Medication use in pregnancy: a cross-sectional, multinational web-based study

Multi-cellular engineered living systems to assess reproductive toxicology

Toxicants and some drugs can negatively impact reproductive health. Many toxicants haven't been tested due to lack of available models. The impact of many drugs taken during pregnancy to address maternal health may adversely affect fetal development with life-long effects and clinical trials do not examine toxicity effects on the maternal-fetal interface, requiring indirect assessment of safety and efficacy. Due to current gaps in reproductive toxicological knowledge and limitations of animal models, multi-cellular engineered living systems may provide solutions for modeling reproductive physiology and pathology for chemical and xenobiotic toxicity studies. Multi-cellular engineered living systems, such as microphysiological systems (MPS) and organoids, model of functional units of tissues. In this review, we highlight the key functions and structures of human reproductive organs and well-known representative toxicants afflicting these systems. We then discuss current approaches and specific studies where scientists have used MPS or organoids to recreate in vivo markers and cellular responses of the female and male reproductive system, as well as pregnancy-associated placenta formation and embryo development. We provide specific examples of organoids and organ-on-chip that have been used for toxicological purposes with varied success. Finally, we address current issues related to usage of MPS, emerging techniques for improving upon these complications, and improvements needed to make MPS more capable in assessing reproductive toxicology. Overall, multi-cellular engineered living systems have considerable promise to serve as a suitable, alternative reproductive biological model compared to animal studies and 2D culture.

Partner support for women's antidepressant treatment and its association with depressive symptoms in pregnant women, mothers, and women planning pregnancy

PURPOSE

To examine the association between partner support for women's antidepressant treatment and depressive symptoms in pregnant women, those planning pregnancy, and mothers who ever used antidepressants.

METHODS

We included 334 women (n=44 planners, n=182 pregnant, n=108 mothers) ever treated with antidepressants within the HEALTHx2 study, a web-based cross-sectional study conducted across Norway in June 2020 to June 2021. The Edinburgh Postnatal Depression Scale and two questions of the Patient Health Questionnaire measured depressive symptoms, by degree of severity and for depressed mood, anxiety, and anhedonia sub-dimensions. Partner support was measured using one item from the Antidepressant Compliance Questionnaire. Association was estimated via unadjusted and adjusted linear and logistic regression models.

RESULTS

Being unsupported by the partner was associated with increased odds of reporting moderate-to-very-severe depressive symptoms in mothers (adjusted odds ratio (aOR), 3.57; 95% confidence interval (CI), 1.04-12.19) and pregnant women (aOR, 3.26; 95% CI, 0.95-11.14), relative to being supported. Pregnant women (adjusted mean difference (β), 0.76; 95% CI, 0.14-1.38) and mothers (β, 0.93; 95% CI, 0.23-1.64) with no support for their antidepressant treatment presented greater symptoms of anhedonia; for women planning pregnancy, this association emerged in relation to anxiety symptoms (β among non-users of antidepressant, 2.58; 95% CI, 1.04-4.13).

CONCLUSIONS

Partner support for women's antidepressant treatment may play a key role in depressive symptoms severity and the subtypes of anhedonia and anxiety, among women planning pregnancy, pregnant women, and mothers. This highlights the importance of partner inclusion in the complex decision-making process for antidepressant treatment around the time of pregnancy.

Prenatal efavirenz exposure is independently associated with maternal, but not fetal CYP2B6 genotype

OBJECTIVES

Understanding the influence of fetal and maternal genetics on prenatal drug exposure could potentially improve benefit-risk evaluation. In this study, we investigated the impact of two functional polymorphisms in CYP2B6 on prenatal exposure to efavirenz.

METHODS

Dried blood spot (DBS) samples were collected from HIV-positive pregnant women (n = 112) and their newborns (n = 107) at delivery. They were genotyped for single nucleotide polymorphisms in CYP2B6. Efavirenz was quantified by liquid chromatography-tandem mass spectrometry (LC-MS/MS).

RESULTS

Significant correlations were observed in efavirenz concentration between maternal and newborn (r = 0.46, R2 = 0.21, P < 0.001), and maternal and cord (r = 0.83, R2 = 0.68, P < 0.001) samples. Median (interquartile range) newborn plasma-to-maternal plasma and cord-to-maternal plasma ratios were 0.85 (0.03-3.49) and 0.78 (0.23-1.96), respectively. Newborn efavirenz concentration in DBS varied significantly based on composite maternal CYP2B6 genotype: fast (CYP2B6 516GG and 983TT, n = 26), 747 ng/ml (602-1060); intermediate (CYP2B6 516GT or 983TC n = 50), 1177 ng/ml (898-1765); and slow (CYP2B6 516GT and 983TC or 516TT or 983CC, n = 14), 3094 ng/ml (2126-3812). Composite newborn CYP2B6 genotype was, however, not significantly associated with prenatal exposure. Efavirenz concentration in newborn stratified as fast (n = 25), intermediate (n = 36), and slow metabolizers (n = 19) from prenatal exposure was 999.7 (774-1285), 1240 (709-1984), and 1792 ng/ml (1201-3188), respectively.

CONCLUSION

The clinical relevance of the observed influence of maternal genetics on prenatal efavirenz exposure requires further investigation.

Perceived barriers and facilitators for model-informed dosing in pregnancy: a qualitative study across healthcare practitioners and pregnant women

BACKGROUND

Most women use medication during pregnancy. Pregnancy-induced changes in physiology may require antenatal dose alterations. Yet, evidence-based doses in pregnancy are missing. Given historically limited data, pharmacokinetic models may inform pregnancy-adjusted doses. However, implementing model-informed doses in clinical practice requires support from relevant stakeholders.

PURPOSE

To explore the perceived barriers and facilitators for model-informed antenatal doses among healthcare practitioners (HCPs) and pregnant women.

METHODS

Online focus groups and interviews were held among healthcare practitioners (HCPs) and pregnant women from eight countries across Europe, Africa and Asia. Purposive sampling was used to identify pregnant women plus HCPs across various specialties prescribing or providing advice on medication to pregnant women. Perceived barriers and facilitators for implementing model-informed doses in pregnancy were identified and categorised using a hybrid thematic analysis.

RESULTS

Fifty HCPs and 11 pregnant women participated in 12 focus groups and 16 interviews between January 2022 and March 2023. HCPs worked in the Netherlands (n = 32), the UK (n = 7), South Africa (n = 5), Uganda (n = 4), Kenya, Cameroon, India and Vietnam (n = 1 each). All pregnant women resided in the Netherlands. Barriers and facilitators identified by HCPs spanned 14 categories across four domains whereas pregnant women described barriers and facilitators spanning nine categories within the same domains. Most participants found current antenatal dosing information inadequate and regarded model-informed doses in pregnancy as a valuable and for some, much-needed addition to antenatal care. Although willingness-to-follow model-informed antenatal doses was high across both groups, several barriers for implementation were identified. HCPs underlined the need for transparent model validation and endorsement of the methodology by recognised institutions. Foetal safety was deemed a critical knowledge gap by both groups. HCPs' information needs and preferred features for model-informed doses in pregnancy varied. Several pregnant women expressed a desire to access information and partake in decisions on antenatal dosing.

CONCLUSIONS

Given the perceived limitations of current pharmacotherapy for pregnant women and foetuses, model-informed dosing in pregnancy was seen as a promising means to enhance antenatal care by pregnant women and healthcare practitioners.

Racial Disparities in Medication Use During Pregnancy: Results from the NISAMI Cohort

Purpose

This study aimed to evaluate racial disparities in medication use and associated factors among pregnant women receiving prenatal care at Brazilian Unified Health System primary care health units in the northeast region.

Patients and Methods

A total of 1058 pregnant women in the NISAMI Cohort were interviewed between June 2012 and February 2014. Medicines used during pregnancy were classified according to the Anatomical Therapeutic Chemical (ATC) classification system and ANVISA pregnancy risk categories. Prevalence ratios (crude and adjusted) and 95% confidence intervals (CIs) were estimated using Poisson regression with robust error variance. All analyses were stratified by race (Asian, black, brown/mixed, Brazilian indigenous, and white).

Results

Approximately 84% of the pregnant women used at least one medication, with a lower proportion among white women. The most reported medications were antianemic preparations (71.08%; 95% CI 68.27-73.72%), analgesics (21.74%; 95% CI 19.36-24.32%), and drugs for functional gastrointestinal disorders (18.81%; 95% CI 16.57-21.28%). Approximately 29% of women took potentially risky medications during pregnancy, with a higher prevalence among Asian and white women. Factors associated with medication use during pregnancy include a greater number of prenatal consultations, higher education levels, health problems, and smoking. In addition, maternal age above 25 years, smoking status, and two or more previous pregnancies were associated with potentially risky medication use during pregnancy.

Conclusion

A high prevalence of medication use during pregnancy was found; however, this prevalence was lower among white women. Nonetheless, black and brown women used antianemic preparations less frequently. This finding suggests that race is a factor of inequity in prenatal care, demanding public policies to mitigate it.

