Placental Complications Associated With Psychostimulant Use in Pregnancy

Attention-deficit/hyperactivity disorder in pregnancy and the postpartum period

Attention-deficit/hyperactivity disorder is a childhood-onset neurodevelopmental disorder that frequently persists into adulthood with 3% of adult women having a diagnosis of attention-deficit/hyperactivity disorder. Many women are diagnosed and treated during their reproductive years, which leads to management implications during pregnancy and the postpartum period. We know from clinical practice that attention-deficit/hyperactivity disorder symptoms frequently become challenging to manage during the perinatal period and require additional support and attention. There is often uncertainty among healthcare providers about the management of attention-deficit/hyperactivity disorder in the perinatal period, particularly the safety of pharmacotherapy for the developing fetus. This guideline is focused on best practices in managing attention-deficit/hyperactivity disorder in the perinatal period. We recommend (1) mitigating the risks associated with attention-deficit/hyperactivity disorder that worsen during the perinatal period via individualized treatment planning; (2) providing psychoeducation, self-management strategies or coaching, and psychotherapies; and, for those with moderate or severe attention-deficit/hyperactivity disorder, (3) considering pharmacotherapy for attention-deficit/hyperactivity disorder, which largely has reassuring safety data. Specifically, providers should work collaboratively with patients and their support networks to balance the risks of perinatal attention-deficit/hyperactivity disorder medication with the risks of inadequately treated attention-deficit/hyperactivity disorder during pregnancy. The risks and impacts of attention-deficit/hyperactivity disorder in pregnancy can be successfully managed through preconception counselling and appropriate perinatal planning, management, and support.

Investigating maternal and neonatal health outcomes associated with continuing or ceasing dexamphetamine treatment for women with attention-deficit hyperactivity disorder during pregnancy: a retrospective cohort study

PURPOSE

Attention-deficit hyperactivity disorder (ADHD) is becoming more commonly diagnosed in women, consequently, more women of reproductive age are taking ADHD medication, such as dexamphetamine. However, the safety associated with continuing or ceasing dexamphetamine during pregnancy is unclear. This study investigates outcomes associated with the continuation of dexamphetamine during pregnancy compared to those who ceased or were unexposed.

METHODS

A population-based retrospective cohort of women from Western Australia who had been dispensed dexamphetamine during pregnancy and gave birth between 2003 and 2018. Women had either continued to take dexamphetamine throughout pregnancy (continuers, n = 547) or ceased dexamphetamine before the end of the second trimester (ceasers, n = 297). Additionally, a matched (1:1) comparison group of women who were dispensed an ADHD medication prior to pregnancy but not during pregnancy (unexposed) was included in the study (n = 844). Multivariable generalised linear models were used to compare maternal and neonatal health outcomes.

RESULTS

Compared to continuers, ceasers had greater odds of threatened abortion (OR: 2.28; 95%CI: 1.00, 5.15; p = 0.049). The unexposed had some benefits compared to the continuers, which included lower risk of preeclampsia (OR: 0.58; 95%CI: 0.35, 0.97; p = 0.037), hypertension (OR: 0.32; 95%CI: 0.11, 0.93; p = 0.036), postpartum haemorrhage (OR: 0.57; 95%CI: 0.41, 0.80; p = 0.001), neonatal special care unit admittance (OR: 0.16; 95%CI: 0.12, 0.20; p < 0.001) and fetal distress (OR: 0.73; 95%CI: 0.54, 0.99; p = 0.042).

CONCLUSION

Continuing dexamphetamine throughout pregnancy was not associated with an increase in adverse neonatal and maternal health outcomes compared to ceasing. Ceasing dexamphetamine during pregnancy was associated with increased odds of threatened abortion compared with continuing dexamphetamine. However, this is something that requires further investigation due to the small sample size, difficulties examining timing, and the inability to examine spontaneous abortions. The unexposed showed some benefits compared to the continuers, suggesting that where possible the cessation of dexamphetamine prior to pregnancy may be advisable.

The State of Use and Utility of Negative Controls in Pharmacoepidemiologic Studies

Uses of real-world data in drug safety and effectiveness studies are often challenged by various sources of bias. We undertook a systematic search of the published literature through September 2020 to evaluate the state of use and utility of negative controls to address bias in pharmacoepidemiologic studies. Two reviewers independently evaluated study eligibility and abstracted data. Our search identified 184 eligible studies for inclusion. Cohort studies (115, 63%) and administrative data (114, 62%) were, respectively, the most common study design and data type used. Most studies used negative control outcomes (91, 50%), and for most studies the target source of bias was unmeasured confounding (93, 51%). We identified 4 utility domains of negative controls: 1) bias detection (149, 81%), 2) bias correction (16, 9%), 3) P-value calibration (8, 4%), and 4) performance assessment of different methods used in drug safety studies (31, 17%). The most popular methodologies used were the 95% confidence interval and P-value calibration. In addition, we identified 2 reference sets with structured steps to check the causality assumption of the negative control. While negative controls are powerful tools in bias detection, we found many studies lacked checking the underlying assumptions. This article is part of a Special Collection on Pharmacoepidemiology.

Trajectories of ADHD medication use before, during, and after pregnancy: A population-based study from Norway and Sweden

PURPOSE

To describe ADHD medication use trajectories around pregnancy in Norway and Sweden.

METHODS

We identified pregnancies resulting in births using linked data from birth and prescribed drug registers of Norway (2006-2019, N = 813 107) and Sweden (2007-2018, N = 1 269 146). We restricted to women who filled prescriptions for ADHD medication during pregnancy or in the year before or after. We described exposure as use versus no use, and total amount of drug dispensed in defined daily doses (DDDs). Group-based trajectory modeling was used to identify distinct medication use trajectories.

RESULTS

In total, 13 286 women (0.64%) filled a prescription for ADHD medication. We identified four trajectory groups: continuers (5.7%), interrupters (23.8%), discontinuers (49.5%), and late initiators (21.0%). Discontinuers were younger, continuers were older on average. More women continued medication in recent years (2014-2019). Most discontinuers (60.7%) were nulliparous; more initiators and continuers had one or multiple previous births, respectively. Continuers were least likely to live with a partner (65.8%). Discontinuers were least likely (24.7%) and continuers most likely (37.6%) to smoke at the beginning of pregnancy. More continuers used amphetamine derivatives and were most likely to use other psychotropics. On modeling continuers, we identified three dose-trajectory groups which suggested that most women reduced medication dose during pregnancy.

