Benzodiazepine use before conception and risk of ectopic pregnancy

Antihypertensive Medication Use before and during Pregnancy and the Risk of Severe Maternal Morbidity in Individuals with Prepregnancy Hypertension

OBJECTIVE

Our objective is to examine severe maternal morbidity (SMM) and patterns of antihypertensive medication use before and during pregnancy among individuals with chronic hypertension.

STUDY DESIGN

We examined 11,759 pregnancies resulting in a live birth or stillbirth to individuals with chronic hypertension and one or more antihypertensive prescription 6 months before pregnancy (Optum, 2007-17). We examined whether study outcomes were associated with the use of medication as compared to no use during pregnancy. In addition, patterns of medication use based on the Food and Drug Administration guidance and literature were evaluated. Medication use was divided into prepregnancy and during pregnancy use and classified as pregnancy recommended (PR) or not pregnancy recommended (nPR) or no medication use. SMM was defined per the Centers for Disease Control and Prevention definition of 21 indicators. Risk ratios (RR) reflecting the association of SMM with the use of antihypertensive medications were computed using modified Poisson regression with robust standard errors and adjusted for maternal age, education, and birth year.

RESULTS

Overall, 83% of individuals filled an antihypertensive prescription during pregnancy and 6.3% experienced SMM. The majority of individuals with a prescription prior to pregnancy had a prescription for the same medication in pregnancy. Individuals with any versus no medication use in pregnancy had increased adjusted RR (aRR) of SMM (1.18, 95% confidence interval [CI]: 0.96-1.44). Compared to the use of PR medications before and during pregnancy, aRRs were 1.42 (95% CI: 1.18-1.69, 12.4% of sample) for nPR use before and during pregnancy, 1.52 (1.23-1.86; 12.4%) for nPR (before) and PR (during) use, and 2.67 (1.73-4.15) for PR and nPR use. Patterns with no medication use during pregnancy were not statistically significant.

CONCLUSION

Pattern of antihypertensive medication use before and during pregnancy may be associated with an elevated risk of SMM. Further research is required to elucidate whether this association is related to the severity of hypertension, medication effectiveness, or suboptimal quality of care.

KEY POINTS

· Individuals with any medication use compared to no medication use in pregnancy had an increased risk of SMM.. · Specific medication use patterns were associated with an elevated risk of SMM.. · Pattern of antihypertensive medication use before and during pregnancy may be associated with an increased risk of SMM..

Maternal, Fetal, and Child Outcomes of Mental Health Treatments in Women: A Meta‐Analysis of Pharmacotherapy

Objective

The authors systematically reviewed evidence on pharmacotherapy for perinatal mental health disorders.

Methods

The authors searched for studies of pregnant, postpartum, or reproductive‐age women with mental health disorders treated with pharmacotherapy in MEDLINE, EMBASE, PsycINFO, the Cochrane Library, and trial registries from database inception through June 5, 2020 and surveilled literature through March 2, 2021. Outcomes included symptoms; functional capacity; quality of life; suicidal events; death; and maternal, fetal, infant, or child adverse events.

Results

164 studies were included. Regarding benefits, brexanolone for third‐trimester or postpartum depression onset may be associated with improved depressive symptoms at 30 days when compared with placebo. Sertraline for postpartum depression may be associated with improved response, remission, and depressive symptoms when compared with placebo. Discontinuing mood stabilizers during pregnancy may be associated with increased recurrence of mood episodes for bipolar disorder. Regarding adverse events, most studies were observational and unable to fully account for confounding. Evidence on congenital and cardiac anomalies for treatment compared with no treatment was inconclusive. Brexanolone for depression onset in the third trimester or the postpartum period may be associated with risk of sedation or somnolence, leading to dose interruption or reduction when compared with placebo.

Conclusions

Evidence from few studies supports the use of pharmacotherapy for perinatal mental health disorders. Although many studies report on adverse events, they could not rule out underlying disease severity as the cause of the association between exposures and adverse events. Patients and clinicians need to make informed, collaborative decisions on treatment choices.

Few studies have been conducted in pregnant and postpartum women on the benefits of pharmacotherapy; many studies report on harms but are of low quality

Brexanolone probably improves depressive symptoms; it may increase the risk of sedation or somnolence, leading to dose interruption or reduction. Sertraline may improve response, remission, and depression and anxiety symptoms. Mood stabilizers may reduce recurrence and increase time to recurrence

Although associations may exist between psychotropic medications and adverse events, causality cannot be inferred. The paucity of evidence does not mean that pharmacotherapy is not beneficial, nor that harms do not exist; rather, it underscores the absence of high‐quality research

Psychiatric Medication Use in Pregnancy and Breastfeeding

Active peripartum psychiatric illness is associated with adverse outcomes for exposed pregnancies/children. Likely due to high rates of obesity, pregnant women with psychiatric illness also have higher rates of preeclampsia, cesarean section, and gestational diabetes. Postpartum depression is associated with lower IQ, slower language development, and behavioral problems in exposed children. Discontinuing psychiatric medications for pregnancy increases risk for relapse significantly, and the postpartum time period is high risk for developing psychiatric illness. Obstetricians-gynecologists are front-line providers for psychiatric care of women during peripartum. This article provides a framework and knowledge base for management of psychiatric illness during peripartum.