FetoML: Interpretable predictions of the fetotoxicity of drugs based on machine learning approaches

Pregnant females may use medications to manage health problems that develop during pregnancy or that they had prior to pregnancy. However, using medications during pregnancy has a potential risk to the fetus. Assessing the fetotoxicity of drugs is essential to ensure safe treatments, but the current process is challenged by ethical issues, time, and cost. Therefore, the need for in silico models to efficiently assess the fetotoxicity of drugs has recently emerged. Previous studies have proposed successful machine learning models for fetotoxicity prediction and even suggest molecular substructures that are possibly associated with fetotoxicity risks or protective effects. However, the interpretation of the decisions of the models on fetotoxicity prediction for each drug is still insufficient. This study constructed machine learning-based models that can predict the fetotoxicity of drugs while providing explanations for the decisions. For this, permutation feature importance was used to identify the general features that the model made significant in predicting the fetotoxicity of drugs. In addition, features associated with fetotoxicity for each drug were analyzed using the attention mechanism. The predictive performance of all the constructed models was significantly high (AUROC: 0.854-0.974, AUPR: 0.890-0.975). Furthermore, we conducted literature reviews on the predicted important features and found that they were highly associated with fetotoxicity. We expect that our model will benefit fetotoxicity research by providing an evaluation of fetotoxicity risks for drugs or drug candidates, along with an interpretation of that prediction.

Use of privacy-preserving record linkage to examine the dispensing of pharmaceutical benefits scheme medicines to pregnant women in Western Australia

PURPOSE

Medications are commonly used during pregnancy to manage pre-existing conditions and conditions that arise during pregnancy. However, not all medications are safe to use in pregnancy. This study utilized privacy-preserving record linkage (PPRL) to examine medications dispensed under the national Pharmaceutical Benefits Scheme (PBS) to pregnant women in Western Australia (WA) overall and by medication safety category.

METHODS

In this retrospective, cross-sectional, population-based study, state perinatal records (Midwives Notification Scheme) were linked with national PBS dispensing data using PPRL. Live and stillborn neonates born between 2012 and 2019 in WA were included. The proportion of pregnancies during which the mother was dispensed a PBS medication was calculated, overall and by medication safety category. Factors associated with PBS medication dispensing were examined using logistic regression.

RESULTS

PPRL linkage identified matching records for 97.4% of women with perinatal records. A total of 271 739 pregnancies were identified, with 158 585 (58.4%) pregnancies involving the dispensing of at least one PBS medication. Category A medications (those considered safe in pregnancy) were the most commonly dispensed (n = 119 126, 43.8%) followed by B3 (n = 51 135, 18.8%) and B1 (n = 42 388, 15.6%) medication (those with unknown safety). Over the study period, the dispensing of PBS medications in pregnancy increased (OR: 1.06, 95%CI: 1.06, 1.07). The strongest predictor of medication dispensing in pregnancy was pre-pregnancy dispensing (OR: 3.61, 95%CI: 3.54, 3.68). Other factors associated with medication use in pregnancy were smoking, older maternal age, obesity, and prior pregnancies.

CONCLUSION

Privacy preserving record linkage provides a way to link cross-jurisdictional data while preserving patient confidentiality and data security. The dispensing of PBS medication in pregnancy was common and increased over time, with approximately 60% of women dispensed at least one medication during pregnancy.

Use of medication in pregnancy on the rise: Study on 1.4 million Danish pregnancies from 1998 to 2018

INTRODUCTION

Maternal demographics have evolved, and more women than ever enter pregnancy with preexisting comorbidity and with potentially complex medication exposure, including polypharmacy (concomitant intake of multiple medications). This study aims to describe the evolution of medication use in pregnancy in Denmark from 1998 to 2018 with special focus on polypharmacy, patterns of use, and underlying demographics.

MATERIAL AND METHODS

A Danish nationwide historical registry study based on all clinically recognized pregnancies with a gestation ≥10 weeks between 1998 and 2018. Medication use was estimated by redemption of prescriptions during pregnancy.

RESULTS

Among a total of 1 402 327 clinically recognized pregnancies, redemption of at least one prescription medication during pregnancy increased from 56.9% in 1998 to 63.3% in 2018, coinciding with an increased use of polypharmacy (from 24.8% in 1998 to 35.2% in 2018). The prevalence of pregnant women who used medications for chronic conditions increased more than the prevalence of women treated for occasional or short-time conditions. Redemption of one or multiple prescription medications during pregnancy was mostly seen among pregnant women ≥35 years of age. However, pregnant women <25 years old exhibited the largest increase in medication use during the study period.

CONCLUSIONS

Medication use in general, and polypharmacy in particular, increased from 1998 to 2008, possibly as the result of an increased prevalence of pregnant women with chronic conditions requiring pharmacological treatment. Notably, a marked maternal age-based discrepancy in usage pattern was observed, highlighting the need for further research in this area. The rise in the prevalence of polypharmacy during pregnancy underscores the need for pharmacovigilance to monitor adverse effects. Future studies should investigate the patterns of polypharmacy and the accompanying maternal and fetal risks.

Psychometric properties of the Decisional Conflict Scale in a sample of perinatal women with depressive symptoms: A study in Portugal and Norway

OBJECTIVE

To assess the psychometric properties, i.e., reliability and construct validity of the 16-item Decisional Conflict Scale (DCS) and sub-scales in women with perinatal depressive symptoms in Norway and Portugal.

METHODS

We included 415 women in Portugal and 163 in Norway (≥18 years) who were pregnant or had given birth in the last 12 months and presenting with active depressive symptoms. Women replied to the original DCS items. We conducted confirmatory factor analysis, estimated internal consistency reliability, and examined factorial invariance across country, perinatal status, and treatment uptake.

RESULTS

The DCS factor model had good fit to the data, with all items loading significantly on their respective factor (.585 to .958). There was configural invariance of the DCS across countries, treatment, and perinatal status. The internal consistency of the total DCS (Cronbach's alpha) was .958, and for the subscales it ranged from .798 to .947.

CONCLUSIONS

The DCS is a valid and reliable measure of the decisional conflict in women with perinatal depressive symptoms in Portugal and Norway.

PRACTICE IMPLICATIONS

Measuring the extent of decisional conflict regarding treatment and the effect of multiple interventions towards its reduction, is critical to facilitate the decision-making process of women with perinatal mental illness.

Knowledge and practice of community pharmacists regarding the safety of drugs during pregnancy: a cross-sectional study from a developing country

BACKGROUND

Drug use during pregnancy can cause unfavorable fetal and maternal outcomes. Information sharing is essential for pharmacists' role within intricate, modern healthcare systems. Community pharmacists (CPs) have demonstrated unsatisfactory knowledge across various pharmacological domains in most developing countries. This study aimed to explore the knowledge and practices of CPs regarding medications and herb safety during pregnancy.

METHODS

A cross-sectional study was conducted in a developing country using a self-administered questionnaire. A sample of CPs working in the northern governorates of the West Bank was selected by convenience sampling. The questionnaire included questions on sociodemographic characteristics, practices and knowledge. Descriptive and inferential statistics were calculated using the Statistical Package for the Social Sciences (SPSS) to analyze the data.

RESULTS

A total of 207 questionnaires were completed. Most respondents had only a bachelor's degree (89.9%) but did not participate in continuous professional development (CPD) (71.0%). Almost one-third of the CP workload involved dispensing drugs to pregnant women. The majority of the participants reported that they inquire about pregnancy status (59.9%), refer to scientific sources (82.6%), and contact a prescribing physician (51.2%) in cases of uncertainty. A higher knowledge score was associated with receiving a master's degree and CPD programs. Most CPs identified folic acid, paracetamol and amoxicillin as safe, while tetracycline, isotretinoin, enalapril, pseudoephedrine and ibuprofen were among the drugs mostly reported as unsafe. Castor oil, Senna, St. John's wort and ginseng were the most frequently reported herbs as unsafe.

CONCLUSIONS

Despite the gaps in knowledge about herb pharmacology, CPs demonstrated acceptable knowledge and practice regarding drug safety during pregnancy. CPD is recommended for addressing gaps in knowledge and practice. Future research evaluating knowledge and practice may benefit from developing a specific, accurate, validated instrument.

Drug-induced fetal and offspring disorders, beyond birth defects

Studies on drug utilization in western countries disclosed that about nine over ten women use at least one or more drugs during pregnancy. Determining whether a drug is safe or not in pregnant women is a challenge of all times. As a developing organism, the fetus is particularly vulnerable to effects of drugs used by the mother. Historically, research has predominantly focused on birth defects, which represent the most studied adverse pregnancy outcomes. However, drugs can also alter the ongoing process of pregnancy and impede the general growth of the fetus. Finally, adverse drug reactions can theoretically damage all developing systems, organs or tissues, such as the central nervous system or the immune system. This extensive review focuses on different aspects of drug-induced damages affecting the fetus or the newborn/infant, beyond birth defects, which are not addressed here.

Improving Data Collection in Pregnancy Safety Studies: Towards Standardisation of Data Elements in Pregnancy Reports from Public and Private Partners, A Contribution from the ConcePTION Project

INTRODUCTION AND OBJECTIVE

The ConcePTION project aims to improve the way medication use during pregnancy is studied. This includes exploring the possibility of developing a distributed data processing and analysis infrastructure using a common data model that could form a foundational platform for future surveillance and research. A prerequisite would be that data from various data access providers (DAPs) can be harmonised according to an agreed set of standard rules concerning the structure and content of the data. To do so, a reference framework of core data elements (CDEs) recommended for primary data studies on drug safety during pregnancy was previously developed. The aim of this study was to assess the ability of several public and private DAPs using different primary data sources focusing on multiple sclerosis, as a pilot, to map their respective data variables and definitions with the CDE recommendations framework.