CONCLUSIONS

Most pregnant women discontinued or interrupted their ADHD medication during pregnancy, but more continued in recent years. Continuers were more likely to have had previous births, less likely to have lived with a partner, and may have had additional comorbidities warranting the use of other psychotropics.

Perioperative Considerations for Patients Exposed to Psychostimulants

Concerns regarding the perioperative management of acute psychostimulant intoxication have been recognized for decades, but novel and diverse substances in this class continue to be developed. Despite the similarities in mechanisms of action among psychostimulants, each subclass within this broad category has unique receptor specificity and different mechanisms that play a role in patient clinical presentation. These issues present challenges to anesthesia providers when caring for patients with either acute or chronic exposure to psychostimulants during the perioperative period. Challenges result from both physiological and psychological effects that influence the action of the primary anesthetic agent, adjuvant anesthetics, and analgesics used for perioperative management of pain. The epidemiology, pharmacology, and perioperative implications of psychostimulant use are presented for amphetamines and similar acting nonamphetamines, cocaine, and, finally, the mixed-action drugs known as entactogens that share stimulant and psychedelic properties. This information is then used as the foundation for safe and effective perioperative management of patients exposed to psychostimulants.

Risk of Major Malformations in Infants After First-Trimester Exposure to Stimulants: Results From the Massachusetts General Hospital National Pregnancy Registry for Psychiatric Medications

PURPOSE/BACKGROUND

The prevalence of attention-deficit/hyperactivity disorder in adult females is 3% to 4%. Attention-deficit/hyperactivity disorder is highly comorbid with other psychiatric disorders such as mood, anxiety, and substance use disorders. For reproductive-aged women, the treatment of attention-deficit/hyperactivity disorder with stimulant medications may be considered during pregnancy or breastfeeding, although historically, data are lacking to inform these decisions. The aim of this investigation was to determine the risk of major malformations in infants after first-trimester prescription stimulant exposure in a small but rigorously characterized sample.

METHODS/PROCEDURES

The Massachusetts General Hospital National Pregnancy Registry for Psychiatric Medications systematically ascertains information from pregnant females including demographic information, medical and psychiatric history, use of prescription medications, and other information relevant to fetal outcomes. Participants provide verbal informed consent and are interviewed twice during gestation and again at approximately 3 months postpartum. The primary outcome of interest is the presence of a major malformation identified within 6 months after birth. Redacted cases of major malformations are reviewed by a dysmorphologist blinded to medication exposure.

FINDINGS/RESULTS

A total of N = 1988 women were eligible for this analysis, including the following exposures: n = 173 to mixed amphetamine salts; n = 40 to lisdexamfetamine; n = 45 to methylphenidate; n = 3 to dexmethylphenidate; and n = 1755 controls. The odds ratio of a major malformation among infants after first-trimester exposure to any stimulant was 0.39 (95% confidence interval, 0.09-1.61) compared with controls. There were no major malformations observed in infants exposed to lisdexamfetamine, methylphenidate, or dexmethylphenidate.

IMPLICATIONS/CONCLUSIONS

Although preliminary, this analysis from an ongoing pregnancy registry provides reassurance that these stimulants do not appear to have major teratogenic effects.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01246765.

In utero exposure to ADHD medication and long-term offspring outcomes

Attention Deficit Hyperactivity Disorder (ADHD) medication is increasingly being used during pregnancy. Concerns have been raised as to whether ADHD medication has long-term adverse effects on the offspring. The authors investigated whether in utero exposure to ADHD medication was associated with adverse long-term neurodevelopmental and growth outcomes in offspring. The population-based cohort study in the Danish national registers included 1,068,073 liveborn singletons from 1998 to 2015 followed until any developmental diagnosis, death, emigration, or December 31, 2018. Children of mothers who continued ADHD medication (methylphenidate, amphetamine, dexamphetamine, lisdexamphetamine, modafinil, atomoxetine, clonidine) during pregnancy and children of mothers who discontinued ADHD medication before pregnancy were compared using Cox regression. Main outcomes were neurodevelopmental psychiatric disorders, impairments in vision or hearing, epilepsy, seizures, or growth impairment during childhood or adolescence. In total, 898 children were exposed to ADHD medication during pregnancy compared to 1270 children whose mothers discontinued ADHD medication before pregnancy. After adjustment for demographic and psychiatric characteristics of the mother, no increased risk of any offspring developmental disorders was found combined (aHR 0.97, 95% CI 0.81 to 1.17) or for separate subcategories. Similarly, no increased risk was found for any sub-categories of outcomes in the negative control or sibling controlled analyses. Neurodevelopment and growth in offspring do not differ based on antenatal exposure to ADHD medication. These findings provide reassurance for women with ADHD who depend on ADHD medication for daily functioning and who consider continuing medication in pregnancy.

The association between psychostimulant use in pregnancy and adverse maternal and neonatal outcomes: results from a distributed analysis in two similar jurisdictions

BACKGROUND

Conflicting evidence suggests a possible association between use of prescribed psychostimulants during pregnancy and adverse perinatal outcomes.

METHODS

We conducted population-based cohort studies including pregnancies conceived between April 2002 and March 2017 (Ontario, Canada; N = 554 272) and January 2003 to April 2011 [New South Wales (NSW), Australia; N = 139 229]. We evaluated the association between exposure to prescription amphetamine, methylphenidate, dextroamphetamine or lisdexamfetamine during pregnancy and pre-eclampsia, placental abruption, preterm birth, low birthweight, small for gestational age and neonatal intensive care unit admission. We used inverse probability of treatment weighting based on propensity scores to balance measured confounders between exposed and unexposed pregnancies. Additionally, we restricted the Ontario cohort to social security beneficiaries where supplementary confounder information was available.