Association between preconception paternal health and pregnancy loss in the USA: an analysis of US claims data

STUDY QUESTION

Is preconception paternal health associated with pregnancy loss?

SUMMARY ANSWER

Poor preconception paternal health is associated with a higher risk of pregnancy loss as confirmed in sensitivity analyses accounting for maternal age and health.

WHAT IS KNOWN ALREADY

Preconception paternal health can negatively impact perinatal outcomes.

STUDY DESIGN, SIZE, DURATION

Retrospective cohort study of US insurance claims database from 2009 to 2016 covering 958 804 pregnancies.

PARTICIPANTS/MATERIALS, SETTING, METHODS

US insurance claims database including women, men and pregnancies within the USA between 2007 and 2016. Paternal preconception health status (e.g. metabolic syndrome diagnoses (MetS), Charlson comorbidity index (CCI) and individual chronic disease diagnoses) was examined in relation to pregnancy loss (e.g. ectopic pregnancy, miscarriage and stillbirth).

MAIN RESULTS AND THE ROLE OF CHANCE

In all, 958 804 pregnancies were analyzed. The average paternal age was 35.3 years (SD 5.3) and maternal age was 33.1 years (SD 4.4). Twenty-two percent of all pregnancies ended in a loss. After adjusting for maternal factors, the risk of pregnancy loss increased with increasing paternal comorbidity. For example, compared to men with no components of MetS, the risk of pregnancy loss increased for men with one (relative risk (RR) 1.10, 95% CI 1.09-1.12), two (RR 1.15, 95% CI 1.13-1.17) or three or more (RR 1.19, 95% CI 1.14-1.24) components. Specifically, less healthy men had a higher risk of siring a pregnancy ending in spontaneous abortion, stillbirth and ectopic pregnancies. Similar patterns remained with other measures of paternal health (e.g. CCI, chronic diseases, etc.). When stratifying by maternal age as well as maternal health, a similar pattern of increasing pregnancy loss risk for men with 1, 2 or 3+ MetS was observed. A statistically significant but weak association between timing of pregnancy loss and paternal health was found.

LIMITATIONS, REASONS FOR CAUTION

Retrospective study design covering only employer insured individuals may limit generalizability.

WIDER IMPLICATIONS OF THE FINDINGS

Optimization of a father's health may improve pregnancy outcomes.

STUDY FUNDING/COMPETING INTERESTS

National Institutes of Health National Center for Advancing Translational Science Clinical and Translational Science Award (UL1 TR001085). M.L.E. is an advisor for Sandstone Diagnostics, Dadi, Hannah and Underdog. No other competing interests were declared.

TRIAL REGISTRATION NUMBER

N/A.

Reproductive sequelae of parental severe illness before the pandemic: implications for the COVID-19 pandemic

OBJECTIVE

To investigate, with pre-COVID-19 data, whether parental exposure to severe systemic infections near the time of conception is associated with pregnancy outcomes.

DESIGN

Retrospective cohort study.

SETTING

Population-based study covering births within the United States from 2009 to 2016.

PARTICIPANTS

The IBM MarketScan Research database covers reimbursed health care claims data on inpatient and outpatient encounters that are privately insured through employment-sponsored health insurance. Our analytic sample included pregnancies to paired fathers and mothers.

INTERVENTIONS(S)

Parental preconception exposure (0-6 months before conception) to severe systemic infection (e.g., sepsis, hypotension, respiratory failure, critical care evaluation).

MAIN OUTCOME MEASURE(S)

Preterm birth (i.e., live birth before 37 weeks) and pregnancy loss.

RESULT(S)

A total of 999,866 pregnancies were recorded with 214,057 pregnancy losses (21.4%) and 51,759 preterm births (5.2%). Mothers receiving intensive care in the preconception period had increased risk of pregnancy loss, as did fathers. Mothers with preconception sepsis had higher risk of preterm birth and pregnancy loss, and paternal sepsis exposure was associated with an increased risk of pregnancy loss. Similar results were noted for hypotension. In addition, a dose response was observed for both mothers and fathers between preconception time in intensive care and the risk of preterm birth and pregnancy loss.

CONCLUSION(S)

In a pre-COVID-19 cohort, parental preconception severe systemic infection was associated with increased odds of preterm birth and pregnancy loss when conception was soon after the illness.