METHODS

Four pregnancy registries (Gilenya, Novartis; Aubagio, Sanofi; the Organization of Teratology Information Specialists [OTIS]; Aubagio, Sanofi; the Dutch Pregnancy Drug Register, Lareb), two enhanced pharmacovigilance programmes (Gilenya PRIM, Novartis; MAPLE-MS, Merck Healthcare KGaA) and four Teratology Information Services (UK TIS, Jerusalem TIS, Zerifin TIS, Swiss TIS) participated in the study. The ConcePTION primary data source CDE includes 51 items covering administrative functions, the description of pregnancy, maternal medical history, maternal illnesses arising in pregnancy, delivery details, and pregnancy and infant outcomes. For each variable in the CDE, the DAPs identified whether their variables were: identical to the one mentioned in the CDE; derived; similar but with a divergent definition; or not available.

RESULTS

The majority of the DAP data variables were either directly taken (85%, n = 305/357, range 73-94% between DAPs) or derived by combining different variables (12%, n = 42/357, range 0-24% between DAPs) to conform to the CDE variables and definitions. For very few of the DAP variables, alignment with the CDE items was not possible, either because of divergent definitions (1%, n = 3/357, range 0-2% between DAPs) or because the variables were not available (2%, n = 7/357, range 0-4% between DAPs).

CONCLUSIONS

Data access providers participating in this study presented a very high proportion of variables matching the CDE items, indicating that alignment of definitions and harmonisation of data analysis by different stakeholders to accelerate and strengthen pregnancy pharmacovigilance safety data analyses could be feasible.

Antibiotic use during pregnancy in Sweden: A nationwide utilization study covering 2007-2019

INTRODUCTION

Antibiotics are often prescribed during pregnancy. Assessing the current state of prenatal antibiotic use is therefore imperative for optimizing prescribing and identifying emerging research priorities. The study aimed to describe recent trends and patterns in antibiotic use during pregnancy among women who gave birth in Sweden, including user characteristics.

MATERIAL AND METHODS

Population-based descriptive study using linked nationwide registers. All pregnancies delivered in Sweden from 2007 to 2019 were included. Prevalence of use was defined as the percentage of pregnancies during which at least one prescription forantibiotics was filled. Temporal trends in the prevalence of antibiotic use by calendar year, trimester and weeks of gestation were assessed from time series graphs.

RESULTS

Prescriptions for systemic antibiotics were filled in 20.7% of 1 434 431 pregnancies overall, decreasing from 24.7% in 2007 to 18.0% in 2019. Phenoxymethylpenicillin (8.5%), pivmecillinam (6.5%), nitrofurantoin (4.7%), amoxicillin (1.6%) and cefadroxil (1.5%) use were the most prevalent. Their use decreased over the 13-year period, except for pivmecillinam, which increased from 4.0% to 7.4%. Prevalence of use was highest in the second trimester (9.5%), with weekly trends peaking at 13 and 34 weeks of gestation. Compared with non-users, antibiotic users more often belonged to the youngest and oldest age strata, carried multipleton pregnancies, had delivered before, had attained a lower education level and smoked in early pregnancy. A higher body mass index, asthma, chronic renal disease and diabetes mellitus were more prevalent among antibiotic users than among non-users.

CONCLUSIONS

Although outpatient antibiotic use during pregnancy in Sweden has been declining, one in five pregnancies was exposed to systemic antibiotics.

Consumption of Acetaminophen During Pregnancy: A Survey on Knowledge, Attitudes and Practices of Lebanese Women

OBJECTIVES

Use of acetamoniphen (paracetamol or N-acetyl-para-aminophenol [APAP]) during pregnancy is considered safe; however certain practices have been related to the risk of developing neurodevelopmental disorders in offspring. Therefore, the present study aimed to assess women's knowledge, attitudes and practices (KAP) towards the use APAP during pregnancy and its associated factors.

METHODS

This cross-sectional study was conducted between May 15 and August 31, 2020, among pregnant Lebanese women and those who had given birth in the last 12 months. Online self-administered questionnaire was used for data collection. KAP were described and a knowledge score was generated. Multivariable linear models were used to test the association of participants' sociodemographic characteristics with their knowledge and practices related to the use of APAP.

RESULTS

Out of 305 participants, 72.8% had moderate knowledge about the use of APAP during pregnancy. Actually, more than 50% of them were unable to differentiate between APAP and other pain medications, determine the maximum recommended daily dose, specify the minimum time to wait between doses and identify potential effects of APAP on both mother and unborn child. A higher level of education was associated with a higher knowledge score (β = 2.32, 95%CI=[0.91; 3.73]; p = 0.001). Moreover, women had positive attitudes towards APAP use, perceiving a low risk of toxicity. Indeed, 70.5% of women used APAP at least once during their pregnancy, with 63.7% using it safely. Women with higher knowledge, experiencing at least five somatic symptoms and having a low socioeconomic level tended to be more APAP users (p < 0.05).

CONCLUSIONS FOR PRACTICE

Health professionals have the responsibility to give adequate and personalized advice to women regarding their medicines.

Exposure to Paracetamol in Early Pregnancy and the Risk of Developing Cerebral Palsy: A Case-Control Study Using Serum Samples

OBJECTIVE

To investigate whether maternal paracetamol use in early pregnancy is associated with cerebral palsy (CP) in offspring.

STUDY DESIGN

We conducted a registry and biobank-based case-control study with mother-child pairs. We identified CP cases (n = 322) born between 1995 and 2014 from a nationwide CP-registry. Randomly selected controls (n = 343) and extra preterm controls (n = 258) were obtained from a birth registry. For each mother, a single serum sample from early pregnancy (gestation weeks 10-14) was retrieved from a biobank and analyzed for serum concentrations of paracetamol, categorized into unexposed (<1 ng/ml), mildly exposed (1-100 ng/ml), and highly exposed (>100 ng/ml), and in quartiles. Analyses were performed using logistic regression and adjusted for potential confounders. Separate analyses were conducted including only those children born preterm and only those born term.

RESULTS

Of the 923 participants, 36.8% were unexposed, 53.2% mildly exposed, and 10% highly exposed to paracetamol. Overall, prenatal exposure to paracetamol was not associated with CP. Sensitivity and subgroup analyses showed no clear associations between paracetamol and CP across strata of term/preterm birth as well as subtypes of CP.

CONCLUSIONS

The present study does not support an association between intrauterine exposure to paracetamol in early pregnancy and the risk of CP. However, it is important to stress that the exposure estimate is based on a single serum sample.

Building a Sustainable Learning Health Care System for Pregnant and Lactating People: Interview Study Among Data Access Providers

BACKGROUND

In many areas of health care, learning health care systems (LHSs) are seen as promising ways to accelerate research and outcomes for patients by reusing health and research data. For example, considering pregnant and lactating people, for whom there is still a poor evidence base for medication safety and efficacy, an LHS presents an interesting way forward. Combining unique data sources across Europe in an LHS could help clarify how medications affect pregnancy outcomes and lactation exposures. In general, a remaining challenge of data-intensive health research, which is at the core of an LHS, has been obtaining meaningful access to data. These unique data sources, also called data access providers (DAPs), are both public and private organizations and are important stakeholders in the development of a sustainable and ethically responsible LHS. Sustainability is often discussed as a challenge in LHS development. Moreover, DAPs are increasingly expected to move beyond regulatory compliance and are seen as moral agents tasked with upholding ethical principles, such as transparency, trustworthiness, responsibility, and community engagement.

OBJECTIVE

This study aims to explore the views of people working for DAPs who participate in a public-private partnership to build a sustainable and ethically responsible LHS.

METHODS

Using a qualitative interview design, we interviewed 14 people involved in the Innovative Medicines Initiative (IMI) ConcePTION (Continuum of Evidence from Pregnancy Exposures, Reproductive Toxicology and Breastfeeding to Improve Outcomes Now) project, a public-private collaboration with the goal of building an LHS for pregnant and lactating people. The pseudonymized transcripts were analyzed thematically.

RESULTS

A total of 3 themes were identified: opportunities and responsibilities, conditions for participation and commitment, and challenges for a knowledge-generating ecosystem. The respondents generally regarded the collaboration as an opportunity for various reasons beyond the primary goal of generating knowledge about medication safety during pregnancy and lactation. Respondents had different interpretations of responsibility in the context of data-intensive research in a public-private network. Respondents explained that resources (financial and other), scientific output, motivation, agreements collaboration with the pharmaceutical industry, trust, and transparency are important conditions for participating in and committing to the ConcePTION LHS. Respondents also discussed the challenges of an LHS, including the limitations to (real-world) data analyses and governance procedures.

CONCLUSIONS

Our respondents were motivated by diverse opportunities to contribute to an LHS for pregnant and lactating people, primarily centered on advancing knowledge on medication safety. Although a shared responsibility for enabling real-world data analyses is acknowledged, their focus remains on their work and contribution to the project rather than on safeguarding ethical data handling. The results of our interviews underline the importance of a transparent governance structure, emphasizing the trust between DAPs and the public for the success and sustainability of an LHS.