RESULTS

In Ontario and NSW respectively, 1360 (0.25%) and 146 (0.10%) pregnancies were exposed to psychostimulants. Crude analyses indicated associations between exposure and nearly all outcomes [OR range 1.15-2.16 (Ontario); 0.97-2.20 (NSW)]. Nearly all associations were attenuated after weighting. Pre-eclampsia was the exception: odds remained elevated in the weighted analysis of the Ontario cohort (OR 2.02, 95% CI 1.42-2.88), although some attenuation occurred in NSW (weighted OR 1.50, 95% CI 0.77-2.94) and upon restriction to social security beneficiaries (weighted OR 1.24, 95% CI 0.64-2.40), and confidence intervals were wide.

CONCLUSIONS

We observed higher rates of outcomes among exposed pregnancies, but the attenuation of associations after adjustment and likelihood of residual confounding suggests psychostimulant exposure is not a major causal factor for most measured outcomes. Our findings for pre-eclampsia were inconclusive; exposed pregnancies may benefit from closer monitoring.

Prevalence trends and individual patterns of ADHD medication use in pregnancy in Norway and Sweden, 2010-2019

PURPOSE

This study aimed to describe recent trends in ADHD medication use in pregnancy in Norway and Sweden, including prevalence, individual characteristics, and patterns of use.

METHODS

We studied ADHD medication use (amphetamine, dexamphetamine, methylphenidate, atomoxetine, lisdexamfetamine, guanfacine) by year and age in pregnancies from 2010 to 2019 identified from the medical birth registers (gestational age ≥ 22 weeks) linked to prescribed drug registers (Norway, N = 577,116; Sweden, N = 1,118,988). We compared characteristics of those who used any ADHD medication in pregnancy to no use in pregnancy. Discontinuation was defined as no use after first trimester.

RESULTS

ADHD medication use increased from 2010 to 2019 by 3.0 users per 1000 pregnancies in Norway (from 2.5 to 5.5/1000) and by 6.3 per 1000 in Sweden (from 1.6 to 7.9/1000), mainly driven by methylphenidate and since 2015 by lisdexamfetamine. Medication use has increased among pregnant individuals of all age groups, with higher use among the youngest. Pregnant individuals who used ADHD medication were less likely to be married/cohabiting, more likely be nulliparous and to smoke. They had particularly high use of co-medication with antidepressants, anxiolytics/hypnotics, and opioids: 42% in Norway and 65% in Sweden used at least one additional class of psychotropic medication. Most individuals discontinued ADHD medication in pregnancy (85% Norway, 78% Sweden).

CONCLUSION

ADHD medication use during pregnancy increased in Norway and Sweden in the last decade. However, discontinuation rates during pregnancy were high. Those who used ADHD medication had more risk factors for pregnancy complications including low parity, smoking, and other psychotropic drug use.

Substance Exposure and Adverse Neonatal Outcomes: A Population-Based Cohort Study

OBJECTIVE

To estimate the independent and combined effects of in utero exposures on birth outcomes in a rural population.

STUDY DESIGN

The study used population-level data (2020-2022) from a state-wide surveillance tool (Working in Appalachia to identify at-risk infants, Critical congenital heart disease, and Hearing loss) in West Virginia. Outcomes included low birth weight, preterm birth, small for gestational age, and birth weight in grams. Exposure included a composite variable with 8 levels of 3 exposure (opioids, stimulants, and cannabis) categories. Analyses were adjusted for sociodemographic covariates using multiple logistic and linear regression analyses.

RESULTS

Of the 34 412 singleton live births, 1 in 8 newborns (12.2%) had in utero exposure(s) to opioids, stimulants, and/or cannabis, 11.5% were preterm, 7.9% had low birthweight, 9.6% were small for gestational age, and mean birth weight was 3249 ± 563.6 g. Preterm birth was associated with stimulant alone exposure (aOR, 1.40; 95% CI, 1.03-1.89) and stimulant and cannabis concurrent exposure (aOR, 1.69; 95% CI, 1.16, 2.47). Low birthweight was associated with opioids alone (aOR, 1.34; 95% CI, 1.10, 1.63), cannabis alone (aOR, 1.31; 95% CI, 1.13 to -1.52), opioid and cannabis (aOR, 1.61; 95% CI, 1.12 to -2.31), and opioids, stimulants, and cannabis concurrent exposures (aOR, 2.27; 95% CI, 1.43-3.61). Five exposure categories were associated with lower birth weights (adjusted mean difference range. -72 to -211 g). Small for gestational age was associated with opioids alone (aOR, 1.48; 95% CI, 1.24-1.78), cannabis alone (aOR, 1.49; 95% CI, 1.31-1.69), and opioids and cannabis concurrent exposures (aOR, 1.91; 95% CI, 1.36-2.67).

CONCLUSIONS

We showed complex associations between in utero substance exposures, preterm birth, birth weight, and sociodemographic factors in a rural population. The results may inform policy efforts to improve maternal and child health in socioeconomically disadvantaged and underserved rural populations.

A Bayesian latent class model for predicting gestational age in health administrative data

Health administrative data are oftentimes of limited use in epidemiological study on drug safety in pregnancy, due to lacking information on gestational age at birth (GAB). Although several studies have proposed algorithms to estimate GAB using claims database, failing to incorporate the unique distributional shape of GAB, can introduce bias in estimates and subsequent modeling. Hence, we develop a Bayesian latent class model to predict GAB. The model employs a mixture of Gaussian distributions with linear covariates within each class. This approach allows modeling heterogeneity in the population by identifying latent subgroups and estimating class-specific regression coefficients. We fit this model in a Bayesian framework conducting posterior computation with Markov Chain Monte Carlo methods. The method is illustrated with a dataset of 10,043 Rhode Island Medicaid mother-child pairs. We found that the three-class and six-class mixture specifications maximized prediction accuracy. Based on our results, Medicaid women were partitioned into three classes, featured by extreme preterm or preterm birth, preterm or" early" term birth, and" late" term birth. Obstetrical complications appeared to pose a significant influence on class-membership. Altogether, compared to traditional linear models our approach shows an advantage in predictive accuracy, because of superior flexibility in modeling a skewed response and population heterogeneity.

Maternal ADHD and Perinatal Prescription Stimulant Use

OBJECTIVE

To describe patterns and predictors of perinatal prescription stimulant use.

METHODS

We used MarketScan^® commercial claims data (2013-2018) and a repeated cross-sectional study design to assess perinatal use of prescription stimulants. Clinical/demographic characteristics were compared across cohorts of women who continued versus discontinued stimulant treatment at various stages of pregnancy. Associations were tested for significance using chi-square tests (categorical variables) and independent t-tests (continuous variables).

