the fetus or neonate of drug administration to the pregnant woman or lactating mother.

Congenital abnormalities and hormones during pregnancy: a clinical review

A review of the extensive literature on the subject indicates that sex hormones have been associated with a wide variety of adverse clinical conditions following usage during pregnancy. About 230 cases of female pseudohermaphroditism have been reported following use of hormones with androgenic potency, but masculinization observed with estrogens in a few females may represent only adrenal-stimulated pseudohermaphroditism. Feminization of males, mostly by progestogens in some 45 cases, is unproven at present. Realizing the limitations of the published studies when all present data are considered, there seems no justification for undue concern over the induction of nongenital congenital malformations through hormone use in pregnancy. The available data on the association to cardiac, limb, and CNS defects, and to several malformative syndromes, are not convincing: the effects appear to be remarkably nonspecific, the studies are contradicted by a large number of negative reports, and an increased incidence of defects with increased usage has not materialized. A possible exception are the CNS malformations associated with the use of the antifertility agent clomiphene, and careful surveillance is warranted at present. While a reasonable interpretation from this review would be that hormones present no major teratogenic hazard, elimination of hormonal exposure whenever possible during pregnancy is suggested.

Threatened abortion, hormone therapy and malformed embryos

Causal relations between maternal genital bleeding, supportive hormone therapy and external malformations of the embryos were investigated with special reference to the critical period of organogenesis. This was done using morphological and obstetrical data obtained by Nishimura and his associates from 667 undamaged embryos derived from induced abortions whose mothers had genital bleeding in early pregnancy. In addition, data from 90 embryos with polydactyly and 38 with limb reductions in the Nishimura collection were used for case history studies. Evidence was presented to demonstrate that, for major malformations such as CNS anomalies, cleft lip, polydactyly and limb reductions, maternal genital bleeding was not a cause but a consequence of the conception of an abnormal embryo. No indication was revealed that exogenous female hormones currently used in Japan for preventing miscarraiges could produce major malformations recognizable at the embryonic stage, including limb reductions, nor salvage the severely malformed embryos. This does not however mean to exclude the possible relationship of progestogens/estrogens intake during early pregnancy with an increased incidence at birth of certain internal and/or external malformations. It was suggested that most, if not all, of the minor anomalies observed at certain embryonic stages are kinds of normal variants without any functional impairment of embryonic development.

Abnormalities among offspring of oral and nonoral contraceptive users

An analysis of 223 children born between 1961 and 1965 to 5,465 women in a controlled experiment at the University of Puerto Rico School of Medicine, regarding the use of oral and nonoral contraceptives, failed to reveal any statistical differences in birth weight and physical abnormalities between the two contraceptive groups. The mean birth weight for the oral group was 7 pounds, 4.1 ounces, whereas for the nonoral group it was 7 pounds, 5.4 ounces. Abnormal physical findings were 10.7% for the oral group and 16.7% for the nonoral group. A comparison is also made between the two groups with respect to incidence of abnormalities by socioeconomic class and by sex of the child, as well as by the number of pregnancies and age of the mother. No significant differences were noted between the groups as an indication of the effect of oral contraceptives.

Are hormonal contraceptives teratogenic?

The widespread use of hormonal contraceptives for a prolonged time in women during the child-bearing period necessitates that appropriate precautions be taken to ensure safety for the patient as well as for her progeny. Hormonal administration during or prior to pregnancy may be potentially teratogenic. Although there have been many reports during the last decade, it has been very difficult to document conclusively such a relationship. Over-all, it seems that hormonal use prior to pregnancy does not lead to an increase in the frequency of chromosomal aberrations or of congenital malformations. The use of certain hormones during pregnancy, on the other hand, may lead to an increase in the incidence of congenital malformations, probably in the genetically predisposed fetus. In view of this concept hormonal contraceptives should not be used to treat threatened abortion, and their use as a pregnancy test should be abandoned. Since the question of the safety of the inadvertent administration of pills during early pregnancy has not been resolved, the mother should be informed of the potential risks.

The outcome of pregnancy in former oral contraceptive users

As part of a continuing major prospective survey, the outcome of 5530 pregnancies in former oral contraceptive (pill) users was compared with the outcome of 11 009 pregnancies in the control series of women who had never used the pill. In former pill users there was a significantly higher induced abortion rate. There was no increase in the reported spontaneous abortion rate, and there is evidence to suggest that the true spontaneous abortion rate may be materially lower in former pill users. The previous use of oral contraceptives appeared to have no adverse effect on subsequent births.

Long-term assessment of children exposed in utero to carbimazole

Twenty-five children aged 3 to 13 years who had been exposed in utero to carbimazole were assessed physically and psychologically to evaluate the long-term effects of the drug on growth and development. 2 children had congenital malformations but all had normal pituitary-thyroid function and appeared to have grown and developed normally.

Endometrial aspiration in fertility control. A report of 500 cases

Outpatient endometrial aspiration was offered to patients who suspected that they were pregnant, but were within 5 to 21 days after failure of expected menstruation and had a uterus of normal size on pelvic examination. This is a report of 500 consecutive cases treated between September, 1973, and April, 1975. Histologic examination of the aspirated tissue was obtained on all 500 cases (100 per cent). Follow-up examination and urine pregnancy was obtained on 407 patients (81.4 per cent). Histologic evidence of pregnancy was obtained in 323 patients (64.6 per cent). Complications were limited to five infections (1 per cent), only one of which led to hospitalization of the patient, and failure to completely evacuate the pregnant uterus in 39 patients (12.1 per cetn of the 323 pregnant). Thirty-four of these had the uterus emptied by a second outpatient procedure and five patients were hospitalized to complete their abortion.