Prevalence and associated factors of self-medication in worldwide pregnant women: systematic review and meta-analysis

BACKGROUND

Self-medication during pregnancy is of great interest. The use of drugs during pregnancy requires a careful reflection on the benefits to the mother and the risks to the fetus. Selecting a drug or drugs for treating pregnant women can be difficult for clinicians owing to the various pharmacokinetic and physiological changes encountered during pregnancy. This systematic review and meta-analysis aimed to estimate the pooled prevalence of self-medication and associated factors among women during pregnancy.

METHODS

Searches were carried out at PubMed, Science Direct, Web of Science, and Google Scholar. The quality of the studies and the risk of bias were analyzed using the Joanna Briggs Critical Appraisal Checklist for Analytical Cross-Sectional Studies instrument. The extracted data were tabulated and analyzed qualitatively and quantitatively through meta-analysis.

RESULTS

The overall prevalence of self-medication among pregnant women was 44.50% (95% CI: 38.92-50.23). Subgroup analyses showed differences in self-medication prevalence influenced by region, county income, and study design. The Heterogeneity, assessed by the statistical test I2 varied from 96 to 99% and was statistically significant. The result of this funnel plot showed that the funnel plot was symmetry with p-value = 0.36, and there is no publication bias.

CONCLUSION

The results obtained from this study showed that the prevalence of self-medication among pregnant women is relatively high. This requires effective measures and interventions to reduce self-medication.

TRIAL REGISTRATION

ID =  CRD42022312333 .

Trends in harmful drug exposure during pregnancy in France between 2013 and 2019: A nationwide cohort study

OBJECTIVE

Describe the trends of exposure to harmful drugs during pregnancy over recent years in France.

DESIGN

Nationwide cohort study.

SETTING

The French National administrative health Data System (SNDS).

POPULATION

Pregnancies starting between 2013 and 2019 and outcomes corresponding to live births, medical terminations of pregnancy, and stillbirths.

METHODS

Each pregnancy was divided into a preconceptional period of 90 days before conception and three trimesters from conception to birth. Harmful drugs were defined according to their risks to the fetus: teratogenicity or fetotoxicity. Exposure was defined using the critical period during pregnancy for each type of harmful drug: preconceptional period or first trimester for teratogenic drugs and second or third trimesters for fetotoxic drugs.

MAIN OUTCOME MEASURES

Prevalence of pregnancies exposed to at least one harmful drug.

RESULTS

Among 5,253,284 pregnancies, 204,402 (389 per 10,000) pregnancies were exposed to at least one harmful drug during the critical periods: 48,326 (92 per 10,000) pregnancies were exposed to teratogenic drugs during the preconceptional period or the first trimester, and 155,514 (299 per 10,000) pregnancies were exposed to fetotoxic drugs during the second or third trimesters. Teratogenic drugs were mainly retinoids for topical use (44 per 10,000 pregnancies), antiepileptics (13 per 10,000 pregnancies) and statins (13 per 10,000 pregnancies). Fetotoxic drugs were mainly non-steroidal anti-inflammatory drugs (NSAIDs), for systemic (128 per 10,000 pregnancies) and topical use (122 per 10,000 pregnancies). Exposure to teratogenic drugs decreased from the preconceptional period to the first trimester. Exposure to fetotoxic drugs decreased from the second to the third trimester. Between 2013 and 2019, we found a decrease in harmful drug exposure overall, mainly for topical and systemic NSAIDs and for topical retinoids.

CONCLUSIONS

In this nationwide study, about one in 25 pregnancies was exposed to at least one harmful drug, mainly NSAIDs and topical retinoids. Although the prevalence of harmful drug exposure decreased over the study period, NSAID exposure in the second and third trimester remains of concern.

Self-medication practice among pregnant and postpartum women attending the regional hospital center of Souss Massa, Morocco: a cross-sectional study

Background: Self-medication among pregnant women represents a serious risk to the mother's and child's health. It is a global concern that requires careful attention from professionals in healthcare. In Morocco, there is a lack of available data on self-medication and predicting variables among pregnant and postpartum women. The purpose of this study was to determine the incidence of self-medication and the factors that contributed to it among pregnant and postpartum women in the Sous Massa Regional Hospital. Methods: A cross-sectional study was conducted using a pretested questionnaire among 420 pregnant and postpartum women who were attending the regional hospital center of the Sous Massa region from April to December 2022. Statistical analysis was performed using Jamovi Software. The logistic regression analysis was used to determine the significance of the association between the outcome and independent variables. Results: The research enrolled 420 pregnant and postpartum women. During the current pregnancy, 24.8% of the women used self-medication. The leading common causes/symptoms that necessitate self-medication among pregnant and postpartum women were Anemia (84.8%), epigastralgia (16.8%), vomiting, pyrosis (15.2%), and urinary and vaginal infections The therapeutic families concerned with self-medication practice were Analgesics (41.4%), Antacids (20.3%), antimicrobials (13.5%), and Vitamin supplements (9%). According to the findings, the most frequent sources of information were pharmacists (45.6%), followed by physicians (44.3%). The primary reasons given by respondents for self-medication were the need for rapid release (51.7%), previous treatments with the same drugs (31.7%), and 20% reported difficulty of access to healthcare professionals. Out of 95.9% of the participants reported that they knew the dangers of self-medication and 96% of them were informed and received information about the dangers and contraindications of self-medication during pregnancy. This was significantly statistically associated with self-medication respectively with p-value = 0.031 and p-value = 0.005. Conclusion: The findings of the present study provide an initial awareness of the state of self-medication among pregnant and postpartum women attending the regional hospital centers. It is recommended that healthcare professionals increase their interventions to improve the consciousness of pregnant women; this might require implementing suitable strategies to regulate the commercialization, delivery, and use of conventional medications.

News in pharmacology for the main medical pathologies of gestation

Obstetric diseases represent a highly complex medical challenge, especially regarding its clinical approach. The use of pharmacological agents during pregnancy is one of the main therapeutic alternatives in this group of patients; however, there is a general lack of knowledge about its use, efficacy, and possible adverse effects that may occur in routine clinical practice, even among medical professionals themselves. The high percentage of pregnant women who undergo drugs at some point during pregnancy, together with the developments that have occurred in recent years in the field of pharmacology, show the need for a detailed analysis that shows the existing current knowledge and helps in the clinical decision making. In this sense, the aim of this work is to conduct a review of the available scientific literature on the novelties in pharmacology for the main medical pathologies of pregnancy. Thus, the role of this field in analgesia, antibiotic therapy, digestive, respiratory, urological, psychiatric and neurological pathologies will be detailed, evaluating the indications, precautions and considerations that must be taken into account for its use.

Development of a Generic Fetal Physiologically Based Pharmacokinetic Model and Prediction of Human Maternal and Fetal Organ Concentrations of Cefuroxime

BACKGROUND AND OBJECTIVE

Physiologically based pharmacokinetic (PBPK) models for pregnant women have recently been successfully used to predict maternal and umbilical cord pharmacokinetics (PK). Because there is very limited opportunity for conducting clinical and PK investigations for fetal drug exposure, PBPK models may provide further insights. The objectives of this study were to extend a whole-body pregnancy PBPK model by multiple compartments representing fetal organs, and to predict the PK of cefuroxime in the maternal and fetal plasma, the amniotic fluid, and several fetal organs.

METHODS

To this end, a previously developed pregnancy PBPK model for cefuroxime was updated using the open-source software Open Systems Pharmacology (PK-Sim®/MoBi®). Multiple compartments were implemented to represent fetal organs including brain, heart, liver, lungs, kidneys, the gastrointestinal tract (GI), muscles, and fat tissue, as well as another compartment lumping organs and tissues not explicitly represented.

RESULTS

This novel PBPK model successfully predicted cefuroxime concentrations in maternal blood, umbilical cord, amniotic fluid, and several fetal organs including heart, liver, and lungs. Further model validation with additional clinical PK data is needed to build confidence in the model.

CONCLUSIONS

Being developed with an open-source software, the presented generic model can be freely re-used and tailored to address specific questions at hand, e.g., to assist the design of clinical studies in the context of drug research or to predict fetal organ concentrations of chemicals in the context of fetal health risk assessment.

How the structural determinants of health inequities impact access to prescription medication for pregnant women in Australia: a narrative review

Structural factors that contribute to health disparities (e.g., population-level policies, cultural norms) impact the distribution of resources in society and can affect medication accessibility; even in high-income countries like Australia. Industry practices and regulatory approaches (e.g., a conservative approach to testing medicines in pregnant women) influence the availability of safety and efficacy data necessary for the licencing and funding of prescription medications used during pregnancy. Consequently, pregnant women may be prescribed medications outside of regulatory or funder-approved indications, posing risks for both prescribers and pregnant women and potentially compromising equitable access to medications. This review examines the regulatory and legislative structural factors that contribute to health disparities and perpetuate the deeply ingrained social norm that we should be protecting pregnant women from clinical research rather than safeguarding them through such research. Addressing these challenges requires a renewed commitment to integrated, woman-centred maternal healthcare and strengthened collaboration across all sectors.

Funding

Australian Government Research Training Program Stipend from the University of Technology Sydney, National Health and Medical Research Council (NHMRC) Fellowship, Channel 7 Children's Research Foundation Fellowship (CRF-210323).