RESULTS

Out of 612,001 pregnancies, 15,413 involved pre-pregnancy stimulant use. Of these, stimulant treatment was discontinued prior to conception in 6,416 (42%), discontinued during trimester 1 in 5,977 (39%), and continued into later trimesters in 3,020 (19%). Compared with pregnancies involving stimulant discontinuation prior to conception, those that continued into pregnancy occurred in women who were older (29.9 vs. 28.9 years) and had more severe ADHD (3.1 vs. 1.8 ADHD-related billing claims).

CONCLUSIONS

There is considerable heterogeneity in the management of ADHD during pregnancy.

Characteristics of Prescription Opioid Analgesics in Pregnancy and Risk of Neonatal Opioid Withdrawal Syndrome in Newborns

IMPORTANCE

Prescription opioids are often used during pregnancy even though they are associated with neonatal opioid withdrawal syndrome (NOWS). Most studies of adverse outcomes of opioid use for pain have assessed only the class-wide outcome despite the pharmacodynamic and pharmacokinetic heterogeneity across opioid medications.

OBJECTIVE

To compare the risk of NOWS across common types of opioids when prescribed as monotherapy during the last 3 months of pregnancy.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed administrative claims data of Medicaid-insured mothers and newborns in 46 states and Washington DC from January 1, 2000, through December 31, 2014. Participants were mothers with 2 or more dispensed opioid prescriptions within 90 days before delivery and their eligible live-born neonates. Data were analyzed from February 2020 to March 2021.

EXPOSURE

Different types of opioid medications were compared by agonist strength (strong vs weak) and half-life (medium vs short and long vs short) of the opioid active ingredient.

MAIN OUTCOMES AND MEASURES

The primary outcome was NOWS, which was identified using an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code in the 30 days after delivery. Relative risks (RRs) were adjusted for an exposure propensity score, including demographic characteristics, comorbidities, other medication use, and opioid treatment characteristics (including morphine milligram equivalents), using fine stratification.

RESULTS

The cohort comprised 48 202 opioid-exposed pregnancies with live newborns. A total of 1069 neonates (2.2%) had NOWS and 559 (1.2%) had severe NOWS. Opioid exposure during pregnancy included 16 202 pregnancies exposed to codeine, 4540 to oxycodone, 1244 to tramadol, 260 to methadone (dispensed for pain), 90 to hydromorphone, and 63 to morphine compared with 25 710 exposed to hydrocodone. Demographic characteristics varied across opioids, with tramadol, oxycodone, methadone, hydromorphone, and morphine being more commonly dispensed at older maternal age (≥35 years). Compared with hydrocodone, codeine had a lower adjusted RR of NOWS (0.57; 95% CI, 0.46-0.70), with a similar adjusted RR for tramadol (RR, 1.06; 95% CI, 0.73-1.56), and 2- to 3-fold higher adjusted RRs for oxycodone (1.87; 95% CI, 1.66-2.11), morphine (2.84; 95% CI, 1.30-6.22), methadone (3.02; 95% CI, 2.45-3.73), and hydromorphone (2.03; 95% CI, 1.09-3.78). Strong agonists were associated with a higher risk of NOWS than weak agonists (RR, 1.97; 95% CI, 1.78-2.17), and long half-life opioids were associated with an increased risk compared with short half-life products (RR, 1.33; 95% CI, 1.12-1.56). Findings were consistent across sensitivity and subgroup analyses.

CONCLUSIONS AND RELEVANCE

Results of this study show higher risk of NOWS and severe NOWS among neonates with in utero exposure to strong agonists and long half-life prescription opioids. Information on the opioid-specific risk of NOWS may help prescribers select opioids for pain management in late stages of pregnancy.

Epidemiology, Risk Factors, and Perinatal Outcomes of Placental Abruption-Detailed Annual Data and Clinical Perspectives from Polish Tertiary Center

Placental abruption (PA) is a separation of the placenta from the uterine wall occurring with the fetus still present in the uterine cavity. It contributes to numerous neonatal and maternal complications, increasing morbidity and mortality. We conducted a retrospective study at a tertiary perinatal care center, which included 2210 cases of labor that took place in 2015 with a PA occurrence of 0.7%. No maternal or fetal death during delivery was reported in this period. The identified PA risk factors were uterine malformations, pPROM, placenta previa spectrum, and oligohydramnios. The significant maternal PA complications identified were maternal anemia, uterine rupture, and HELLP syndrome. Preterm delivery occurred significantly more often in the PA group, and the number of weeks of pregnancy and the birth weight at delivery were both significantly lower in the PA group. PA is a relatively rare perinatal complication with very serious consequences, and it still lacks effective prophylaxis and treatment. Despite its rare occurrence, each center should develop a certain strategy for dealing with this pathology or predicting which patients are at risk. Much work is still needed to ensure the proper care of the mother and the baby in this life-threatening condition.

Ischemic Placental Disease, Preterm Delivery, and Their Association With Opioid Use During Pregnancy

Opioids affect placental development and function in animal models, but human data on their association with ischemic placental disease are limited. Using a cohort of pregnant women in the US nationwide Medicaid Analytic eXtract (2000-2014), we compared women with ≥2 opioid dispensings in pregnancy with unexposed women. Given an uncertain etiologically relevant window, we assessed exposure occurring in early pregnancy, late and not early pregnancy, and both early and late pregnancy. For placental abruption, preterm delivery, small for gestational age (SGA), and preeclampsia, we estimated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) using Cox proportional hazard models adjusting for demographic factors, indications/comorbidities, and medications. Among 1,833,871 eligible pregnancies, ≥2 opioid dispensings were filled in 6.5%. We observed an early exposure aHR of 1.34 (95% CI: 1.26, 1.43) for placental abruption, 1.21 (95% CI: 1.18, 1.23) for preterm delivery, 1.13 (95% CI: 1.09, 1.17) for SGA, and 0.95 (0.91, 0.98) for preeclampsia. Estimates for late exposure were attenuated. Early and late exposure was associated with higher aHRs for placental abruption, 1.62 (95% CI: 1.47, 1.78); preterm delivery, 1.37 (95% CI: 1.33, 1.42); and SGA, 1.26 (95% CI: 1.19, 1.33); but not preeclampsia, 0.99 (95% CI: 0.93, 1.05). Prescription opioids may modestly increase risk of placental abruption, preterm birth and SGA, but they do not appear to be associated with preeclampsia.

Fifteen years' experience with methylphenidate for attention-deficit disorder during pregnancy: Effects on birth weight, Apgar score and congenital malformation rates

BACKGROUND

Methylphenidate (MPD) is increasingly prescribed to fertile women with Attention-Deficit Disorder (AD(H)D), with or without hyperactivity, despite advice for discontinuation during pregnancy. Few studies report on results concerning safety after methylphenidate exposure during pregnancy for the offspring.

AIM

Safety for the offspring of exposure to MPD during pregnancy.

METHODS

This is an observational retrospective cohort study in a population of pregnant women and their offspring, treated with MPD for ADHD in the Psychiatry-Gynaecology-Pediatrics outpatient clinic between 1 January 2005 and 1 June 2020 at Isala hospital. The primary endpoints were birth weight and Apgar score in offspring exposed to MPD during pregnancy, compared to offspring unexposed to MPD. Birth weight was analysed using linear mixed model analysis. Apgar score and (secondary endpoint) neonatal malformations, at 20 week ultrasound, were analysed using basic univariate statistical analysis.

RESULTS

MPD continuation, compared to discontinuation, was associated with higher neonatal birth weight (p = 0.049), but lost statistical significance after incorporating covariates (p = 0.079). There were no significant differences in Apgar scores and congenital malformations between neonates exposed and unexposed to MPD.

CONCLUSIONS

MPD does not seem to affect birth weight, Apgar score and the frequency of neonatal malformations at the 20 week ultrasound.

Amphetamine-Dextroamphetamine and Pregnancy: Neonatal Outcomes After Prenatal Prescription Mixed Amphetamine Exposure

Objective: A retrospective cohort study was performed to evaluate whether birthweight was less among infants of women taking amphetamine-dextroamphetamine during pregnancy at our academic institution. Method: We identified mother-infant pairs with documented exposure to amphetamine-dextroamphetamine in pregnancy from 2005 through 2015. Patients were matched 2:1 with unexposed controls. Charts were reviewed for known causes of intrauterine growth restriction. Analysis of birthweight used generalized estimating equation blocking on matching. Medical histories were analyzed with χ² test or Fisher's exact test. Results: We identified 53 exposed mother-infant pairs. The difference in mean birthweight of infants exposed to amphetamine-dextroamphetamine versus those not exposed was 26.9 g, which is not significant (95% confidence interval [CI] = [-141, 195 g]; p = .75). A significant difference was noted for exposed versus unexposed mothers for comorbid psychiatric illness and history of substance abuse (p < .001). Conclusion: With a limited sample size, our study suggests no significant difference in birthweight.

Bipolar disorder: Treatment strategies for women of childbearing age

PURPOSE

Bipolar disorder is associated with increased rates of morbidity and mortality, magnified in women of childbearing age. The purpose of this paper is to provide an overview of the differential diagnosis and management of bipolar disorder in women of childbearing age.

CONCLUSIONS

Differential diagnoses for bipolar disorder include depressive disorders, anxiety disorders, trauma-related disorders, attention-deficit/hyperactivity disorder, and personality disorders. Pharmacotherapeutic options for the treatment of bipolar disorder include lithium, anti-epileptic medications, and atypical antipsychotics. In regard to women of childbearing age, consideration of risks, benefits, and alternative therapies is needed before initiating therapy.

PRACTICE IMPLICATIONS

Caring for patients with bipolar disorder, particularly women of childbearing age, requires careful differentiation of bipolar disorder from other mental health problems, and prudent consideration of pharmacotherapeutic options.

The application of harm reduction to methamphetamine use during pregnancy: a call to arms

Compared with opioid use disorder, methamphetamine use is a public health crisis that has limited evidence-based pharmacologic interventions for long-term treatment. The prevalence of methamphetamine use during pregnancy is growing and contributes to adverse maternal and neonatal outcomes. Because of widespread stigma and social complexities associated with methamphetamine use during pregnancy, these patients often experience limited prenatal care, further contributing to poor outcomes. In public health circles, harm reduction describes a framework for conceptualizing substance use by championing health promotion and the safest use of substances, as opposed to the unachievable goal of abstinence. There is limited evidence supporting the application of harm reduction in this population. We call for action and research to investigate how the progressive concept of harm reduction might be applied to mitigate adverse outcomes for obstetrical patients who use methamphetamine.

Prevalence and determinants of attention deficit/hyperactivity disorder (ADHD) medication use during pregnancy: Results from the Quebec Pregnancy/Children Cohort

AIMS

The use of attention deficit/hyperactivity disorder (ADHD) medications has grown over the past decade among pregnant women, but these treatments are not without risk. Updated prevalence of ADHD medication use and whether prescribed dosages follow guidelines are needed. The aim of this study is to describe the prevalence of ADHD medication use among pregnant women-dosages and switches-and identify determinants of ADHD medication use.

METHOD

A population-based longitudinal cohort study within the Quebec Pregnancy/Children Cohort (QPC). Women aged 15-45 years old covered by the RAMQ prescription drug plan for at least 12 months before and during pregnancy from 1998 to 2015. ADHD medication exposure was assessed before and during pregnancy. We estimated odds ratios (ORs) for determinants of ADHD medication use during pregnancy with generalized estimating equations.

RESULTS

Among 428,505 included pregnant women, 1,130 (0.26%) used ADHD medication. A 14-fold increase in the prevalence of ADHD medication use in pregnant women was observed, from 1998 (0.08%) to 2015 (1.2%). Methylphenidate was the most prevalent medication at 70.1%. ADHD medication fillings were at optimal dosage 91.8% of the time based on guidelines and 18.1% of women switched to another ADHD medication class during gestation. Main determinants of ADHD medication use during pregnancy were psychiatric disorders (aOR 2.19; 95% confidence interval [CI] 1.57, 2.96), mood and anxiety disorders (aOR 1.74; 95% CI 1.32, 2.24), and calendar year.

CONCLUSIONS

The number of pregnancies exposed to ADHD medications has increased similarly to the increase reported in other countries between 1998 and 2015. In addition to the current literature, the use of ADHD medications during pregnancy is consistent with Canadian guidelines recommendations on dosage.