Variation in clinical practice guideline recommendations for medication use in pregnancy in Australia: A systematic review

BACKGROUND

Medication use in pregnancy is common; however, it is unknown if clinical practice guideline (CPG) prescribing recommendations referred to in Australia at the state, national and international level are consistent.

AIMS

This systematic review aimed to: (1) identify sources of CPGs that inform prescribing during pregnancy in Australia; (2) assess CPG quality; and (3) evaluate variation within CPG recommendations for medication use in three common conditions in pregnancy: prophylactic antibiotics following premature rupture of membranes (PROM) at term, antidepressants in pregnancy and metformin in gestational diabetes mellitus (GDM).

MATERIALS AND METHODS

A literature search was conducted across PubMed, Scopus and EMBASE databases. Grey literature was identified through publicly available Australian policy statements. Prescribing recommendations for prophylactic antibiotics following PROM at term, antidepressants in pregnancy and metformin in GDM, were compared at the state, national and international levels. CPG quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

RESULTS

We identified 39 CPG sources that inform prescribing during pregnancy in Australia. CPG quality varied between resources. There was minor variation in recommendations for antibiotic prophylaxis in PROM at term. Recommendations regarding metformin use in GDM were also variable, with CPGs either recommending its use as a first-line agent when lifestyle modifications are not effective or when insulin therapy is not practicable. Recommendations for antidepressant use were consistent across CPGs analysed.

CONCLUSION

Multiple CPGs exist to inform prescribing during pregnancy in Australia, with variation present within CPG quality and recommendations. These findings offer insight into potential sources of variation in maternal and neonatal health outcomes.

The inclusion of pregnant women in vaccine clinical trials: An overview of late-stage clinical trials' records between 2018 and 2023

Pregnant women are generally excluded from clinical research over safety concerns. However, demands to include them in clinical vaccine development have intensified after recent COVID-19, Ebola, and Lassa fever outbreaks given the disproportionate effect of these diseases on pregnant women and/or their foetuses. Numerous studies highlighted the scarcity of safety data for therapeutic interventions in pregnant women. Nevertheless, only a small number have assessed the number of vaccine trials including this population. Therefore, we searched for phase 3 and 4 vaccine clinical trials in healthy populations registered between 2018 and 2023 in clinicaltrials.gov and the International Clinical Trial Registry Platform. Out of 400 registered vaccine trials matching our inclusion criteria, 217 (54 %) were industry-sponsored, and 222 (56 %) had COVID-19 as a target. We found 22 studies (6 %) that either were designed for pregnant women or included them as part of a larger population. Out of these 22 trials, 13 were designed specifically for pregnant women; seven of these were maternal vaccines aiming at protecting the foetus, namely pertussis (3), Respiratory Syncytial Virus (RSV) (3), and meningitis plus tetanus (1) vaccines, and six others targeted either flu (3), COVID-19 (2) or Ebola (1). Only the RSV and Ebola vaccine trials were industry-sponsored. We also found that nine studies targeting the general population included pregnant women. These focused on COVID-19 (3), flu (2), COVID-19 + flu (2), Ebola (1), and Hepatitis B (1). None of these studies was industry-sponsored. Our findings show that a gap still exists in terms of pregnant women's inclusion in vaccine trials. Such a gap needs to be tackled urgently to minimise the devastating effects that a future infectious disease outbreak could have on this population. This study can inform future demands for increased inclusion, especially in industry-sponsored trials, as it provides an overview of the current vaccine trials scene.

A Literature Review of Changes in Phase II Drug-Metabolizing Enzyme and Drug Transporter Expression during Pregnancy

The purpose of this literature review is to comprehensively summarize changes in the expression of phase II drug-metabolizing enzymes and drug transporters in both the pregnant woman and the placenta. Using PubMed®, a systematic search was conducted to identify literature relevant to drug metabolism and transport in pregnancy. PubMed was searched with pre-specified terms during the period of 26 May 2023 to 10 July 2023. The final dataset of 142 manuscripts was evaluated for evidence regarding the effect of gestational age and hormonal regulation on the expression of phase II enzymes (n = 16) and drug transporters (n = 38) in the pregnant woman and in the placenta. This comprehensive review exposes gaps in current knowledge of phase II enzyme and drug transporter localization, expression, and regulation during pregnancy, which emphasizes the need for further research. Moreover, the information collected in this review regarding phase II drug-metabolizing enzyme and drug transporter changes will aid in optimizing pregnancy physiologically based pharmacokinetic (PBPK) models to inform dose selection in the pregnant population.

Development and evaluation of an algorithm to link mothers and infants in two US commercial healthcare claims databases for pharmacoepidemiology research

BACKGROUND

Administrative healthcare claims databases are used in drug safety research but are limited for investigating the impacts of prenatal exposures on neonatal and pediatric outcomes without mother-infant pair identification. Further, existing algorithms are not transportable across data sources. We developed a transportable mother-infant linkage algorithm and evaluated it in two, large US commercially insured populations.

METHODS

We used two US commercial health insurance claims databases during the years 2000 to 2021. Mother-infant links were constructed where persons of female sex 12-55 years of age with a pregnancy episode ending in live birth were associated with a person who was 0 years of age at database entry, who shared a common insurance plan ID, had overlapping insurance coverage time, and whose date of birth was within ± 60-days of the mother's pregnancy episode live birth date. We compared the characteristics of linked vs. non-linked mothers and infants to assess similarity.

RESULTS

The algorithm linked 3,477,960 mothers to 4,160,284 infants in the two databases. Linked mothers and linked infants comprised 73.6% of all mothers and 49.1% of all infants, respectively. 94.9% of linked infants' dates of birth were within ± 30-days of the associated mother's pregnancy episode end dates. Characteristics were largely similar in linked vs. non-linked mothers and infants. Differences included that linked mothers were older, had longer pregnancy episodes, and had greater post-pregnancy observation time than mothers with live births who were not linked. Linked infants had less observation time and greater healthcare utilization than non-linked infants.

CONCLUSIONS

We developed a mother-infant linkage algorithm and applied it to two US commercial healthcare claims databases that achieved a high linkage proportion and demonstrated that linked and non-linked mother and infant cohorts were similar. Transparent, reusable algorithms applied to large databases enable large-scale research on exposures during pregnancy and pediatric outcomes with relevance to drug safety. These features suggest studies using this algorithm can produce valid and generalizable evidence to inform clinical, policy, and regulatory decisions.

Multi-omics approach reveals dysregulated genes during hESCs neuronal differentiation exposure to paracetamol

Prenatal paracetamol exposure has been associated with neurodevelopmental outcomes in childhood. Pharmacoepigenetic studies show differences in cord blood DNA methylation between unexposed and paracetamol-exposed neonates, however, causality and impact of long-term prenatal paracetamol exposure on brain development remain unclear. Using a multi-omics approach, we investigated the effects of paracetamol on an in vitro model of early human neurodevelopment. We exposed human embryonic stem cells undergoing neuronal differentiation with paracetamol concentrations corresponding to maternal therapeutic doses. Single-cell RNA-seq and ATAC-seq integration identified paracetamol-induced chromatin opening changes linked to gene expression. Differentially methylated and/or expressed genes were involved in neurotransmission and cell fate determination trajectories. Some genes involved in neuronal injury and development-specific pathways, such as KCNE3, overlapped with differentially methylated genes previously identified in cord blood associated with prenatal paracetamol exposure. Our data suggest that paracetamol may play a causal role in impaired neurodevelopment.

Patterns of Prescription Medication Use during the First Trimester of Pregnancy in the United States, 1997-2018

The objective of this analysis was to describe patterns of prescription medication use during pregnancy, including secular trends, with consideration of indication, and distributions of use within demographic subgroups. We conducted a descriptive secondary analysis using data from 9,755 women whose infants served as controls in two large United States case-control studies from 1997-2011 and 2014-2018. After excluding vitamin, herbal, mineral, vaccine, i.v. fluid, and topical products and over-the-counter medications, the proportion of women that reported taking at least one prescription medication in the first trimester increased over the study years, from 37% to 50% of women. The corresponding proportions increased with increasing maternal age and years of education, were highest for non-Hispanic White women (47%) and lowest for Hispanic women (24%). The most common indication for first trimester use of a medication was infection (12-15%). Increases were observed across the years for medications used for indications related to nausea/vomiting, depression/anxiety, infertility, thyroid disease, diabetes, and epilepsy. The largest relative increase in use among women was observed for medications to treat nausea/vomiting, which increased from 3.8% in the earliest years of the study (1997-2001) to 14.8% in 2014-2018, driven in large part by ondansetron use. Prescription medication use in the first trimester of pregnancy is common and increasing. Many medical conditions require treatments among pregnant women, often involving pharmacotherapy, which necessitates consideration of the risk and safety profiles for both mother and fetus.

Pharmacoepidemiology and costs of medications dispensed during pregnancy: A retrospective population-based study

OBJECTIVE

To describe the pharmacoepidemiology and costs associated with medications dispensed during pregnancy.

DESIGN

Pharmacoepidemiological study and cost analysis.

SETTING

Queensland, Australia.

POPULATION

All women who gave birth in Queensland between January 2013 and June 2018.