Parental ADHD in pregnancy and the postpartum period - A systematic review

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders worldwide, and in the majority of patients persists into adulthood. However, it remains unclear how maternal ADHD could affect pregnancy and birth as well as early mother-(father)-child interaction. There are several studies investigating the effect of depressed or anxious parents on parent-child-interactions in early infancy, but data about the influence of parental ADHD is lacking although it is a common mental disorder in parents. Additionally, the prescription of stimulant and other ADHD medication for adult ADHD patients is rising due to improved diagnostic procedures and a greater awareness of this disorder in adulthood among psychiatrists and psychologists. However, this leads to increased numbers of treated ADHD women that wish to have children or experience unplanned pregnancies while taking stimulant medication. In our systematic review we aimed at analysing the current evidence for the association of maternal ADHD with pregnancy and birth outcomes, pregnancy risks and health behaviour in pregnancy, as well as the association of parental ADHD with early parent-child interaction and early child development in the first 3 years. Furthermore, we reviewed recent evidence on the risks of stimulant and non-stimulant treatment for ADHD in pregnancy and lactation.

Substance use disorders and risk of severe maternal morbidity in the United States

BACKGROUND

The contribution of substance use disorders to the burden of severe maternal morbidity in the United States is poorly understood. The objective was to estimate the independent association between substance use disorders during pregnancy and risk of severe maternal morbidity.

METHODS

Retrospective analysis of a weighted 53.4 million delivery hospitalizations from 2003 to 2016 among females aged>18 in the National Inpatient Sample. We constructed measures of substance use disorders using diagnostic codes for cannabis, opioids, and stimulants (amphetamines or cocaine) abuse or dependence during pregnancy. The outcome was the presence of any of the 21 CDC indicators of severe maternal morbidity. Using weighted multivariable logistic regression, we estimated the association between substance use disorders and adjusted risk of severe maternal morbidity. Because older age at delivery is predictive of severe maternal morbidity, we tested for effect modification between substance use and maternal age by age group (18-34 y vs >34 y).

RESULTS

Pregnant women with an opioid use disorder had an increased risk of severe maternal morbidity compared with women without an opioid use disorder (18-34 years: aOR: 1.51; 95 % CI: 1.41,1.61, >34 years: aOR: 1.17; 95 % CI: 1.00,1.38). Compared with their counterparts without stimulant use disorders, pregnant women with a simulant use disorder (amphetamines, cocaine) had an increased risk of severe maternal morbidity (18-34 years: aOR: 1.92; 95 % CI: 1.80,2.0, >34 years: aOR: 1.85; 95 % CI: 1.66,2.06). Cannabis use disorders were not associated with an increased risk of severe maternal morbidity.

CONCLUSION

Substance use disorders during pregnancy, particularly opioids, amphetamines, and cocaine use disorders, may contribute to severe maternal morbidity in the United States.

Polysubstance Use Among Pregnant Women With Opioid Use Disorder in the United States, 2007-2016

OBJECTIVE

To assess trends in polysubstance use among pregnant women with opioid use disorder in the United States.

METHODS

We conducted a time trend analysis of pooled, cross-sectional data from the National Inpatient Sample, an annual nationally representative sample of U.S. hospital discharge data. Among 38.0 million females aged 15-44 years with a hospitalization for delivery from 2007 to 2016, we identified 172,335 pregnant women with an International Classification of Diseases, Ninth Revision, Clinical Modification or International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis of opioid use disorder. Polysubstance use among pregnant women with opioid use disorder was defined as at least one co-occurring diagnosis of other substance use, including alcohol, amphetamine, cannabis, cocaine, sedative, or tobacco. We fit weighted multivariable logistic regression models to produce nationally representative estimates, including an interaction between year and rural compared with urban county of residence; controlled for age, race, and insurance type. Average predicted probabilities and 95% CIs were derived from regression results.

RESULTS

Polysubstance use among women with opioid use disorder increased from 60.5% (95% CI 58.3-62.8%) to 64.1% (95% CI 62.8%-65.3%). Differential time trends in polysubstance use among women with opioid use disorder were found in rural compared with urban counties. Large increases in amphetamine use occurred among those in both rural and urban counties (255.4%; 95% CI 90.5-562.9% and 150.7%; 95% CI 78.2-52.7%, respectively), similarly to tobacco use (30.4%; 95% CI 16.9-45.4% and 23.2%; 95% CI 15.3-31.6%, respectively). Cocaine use diagnoses declined among women with opioid use disorder at delivery in rural (-70.5%; 95% CI -80.4% to -55.5%) and urban (-61.9%; 95% CI -67.6% to -55.1%) counties. Alcohol use diagnoses among those with opioid use disorder declined -57% (95% CI -70.8% to -37.7%) in urban counties but did not change among those in rural counties.

CONCLUSION

Over the past decade, polysubstance use among pregnant women with opioid use disorder has increased more rapidly in rural compared with urban counties in the United States, with amphetamines and tobacco use increasing most rapidly.

Teratogen update: Amphetamines

Amphetamines are synthetic noncatecholamine sympathomimetic amines that act as psychostimulants. They have been prescribed for the treatment of attention-deficit/hyperactivity disorder (ADHD), narcolepsy, and additional health conditions. Amphetamines are also drugs of abuse. Some experimental animal studies suggested adverse developmental effects of amphetamines, including structural malformations. These effects were most often observed in experimental animals at higher dose levels than those used for treatment or abuse and at dose levels that produce maternal toxicity. Controlled studies of amphetamine use for the treatment of ADHD and other indications did not suggest that amphetamines are likely to cause structural malformations, although there are three studies associating medication for ADHD or methamphetamine abuse with gastroschisis. We did not locate studies on the neurobehavioral effects of prenatal exposures to therapeutic amphetamine use. Amphetamine abuse was associated with offspring neurobehavioral abnormalities, but lack of adequate adjustment for confounding interferes with interpretation of the associations. Adverse effects of methamphetamine abuse during pregnancy may be due to factors associated with drug abuse rather than methamphetamine itself. The adverse effects observed in methamphetamine abuse studies may not be extrapolatable to amphetamine medication use.

Associations of Prescribed ADHD Medication in Pregnancy with Pregnancy-Related and Offspring Outcomes: A Systematic Review

BACKGROUND

Increasing numbers of reproductive-aged women are using attention-deficit/hyperactivity disorder (ADHD) medications. Findings from studies exploring the safety of these medications during pregnancy are mixed, and it is unclear whether associations reflect causal effects or could be partially or fully explained by other factors that differ between exposed and unexposed offspring.

OBJECTIVES

The aim of this systematic review was to evaluate the adverse pregnancy-related and offspring outcomes associated with exposure to prescribed ADHD medication during pregnancy with a focus on how studies to date have handled the influence of confounding.

METHODS

We searched PubMed, Embase, PsycINFO, and Web of Science up to 1 July 2019 without any restrictions on language or date of publication. We included all observational studies (e.g., cohort studies, case-control studies, case-crossover studies, cross-sectional studies, and registry-based studies) with pregnant women of any age or from any setting who were prescribed ADHD medications and evaluated any outcome, including both short- and long-term maternal and offspring outcomes. Two independent authors then used the Newcastle-Ottawa Scale to rate the quality of the included studies.

RESULTS

Eight cohort studies that estimated adverse pregnancy-related and offspring outcomes associated with exposure to ADHD medication during pregnancy were included in the qualitative review. The included studies had substantial methodological differences in data sources, type of medications examined, definitions of studied pregnancy-related and offspring outcomes, types of control groups, and confounding adjustment. There was no convincing evidence for teratogenic effects according to the relative risk of pregnancy-related and offspring outcomes, and the observed differences in absolute risks were overall small in magnitude. Adjustment for confounding was inadequate in most studies, and none of the included studies adjusted for ADHD severity in the mothers.

CONCLUSION

The current evidence does not suggest that the use of ADHD medication during pregnancy results in significant adverse consequences for mother or offspring. However, the data are too limited to make an unequivocal recommendation. Therefore, physicians should consider whether the advantages of using ADHD medication outweigh the potential risks for the developing fetus according to each woman's specific circumstances. Future research should attempt to triangulate research findings based on a combination of different designs that differ in their underlying strengths and limitations and should investigate specific confounding factors, the potential impact of timing of exposure, and potential long-term outcomes in the offspring.

Association of maternal attention deficit hyperactivity disorder and preterm birth: a cohort study

OBJECTIVE

Attention deficit hyperactivity disorder (ADHD) affects 3-7% of women of childbearing age. Whether ADHD is associated with an increased risk of preterm birth is unclear.

DESIGN

National register-based cohort study.

SETTING

Sweden.

POPULATION

Nulliparous women giving birth to singleton infants 2007-2014 (n = 377 381).

METHODS

Women were considered to have ADHD if they had been dispensed at least one prescription for ADHD medication, i.e. a central nervous system stimulant or non-stimulant drugs for ADHD, prior to, during or after pregnancy (2005-2014). Women with ADHD were compared with women without ADHD in regard to prevalence, severity and mode of onset of preterm birth. Logistic regression models were used, estimating adjusted odds ratios (aOR) with 95% confidence intervals (CI). Adjustments were made for maternal age and country of birth (model 1), and in addition for body mass index (BMI), education, alcohol or substance use disorders, and pre-gestational medical and psychiatric co-morbidity (model 2).

MAIN OUTCOME MEASURES

Preterm birth (<37 weeks).

RESULTS

During the study period, 6327 (1.7%) women gave birth and had ADHD according to our definition. These women had a higher rate of preterm birth compared with women without ADHD (7.3 versus 5.8%, aOR model 2: 1.17; 95% CI 1.05-1.30). ADHD was particularly associated with very (<32 weeks) preterm births, and associations were seen with both spontaneous and medically indicated onsets.

CONCLUSIONS

Women with ADHD (i.e. who had been dispensed ADHD medication at any time in 2005-2014) had an increased risk of preterm birth.

TWEETABLE ABSTRACT

Women with ADHD have a higher risk of preterm birth but most of it is due to modifiable risk factors.

Maternal use of drugs and preeclampsia

AIMS

The aim was to compare and describe maternal use of drugs between women with preeclampsia and controls and to estimate the possible association with preeclampsia.

METHODS

The study cohort was collected from the Kuopio University Hospital Birth Register, which includes information about all women who gave birth in Kuopio University Hospital during the years 2002-2016, including information from approximately 36 000 parturients, of whom 1252 had preeclampsia. Maternal use of 16 groups of drugs during pregnancy was analysed from all women with preeclampsia and 1256 controls.

RESULTS

Every second woman had used at least 1 drug during pregnancy but those with preeclampsia had used significantly more than the controls (cases 59.5% vs controls 35.5%; p < 0.001). In both study groups, the most commonly used drugs were antibiotics (cases 19.5%, controls 17.0%), antihypertensives (cases 29.0%, controls 7.6%) and paracetamol (cases 13.1%, controls 5.9%). Women with preeclampsia had used significantly more benzodiazepines, paracetamol, antihypertensives and acid-suppressive drugs than the women in the control group (p < 0.05).

CONCLUSIONS

Women with preeclampsia were more likely to use medicines during pregnancy. While the association between benzodiazepines, antihypertensives and acid-suppressive drugs and preeclampsia may be explained by reverse causation, the association of paracetamol with preeclampsia remains to be clarified. Because paracetamol is a frequently used drug, more information about its safety during pregnancy including its role in preeclampsia is urgently needed.

Sleep Pharmacotherapy for Common Sleep Disorders in Pregnancy and Lactation

Sleep disturbances are common in pregnancy, and sleep disorders may worsen or present de novo in the course of gestation. Managing a pregnant patient is complicated by the risk of teratogenicity, pharmacokinetic changes, and the dynamic nature of pregnancy. Although nonpharmacologic interventions are likely safest, they are often ineffective, and a patient is left dealing with frustrations of the sleep disturbance, as well as the negative outcomes of poor sleep in pregnancy. As with any other condition in pregnancy, management requires an understanding of pregnancy physiology, knowledge of the impact of a given condition on pregnancy or fetal and neonatal outcomes, and an ability to weigh the risk of the exposure to an untreated, or poorly treated condition, against the risk of a given drug. In partnership with the pregnant patient or couple, options for therapy should be reviewed in the context of the impact of the condition on pregnancy and offspring outcomes, while understanding that data (positive or negative) on the impact of therapy on perinatal outcomes are lacking. This article reviews the epidemiology of sleep disorders in pregnancy, general principles of prescribing in pregnancy and lactation, and safety surrounding therapeutic options in pregnancy.