METHODS

We used a whole-of-population linked administrative dataset, Maternity1000, to describe medications approved for public subsidy that were dispensed to 255 408 pregnant women. We describe the volume of medications dispensed and their associated costs from a Government and patient perspective.

MAIN OUTCOME MEASURES

Prevalence of medication use; proportion of total dispensings; total medication costs in AUD 2020/21 ($1AUD = $0.67USD/£0.55GBP in December 2022).

RESULTS

During pregnancy, 61% (95% CI 60.96-61.29%) of women were dispensed at least one medication approved for public subsidy. The mean number of items dispensed per pregnancy increased from 2.14 (95% CI 2.11-2.17) in 2013 to 2.47 (95% CI 2.44-2.51) in 2017; an increase of 15%. Furthermore, mean Government cost per dispensing increased by 41% from $21.60 (95% CI $20.99-$22.20) in 2013 to $30.44 (95% CI $29.38-$31.49) in 2017. These factors influenced the 53% increase in total Government expenditure observed for medication use during pregnancy between 2013 and 2017 ($2,834,227 versus $4,324,377); a disproportionate rise compared with the 17% rise in women's total out-of-pocket expenses observed over the same timeframe ($1,880,961 versus $2,204,415).

CONCLUSIONS

Prevalence of medication use in pregnancy is rising and is associated with disproportionate and rapidly escalating cost implications for the Government.

A cross-sectional study on the knowledge, attitude, and practice of pregnant women regarding medication use and restriction during pregnancy

Background

The use of medication during pregnancy is a complex issue that requires careful consideration to avoid potential harm to the developing fetus. Despite the existence of guidelines and restrictions on medication use during pregnancy, pregnant women in Nigeria often have limited access to information regarding drug use and may rely on their own judgment or the advice of non-professionals when making decisions about medication use.

Objectives

To assess Nigerian pregnant women's knowledge, attitude, and practice toward the use of drugs and restriction/contraindications in pregnancy.

Methods

A descriptive cross-sectional study was conducted among pregnant women who visited the Federal Medical Center, Umuahia, from January to February 2023. A self-administered questionnaire was answered by conveniently sampled participants. Data were collected about their sociodemographic characteristics, knowledge, attitude, and practice. Descriptive statistics and inferential statistics utilizing the Pearson's chi-Square test were used for data analysis. The level of significance was set at p < 0.05.

Results

One hundred and fifty-two pregnant women completed the questionnaire (60.8% response rate) and were mostly married (n = 148; 95.0%). Majority were between the age of 25 to 35 years (n = 107; 70.4%), had a university/bachelor's degree (n = 94; 61.8%), and were business women (n = 85; 56.0%). About 35.5% of the respondents had good knowledge of medication restrictions in pregnancy. The majority of the respondents had a positive attitude (n = 98; 64.5%) and good practice (n = 139; 91.4%).

Conclusion

The findings established that a substantial proportion of the women had a positive attitude and good practice of medication use and restrictions in pregnancy. However, the level of knowledge was surprisingly poor among the study group. There is a need to educate pregnant women on safe medication use and avoidance during pregnancy.

Over-the-Counter Pain Medication Use During Pregnancy

PURPOSE

To examine over-the-counter pain medication use in pregnancy.

STUDY DESIGN AND METHODS

Secondary analysis of a weighted surveillance survey using the 2019 Iowa Pregnancy Risk Assessment Monitoring System (PRAMS) data. A sample of 759 pregnant women of childbearing age from Iowa was weighted to represent 31,728 Iowa mothers. The weighted sample represents 80% non-Hispanic White mothers, with smaller percentages of Hispanic (10%) mothers and non-Hispanic Black (7%) mothers, consistent with the population of Iowa. Approximately two-thirds of women had commercial insurance (66%), some college or greater education (62%), and were from urban areas (59%).

ANALYSIS

Descriptive statistics were calculated. Variables include over-the-counter pain reliever usage among all respondents and by race/ethnicity and education level.

RESULTS

Seventy-six percent of women reported taking over-the-counter pain relievers during pregnancy. Of these, 71% reported taking acetaminophen, 11% reported taking ibuprofen, 8% aspirin, and 3% naproxen. Nearly 80% of non-Hispanic White mothers reported taking an over-the-counter pain reliever during pregnancy compared to just 64% of mothers reported as Hispanic. Iowa mothers with a college education or greater were more likely to report over-the-counter pain reliever use during pregnancy (84%) than their counterparts with a high school education or less (64%).

CLINICAL IMPLICATIONS

Some medications may cause harm to the fetus if taken at specific time during pregnancy. Reinforcement of current pain medication education, including risks to fetus throughout pregnancy may be needed.

Stimulating solidarity to improve knowledge on medications used during pregnancy : A contribution from the ConcePTION project

BACKGROUND

Pregnant people have been overlooked or excluded from clinical research, resulting in a lack of scientific knowledge on medication safety and efficacy during pregnancy. Thus far, both the opportunities to generate evidence-based knowledge beyond clinical trials and the role of pregnant people in changing their status quo have not been discussed. Some scholars have argued that for rare disease patients, for whom, just like pregnant people, a poor evidence base exists regarding treatments, solidarity has played an important role in addressing the evidence gap. This paper explores whether and how the enactment of solidarity among pregnant people can be stimulated to help address the poor evidence base on medications used during pregnancy.

METHOD

We use the concept of solidarity formulated by Prainsack and Buyx and enrich their concept by providing an account for stimulating the enactment of solidarity. Then we apply this account to the case of pregnant people who use medication.

RESULTS

Solidarity means enacted commitment on the part of an individual to assisting others with whom the person recognizes a similarity in a relevant respect. Although solidarity cannot be imposed, we argue that the empowerment of people is a crucial concept in understanding how solidarity can be stimulated. Empowerment in the context of pregnant people means creating awareness about their status quo, explaining how scientific research can help close the knowledge gap, and how pregnant people can themselves contribute. In particular, how pregnant people can contribute to the collection of health data to strengthen the evidence base for medications used during pregnancy.

CONCLUSIONS

We conclude that acting in solidarity can help change the status quo for pregnant people. Furthermore, we argue that the empowerment of pregnant people and other relevant stakeholders is a way to stimulate the enactment of solidarity. The process of empowerment starts by raising awareness about the lack of evidence on medications used during prengnacy and by explaining to pregnant people how they can contribute to changing the way knowledge is being generated by, for example, sharing data on the health effects of medications.

Monitoring medicine prescriptions before, during and after pregnancy in Italy

BACKGROUND

The use of medications during pregnancy is a common event worldwide. Monitoring medicine prescriptions in clinical practice is a necessary step in assessing the impact of therapeutic choices in pregnant women as well as the adherence to clinical guidelines. The aim of this study was to provide prevalence data on medication use before, during and after pregnancy in the Italian population.

METHODS

A retrospective prevalence study using administrative healthcare databases was conducted. A cohort of 449,012 pregnant women (15-49 years) residing in eight Italian regions (59% of national population), who delivered in 2016-2018, were enrolled. The prevalence of medication use was estimated as the proportion (%) of pregnant women with any prescription.

RESULTS

About 73.1% of enrolled women received at least one drug prescription during pregnancy, 57.1% in pre-pregnancy and 59.3% in postpartum period. The prevalence of drug prescriptions increased with maternal age, especially during the 1st trimester of pregnancy. The most prescribed medicine was folic acid (34.6%), followed by progesterone (19%), both concentrated in 1st trimester of pregnancy (29.2% and 14.8%, respectively). Eight of the top 30 most prescribed medications were antibiotics, whose prevalence was higher during 2nd trimester of pregnancy in women ≥ 40 years (21.6%). An increase in prescriptions of anti-hypertensives, antidiabetics, thyroid hormone and heparin preparations was observed during pregnancy; on the contrary, a decrease was found for chronic therapies, such as anti-epileptics or lipid-modifying agents.

CONCLUSIONS

This study represents the largest and most representative population-based study illustrating the medication prescription patterns before, during and after pregnancy in Italy. The observed prescriptive trends were comparable to those reported in other European countries. Given the limited information on medication use in Italian pregnant women, the performed analyses provide an updated overview of drug prescribing in this population, which can help to identify critical aspects in clinical practice and to improve the medical care of pregnant and childbearing women in Italy.

Paracetamol use in pregnancy: Not as safe as we may think?

Paracetamol is used by more than 50% of women worldwide during pregnancy; headache representing the most frequent indication. Several studies report that long-term exposure to paracetamol in utero is associated with adverse neurodevelopmental outcomes in children, indicating a dose-response effect. However, less or no risk is found to be associated with short-term exposure. Paracetamol most likely crosses the placenta through passive diffusion, and there are several possible mechanisms for how paracetamol might affect fetal brain development. Although the literature suggests an association between prenatal paracetamol exposure and neurodevelopmental outcomes, the role of confounders cannot be ruled out. Consequently, as a precaution, we believe that pregnant women should be recommended ideally to only use paracetamol to treat conditions that might harm the fetus, such as severe pain or a high fever. This Comment aims to put focus on the potential fetal risks of paracetamol exposure in utero.