Use of real-world evidence from healthcare utilization data to evaluate drug safety during pregnancy

PURPOSE

Because preapproval clinical trials typically exclude pregnant women, the evidence on drug safety during pregnancy required to inform drug labeling must come from postapproval controlled observational studies. Common designs have included pregnancy registries and case-control studies. Recently, pregnancy cohorts nested within healthcare utilization databases are increasingly being used. Despite clear advantages, these databases share some important limitations that may threaten the validity of studies emerging from them.

METHODS

This paper describes the distinctive methodological aspects of conducting drug safety studies in healthcare utilization databases with special emphasis on design and analytic approaches to minimize biases.

RESULTS

We describe considerations for study design, cohort definition, and follow-up. We then address issues related to exposure ascertainment based on prescription fills, including the importance of the etiologically relevant window and of properly accounting for preterm births. This is followed by a discussion of advantages and challenges when ascertaining maternal and infant outcomes based on secondary data. We then explore useful approaches to address confounding within the context of pregnancy research and of the potential for selection bias when restricting the cohort to live births. Finally, we consider issues related to external validity and statistical significance. The examples are mainly drawn from a pregnancy cohort nested in the Medicaid Analytic Extract.

CONCLUSIONS

The approaches presented provide guidance regarding the important methodological considerations that need to be attended to in order to generate valid, minimally biased risk when using large healthcare utilization databases for drug safety surveillance in pregnancy.

Stimulant Use in Pregnancy: An Under-recognized Epidemic Among Pregnant Women

Stimulant use, including cocaine, methamphetamines, ecstasy, and prescription stimulants, in pregnancy is increasingly common. In the United States, stimulants are the second most widely used and abused substances during pregnancy and pregnant women using stimulants in pregnancy are at increased risk of adverse perinatal, neonatal, and childhood outcomes. In this review, we describe the pharmacology, pathophysiology, and epidemiology of stimulants, summarize the maternal and neonatal effects of perinatal stimulant use, and outline treatment options for stimulant use disorders among pregnant women. Development of effective treatment strategies for stimulant use disorders identified among pregnant women are urgently needed.

Maternal and neonatal outcomes after exposure to ADHD medication during pregnancy: A systematic review and meta-analysis

PURPOSE

Attention-deficit/hyperactivity disorder (ADHD) medications are used by increasing numbers of reproductive-age women. The safety of these medications during pregnancy has not been well described.

METHODS

A systematic review and meta-analysis was performed to evaluate the adverse maternal and neonatal outcomes associated with exposure to ADHD medication during pregnancy. The PubMed and Embase databases were searched to identify potential studies for inclusion.

RESULTS

Eight cohort studies that estimated adverse maternal or neonatal outcomes associated with exposure to ADHD medication during pregnancy were included. Exposure to ADHD medication was associated with an increased risk of neonatal intensive care unit (NICU) admission compared with no exposure at any time (risk ratio (RR) 1.88; 95% confidence interval (CI), 1.7-2.08) and compared with women with exposure either before or after pregnancy (RR 1.38; 95% CI, 1.23-1.54; P < 0.001). Exposure to methylphenidate (MPH) was marginally associated with an increased risk for cardiac malformation (RR 1.27; 95% CI, 0.99-1.63; P = 0.065) compared with no exposure. However, exposure to ADHD medication was not associated with an increased risk for other adverse maternal or neonatal outcomes. This analysis was limited by the small number of studies included and the limited adjustments for the possible confounders in the studies.

CONCLUSIONS

Exposure to ADHD medication during pregnancy does not appear to be associated with adverse maternal or neonatal outcomes. Given the few studies included, further larger, prospective studies that control for important confounders are needed to verify our findings.

Amphetamine- and Opioid-Affected Births: Incidence, Outcomes, and Costs, United States, 2004-2015

Objectives. To estimate trends in incidence, outcomes, and costs among hospital deliveries related to amphetamines and opioids.Methods. We analyzed 2004-to-2015 data from the National Inpatient Sample, a nationally representative sample of hospital discharges in the United States compiled by the Healthcare Cost and Utilization Project, by using a repeated cross-sectional design. We estimated the incidence of hospital deliveries related to maternal amphetamine or opioid use with weighted logistic regression. We measured clinical outcomes and costs with weighted multivariable logistic regression and generalized linear models.Results. Amphetamine- and opioid-related deliveries increased disproportionately across rural compared with urban counties in 3 of 4 census regions between 2008 to 2009 and 2014 to 2015. By 2014 to 2015, amphetamine use was identified among approximately 1% of deliveries in the rural West, which was higher than the opioid-use incidence in most regions. Compared with opioid-related and other hospital deliveries, amphetamine-related deliveries were associated with higher incidence of preeclampsia, preterm delivery, and severe maternal morbidity and mortality.Conclusions. Increasing incidence of amphetamine and opioid use among delivering women and associated adverse gestational outcomes indicate that amphetamine and opioid use affecting birth represent worsening public health crises.

Midwives' attitudes towards pregnant women using substances: Informing a care pathway

OBJECTIVE

The purpose of this study was to identify midwives' attitudes towards women using substances during pregnancy, which informed the development of an integrated care pathway for the provision of optimal care.

METHODS

A mixed methods research design was used, that included an online survey via the online survey tool Qualtrics™ which collected quantitative data, and interviews and focus groups were used to collect qualitative data.

FINDINGS

Participants held a positive or neutral view towards women who used substances during pregnancy, and the participants had an empathetic perception of the issue of substance use within pregnancy, believing that women were using substances due to the environment and circumstances that they lived in, and that they had been raised and socialised in.

CONCLUSION

Caring for women during pregnancy with substance misuse issues is complex and requires coordination and multidisciplinary care. Midwives have the capacity to provide sensitive midwifery care but require the framework to ensure women needing additional resources during pregnancy receive the services available and specific to their needs. The midwives in this study were supportive of developing an integrated care pathway to allow for collaborative care, and to enable a specialised midwifery approach.