Association of maternal personality traits with medication use during pregnancy to appraise unmeasured confounding in long-term pharmacoepidemiological safety studies

Maternal personality is a possible confounder on the association between prenatal medication exposure and long-term developmental outcomes in offspring, but it is often unmeasured. This study aimed to (i) estimate the association between five maternal personality traits and prenatal use of acetaminophen (including extended use), opioid analgesics, antidepressants, benzodiazepines/z-hypnotics, and antipsychotics; (ii) evaluate, using an applied example, whether unmeasured confounding by maternal neuroticism would make the association between prenatal antidepressant-child ADHD null, using the E-value framework. We used data from 8,879 pregnant women and recent mothers who participated in the Multinational Medication Use in Pregnancy Study, a web-based cross-sectional study performed within the period from 1-Oct-2011 to 29-Feb-2012 in Europe, North America and Australia. Medication use in pregnancy was self-reported by the women. Personality was assessed with the Big Five Inventory, capturing the dimensions of neuroticism, extraversion, openness, agreeableness, and conscientiousness. Adjusted logistic regression analyses were conducted for each trait-medication pair, using the survey weighting. There was a strong association between having high neuroticism and prenatal use of antidepressants (Odds Ratio (OR): 5.63, 95% Confidence Interval (CI): 3.96-8.01), benzodiazepines/z-hypnotics (OR: 6.66, 95% CI: 4.05-10.95), and analgesic opioids (OR: 2.24, 95% CI: 1.41-3.56), but not with antipsychotics. Among women with mental illness, this association attenuated for benzodiazepines/z-hypnotics, but decreased to the null for antidepressants. High neuroticism (OR: 1.31, 95% CI: 1.08-1.59) and high openness (OR: 0.77, 95% CI: 0.64-0.93) were associated with extended use of acetaminophen. The E-value for the Hazard Ratio 1.93 in the applied example was 3.27. If the example study was conducted using a population comparison group, high maternal neuroticism could have explained away the association antidepressant-ADHD. Because the example study included only women with a mental illness, this risk of bias was assessed as minimal. Various personality dispositions in the mother are associated, with a different degree, to prenatal use of medication. The strength of these association can aid researchers in evaluating the influence of uncontrolled confounding by maternal personality in long-term safety studies in pregnancy, using the E-value. This assessment should always be performed in addition to a rigorous study design using approaches to triangulate the evidence.

Impact of a primary care pharmacist consultations on pregnant women's medication use: the SafeStart intervention study linked to a national prescription database

BACKGROUND

Prior studies show that pharmacist consultations are highly appreciated by pregnant women and feasible in community pharmacies. However, it is unknown whether such counseling has an impact on medication use during pregnancy.

AIM

This study aimed to assess whether a pharmacist consultation in early pregnancy was associated with pregnant women's medication use, with a focus on antiemetic medications.

METHOD

The SafeStart study recruited Norwegian pregnant women in the first trimester between February 2018 and February 2019. Women in the intervention group received a pharmacist consultation in a community pharmacy or by phone. A follow-up questionnaire was completed 13 weeks after enrollment. Data from the SafeStart study were linked to the Norwegian Prescription Database. Logistic regression was used to assess the association between the pharmacist intervention and medication use in the second trimester.

RESULTS

The study included 103 women in the intervention group and 126 in the control group. Overall prescription fills in the first and second trimesters were 55% and 45% (intervention group) and 49% and 52% (control group), respectively. In total, 16-20% of women in the first trimester and 21-27% of women in the second trimester had a prescription for antiemetics. The pharmacist intervention was not associated with women's medication use in the second trimester.

CONCLUSION

This study did not detect an impact of a pharmacist consultation on pregnant women's use of medications. In the future, pharmacist consultations should focus on other outcome factors, such as risk perception, knowledge level, and the use of other health care services. Trial registration The SafeStart study is registered with ClinicalTrials.gov (identifier: NCT04182750, registration date: December 2, 2019).

Effects of prenatal exposure to (es)citalopram and maternal depression during pregnancy on DNA methylation and child neurodevelopment

Studies assessing associations between prenatal exposure to antidepressants, maternal depression, and offspring DNA methylation (DNAm) have been inconsistent. Here, we investigated whether prenatal exposure to citalopram or escitalopram ((es)citalopram) and maternal depression is associated with differences in DNAm. Then, we examined if there is an interaction effect of (es)citalopram exposure and DNAm on offspring neurodevelopmental outcomes. Finally, we investigated whether DNAm at birth correlates with neurodevelopmental trajectories in childhood. We analyzed DNAm in cord blood from the Norwegian Mother, Father and Child Cohort Study (MoBa) biobank. MoBa contains questionnaire data on maternal (es)citalopram use and depression during pregnancy and information about child neurodevelopmental outcomes assessed by internationally recognized psychometric tests. In addition, we retrieved ADHD diagnoses from the Norwegian Patient Registry and information on pregnancies from the Medical Birth Registry of Norway. In total, 958 newborn cord blood samples were divided into three groups: (1) prenatal (es)citalopram exposed (n = 306), (2) prenatal maternal depression exposed (n = 308), and (3) propensity score-selected controls (n = 344). Among children exposed to (es)citalopram, there were more ADHD diagnoses and symptoms and delayed communication and psychomotor development. We did not identify differential DNAm associated with (es)citalopram or depression, nor any interaction effects on neurodevelopmental outcomes throughout childhood. Trajectory modeling identified subgroups of children following similar developmental patterns. Some of these subgroups were enriched for children exposed to maternal depression, and some subgroups were associated with differences in DNAm at birth. Interestingly, several of the differentially methylated genes are involved in neuronal processes and development. These results suggest DNAm as a potential predictive molecular marker of later abnormal neurodevelopmental outcomes, but we cannot conclude whether DNAm links prenatal (es)citalopram exposure or maternal depression with child neurodevelopmental outcomes.

Treatment options and their uptake among women with symptoms of perinatal depression: exploratory study in Norway and Portugal

BACKGROUND

Perinatal depression is the most undertreated clinical condition during the perinatal period. Knowledge about women's decision-making in seeking and receiving treatment is scarce.

AIMS

To investigate and compare treatment option uptake in perinatal women with depressive symptoms in Portugal and Norway, and to identify sociodemographic and health-related factors associated with treatment uptake.

METHOD

Participants were women resident in Portugal or Norway (≥18 years) who were pregnant or had given birth in the past 12 months, who presented with active depressive symptoms (Edinburgh Postnatal Depression Scale score ≥10). In an electronic questionnaire, women reported treatment received and sociodemographic and health-related factors.

RESULTS

The sample included 416 women from Portugal and 169 from Norway, of which 79.8% and 53.9%, respectively, were not receiving any treatment. Most Portuguese women were receiving psychological treatment, either alone (45.2%) or combined with pharmacological treatment (21.4%). Most Norwegian participants were receiving only pharmacological (36.5%) or combined treatment (35.4%). Compared with the Portuguese sample, a higher proportion of Norwegian women started treatment before pregnancy (P < 0.001). In Portugal, lower depressive symptoms and self-reported psychopathology were significantly associated with higher likelihood of receiving treatment.

CONCLUSIONS

We found that, in both Norway and Portugal, a substantial number of perinatal women with depressive symptoms do not receive any treatment. Differences exist regarding the chosen treatment option and timing of treatment initiation in the two countries. Only mental health-related factors were associated with treatment uptake for perinatal depression in Portugal. Our results highlight the importance of implementing strategies aimed to improve help-seeking behaviours.

Core Data Elements for Pregnancy Pharmacovigilance Studies Using Primary Source Data Collection Methods: Recommendations from the IMI ConcePTION Project

INTRODUCTION AND OBJECTIVE

The risks and benefits of medication use in pregnancy are typically established through post-marketing observational studies. As there is currently no standardised or systematic approach to the post-marketing assessment of medication safety in pregnancy, data generated through pregnancy pharmacovigilance (PregPV) research can be heterogenous and difficult to interpret. The aim of this article is to describe the development of a reference framework of core data elements (CDEs) for collection in primary source PregPV studies that can be used to standardise data collection procedures and, thereby, improve data harmonisation and evidence synthesis capabilities.

METHODS

This CDE reference framework was developed within the Innovative Medicines Initiative (IMI) ConcePTION project by experts in pharmacovigilance, pharmacoepidemiology, medical statistics, risk-benefit communication, clinical teratology, reproductive toxicology, genetics, obstetrics, paediatrics, and child psychology. The framework was produced through a scoping review of data collection systems used by established PregPV datasets, followed by extensive discussion and debate around the value, definition, and derivation of each data item identified from these systems.

RESULTS

The finalised listing of CDEs comprises 98 individual data elements, arranged into 14 tables of related fields. These data elements are openly available on the European Network of Teratology Information Services (ENTIS) website ( http://www.entis-org.eu/cde ).

DISCUSSION

With this set of recommendations, we aim to standardise PregPV primary source data collection processes to improve the speed at which high-quality evidence-based statements can be provided about the safety of medication use in pregnancy.

Potential adverse actions of prenatal exposure of acetaminophen to offspring

Acetaminophen (APAP) is a widely used as analgesic and antipyretic drug. APAP is also added as an active ingredient in various medications to relieve pain and reduce fever. APAP has been widely used in pregnant women in the past decades because it is considered a relatively safe drug with recommended dose in different countries. However, an increasing number of epidemiological and experimental studies have shown that APAP exposure during pregnancy may increase the risk of inducing reproductive and neurobehavior dysfunctions, hepatotoxicity in offspring. This review aims to assess the potential effects of prenatal APAP exposure on offspring growth and development.

Concomitant use of medicinal plants and pharmaceutical drugs among pregnant women in southern Ethiopia

Background

In several African nations, including Ethiopia, improving mother and child health is a top public health concern. Unfortunately, there is a dearth of study on pregnant women in Ethiopia who concomitantly utilize pharmaceutical drugs and medicinal plants. Hence, the objective of this research was to assess the concomitant use of pharmaceutical drugs and medicinal plants among pregnant women in Southern Ethiopia in 2021.

Methods

A community-based cross-sectional study was conducted among systematically selected 400 pregnant women in Shashamane town, Southern Ethiopia, from July 1-30/2021. An interviewer-administered structured questionnaire was used to collect data. Binary logistic regression was performed to examine the association between a dependent variable and independent variables.

Results

According to this study, among those who self-medicated, 90 (22.5%) reported using at least one pharmaceutical drug, while 180 (45%) reported using at least one medicinal plant. Moreover, 68 (17%) of the participants who had taken drugs while pregnant also used pharmaceutical drugs and medicinal plants concomitantly. Having a medical condition during pregnancy (AOR = 5.6, 95% CI: 2.7-11.6), not having ANC follow up (AOR = 2.9, 95% CI: 1.3-6.2), gestational age (AOR = 4.2, 95% CI: 1.6-10.7), and not having a formal education (AOR = 4.2, 95% CI: 1.3-13.4) were all significantly associated with concomitant use of pharmaceutical drugs and medicinal plants during pregnancy.

Conclusion

This study showed that nearly one in five pregnant women used medicinal plants concomitantly with pharmaceutical drugs. Mother's educational status, medical illness during pregnancy, having ANC follow up and gestational period were significantly associated with concomitant use of medicinal plants and pharmaceutical drugs. Therefore, health care providers and concerned stakeholders should consider these factors to minimize the risks associated with drug use during pregnancy on both mother and fetus.

Drug exposure during pregnancy: Current understanding and approaches to measure maternal-fetal drug exposure

Prescription drug use is prevalent during pregnancy, yet there is limited knowledge about maternal-fetal safety and efficacy of this drug use because pregnant individuals have historically been excluded from clinical trials. Underrepresentation has resulted in a lack of data available to estimate or predict fetal drug exposure. Approaches to study fetal drug pharmacology are limited and must be evaluated for feasibility and accuracy. Anatomic and physiological changes throughout pregnancy fluctuate based on gestational age and can affect drug pharmacokinetics (PK) for both mother and fetus. Drug concentrations have been studied throughout different stages of gestation and at or following delivery in tissue and fluid biospecimens. Sampling amniotic fluid, umbilical cord blood, placental tissue, meconium, umbilical cord tissue, and neonatal hair present surrogate options to quantify and characterize fetal drug exposure. These sampling methods can be applied to all therapeutics including small molecule drugs, large molecule drugs, conjugated nanoparticles, and chemical exposures. Alternative approaches to determine PK have been explored, including physiologically based PK modeling, in vitro methods, and traditional animal models. These alternative approaches along with convenience sampling of tissue or fluid biospecimens can address challenges in studying maternal-fetal pharmacology. In this narrative review, we 1) present an overview of the current understanding of maternal-fetal drug exposure; 2) discuss biospecimen-guided sampling design and methods for measuring fetal drug concentrations throughout gestation; and 3) propose methods for advancing pharmacology research in the maternal-fetal population.

Interventions to enhance medication adherence in pregnancy- a systematic review

BACKGROUND

Sub-optimal medication adherence in pregnant women with chronic disease and pregnancy-related indications has the potential to adversely affect maternal and perinatal outcomes. Adherence to appropriate medications is advocated during and when planning pregnancy to reduce risk of adverse perinatal outcomes relating to chronic disease and pregnancy-related indications. We aimed to systematically identify effective interventions to promote medication adherence in women who are pregnant or planning to conceive and impact on perinatal, maternal disease-related and adherence outcomes.

METHODS

Six bibliographic databases and two trial registries were searched from inception to 28th April 2022. We included quantitative studies evaluating medication adherence interventions in pregnant women and women planning pregnancy. Two reviewers selected studies and extracted data on study characteristics, outcomes, effectiveness, intervention description (TIDieR) and risk of bias (EPOC). Narrative synthesis was performed due to study population, intervention and outcome heterogeneity.

RESULTS

Of 5614 citations, 13 were included. Five were RCTs, and eight non-randomised comparative studies. Participants had asthma (n = 2), HIV (n = 6), inflammatory bowel disease (IBD; n = 2), diabetes (n = 2) and risk of pre-eclampsia (n = 1). Interventions included education +/- counselling, financial incentives, text messaging, action plans, structured discussion and psychosocial support. One RCT found an effect  of the tested intervention on self-reported antiretroviral adherence but not objective adherence. Clinical outcomes were not evaluated. Seven non-randomised comparative studies found an association between the tested intervention and at least one outcome of interest: four found an association between receiving the intervention and both improved clinical or perinatal outcomes and adherence in women with IBD, gestational diabetes mellitus (GDM), and asthma. One study in women with IBD reported an association between receiving the intervention and maternal outcomes but not for self-reported adherence. Two studies measured only adherence outcomes and reported an association between receiving the intervention and self-reported and/or objective adherence in women with HIV and risk of pre-eclampsia. All studies had high or unclear risk of bias. Intervention reporting was adequate for replication in two studies according to the TIDieR checklist.

CONCLUSIONS

There is a need for high-quality RCTs reporting replicable interventions to evaluate medication adherence interventions in pregnant women and those planning pregnancy. These should assess both clinical and adherence outcomes.

Safety of drugs used for the treatment of migraine during pregnancy: a narrative review

INTRODUCTION

Migraine is common in females of childbearing age and negatively impacts quality of life. The majority of those with migraine who become pregnant see an improvement in their condition but not all do. Providing evidence-based recommendations for the pharmacological management of migraine in pregnancy is challenging.

AREAS COVERED

This narrative review provides an update on the safety of drugs used for migraine in pregnancy. National and international guidelines on the management of episodic migraine in adults were used to select the drugs of relevance to pregnant women. The final list of drugs was chosen by a pain specialist who categorized them according to drug class and use in acute management or prevention. PubMed was searched from inception to 31st July 2022 for evidence on drug safety.

EXPERT OPINION

Obtaining high-quality drug safety data in pregnant migraineurs is difficult not least because exposing a fetus to research-related risks is often considered unethical. There is reliance on observational studies which often group drugs together and lack specificities pertinent to drug prescribing like timing, dosing and duration. Improved statistical tools, study designs and the creation of international collaborative frameworks are ways to advance knowledge on drug safety in pregnancy.

Women's experiences of over-the-counter and prescription medication during pregnancy in the UK: findings from survey free-text responses and narrative interviews

OBJECTIVES

To explore women's experiences of over-the-counter and prescription medication advice and use during pregnancy.

DESIGN

A study design consisting of an online survey and nested in-depth interviews with a subsample of participants. We analysed data from survey free-text responses and in-depth interviews using thematic analysis. Quantitative survey data is published elsewhere.

SETTING

The UK.

PARTICIPANTS

Women were eligible if living in the UK, aged 16-45 years, were pregnant or had been pregnant in the last 5 years regardless of pregnancy outcome. A total of 7090 women completed the survey, and 34 women who collectively had experienced 68 pregnancies were subsequently interviewed.

RESULTS

Medication prescribing and use during pregnancy was common. The prescribing, dispensing and taking of some advised medications were restricted through women's or prescribers' fear of fetal harm. Lack of adherence to national prescribing guidance, conflicting professional opinion and poor communication resulted in maternal anxiety, avoidable morbidity and women negotiating complex and distressing pathways to obtain recommended medications. In contrast, some women felt overmedicated and that pharmacological treatments were used without exploring other options first.

CONCLUSION

Increased translation of national guidance into practice and greater personalisation of antenatal care are needed to improve the safety, efficacy and personalisation of prescribing in pregnancy.

Effects of Prenatal Paracetamol Exposure on the Development of Asthma and Wheezing in Childhood: A Systematic Review and Meta-Analysis

The aim of the report was to evaluate whether in utero exposure to paracetamol is associated with risk towards developing respiratory disorders such as asthma and wheeze after birth. MEDLINE (PubMed), EMBASE and Cochrane Library databases were searched for articles published in English to December 2021. The study involved 330,550 women. We then calculated the summary risk estimates and 95% CIs and plotted forest plots using random effect models (DerSimonian-Laird method) and fixed effect models. We also performed a systematic review of the chosen articles and a meta-analysis of studies based on the guidelines outlined in the PRISMA statement. Accordingly, maternal exposure to paracetamol during pregnancy was associated with a significant increased risk of asthma: crude OR = 1.34, 95% CI: 1.22 to 1.48, p < 0.001; and significant increased risk of wheeze: crude OR = 1.31, 95% CI: 1.12 to 1.54, p < 0.002. Results of our study confirmed that maternal paracetamol use in pregnancy is associated with an enhanced risk of asthma and wheezing in their children. We believe paracetamol should be used with caution by pregnant women, and at the lowest effective dose, and for the shortest duration. Long-term use or the use of high doses should be limited to the indications recommended by a physician and with the mother-to-be under constant supervision.