Major Malformations Following Exposure to Nonsteroidal Antiinflammatory Drugs During the First Trimester of Pregnancy

Pregnancy outcomes and birth defects in offspring following Non-steroidal anti-inflammatory drugs exposure during pregnancy: A systematic review and meta-analysis

There is a high global prevalence of NSAIDs during pregnancy. However, current evidence is largely conflicting regarding the safety of gestational NSAIDs use both for the pregnancy and offspring health. The aim of this study is to systematically review the relationship between NSAIDs use during pregnancy and the risk of adverse pregnancy outcomes and congenital abnormalities. Cohort studies and case control studies on congenital malformations, miscarriage and preterm birth in infants born to mothers who were exposed to NSAIDs during pregnancy were identified via PubMed, Medline, Embase, the Cochrane Library databases and the Reprotox® database from inception to 26 March 2021, and updated on 6 April 2023. On the whole, compared with the unexposed group, infants exposed to NSAIDs during early pregnancy showed a 28% increased risk of overall congenital anomalies (OR 1.28, 95%CI 1.16-1.40), and 19% for major birth defects (OR 1.19, 95%CI 1.08-1.30). Contrary to previous beliefs, there appeared to be a trend towards a higher risk of miscarriage among women who were exposed to NSAIDs during pregnancy, but the association was not statistically significant (OR 1.20, 95%CI 0.93-1.55). According to our study findings, the use of NSAIDs by pregnant women has been linked to a higher risk of congenital anomalies and a negative impact on preterm birth. Therefore, we advise pregnant women to carefully consider the potential benefits and risks before using NSAIDs during pregnancy.

Pericardial Diseases in Pregnancy

Pericardial effusion is the most common manifestation of pericardial diseases during pregnancy. This effusion is benign, mild, or moderate, well tolerated, with spontaneous resolution after delivery; no specific treatment is required. Acute pericarditis is the second most common condition, usually requiring medical therapy during pregnancy. Cardiac tamponade and constrictive pericarditis are rare in pregnancy. Pre-pregnancy counselling is essential in women of childbearing age with recurrent pericarditis to plan pregnancy in a phase of disease quiescence and to review therapy. High-dose aspirin or nonselective nonsteroidal anti-inflammatory drugs, such as ibuprofen and indomethacin, can be used up to the 20th week of gestation. Low-dose prednisone (2.5-10 mg/d) can be administered throughout pregnancy. All of these medications, apart from high-dose aspirin, may be used during lactation. Colchicine is compatible with pregnancy and breastfeeding, and it can be continued throughout pregnancy to prevent recurrences. Appropriate follow-up with a multidisciplinary team with experience in the field is recommended throughout pregnancy to ensure good maternal and fetal outcomes.

Maternal and fetal outcomes in pregnant women with rheumatoid arthritis: a systematic review and meta-analysis

OBJECTIVE

Rheumatoid arthritis (RA) is a common chronic systemic autoimmune disease affecting women of childbearing age. We aimed to conduct a meta-analysis of published observational studies to systematically evaluate the association between RA and adverse pregnancy outcomes.

METHODS

Medline (PubMed), EMBASE, and Web of Science were searched for keywords from the date of inception to December 28, 2021, to identify relevant studies reporting adverse maternal and/or fetal outcomes in RA pregnancies. Data from individual studies were pooled using random-effects models and presented as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Eighteen studies with a total number of over 50 million participants were eligible for inclusion. This current analysis showed that in pregnant women with RA, there was a significantly increased risk of adverse maternal outcomes, including caesarean section (OR, 1.39; 95% CI 1.24-1.55), pre-eclampsia (OR, 1.48; 95% CI 1.19-1.83), gestational hypertension (OR, 1.34; 95% CI 1.07-1.68) and spontaneous abortion (OR, 1.16; 95% CI 1.04-1.29). Similarly, maternal RA during pregnancy was also associated with a significantly increased risk of adverse fetal outcomes, including preterm birth (OR, 1.58; 95% CI 1.44-1.74), small for gestational age (OR, 1.49; 95% CI 1.22-1.82), low birth weight (OR, 1.45; 95% CI 1.30-1.63), congenital anomalies (OR, 1.36; 95% CI 1.01-1.83) and stillborn (OR, 1.38; 95% CI 1.09-1.74).

CONCLUSION

Maternal RA is significantly associated with an increased risk of adverse maternal and fetal outcomes. Close monitoring of the clinical status of RA patients before and during pregnancy is essential in clinical practice. Key Points • Pregnant women with rheumatoid arthritis (RA) are at significantly increased risk for adverse maternal and fetal outcomes. • The increased risk of adverse pregnancy outcomes in women with RA may be closely related to medication use and disease activity. • Close monitoring of the clinical status of RA patients before and during pregnancy is essential in clinical practice.

Neonatal and maternal adverse outcomes and exposure to nonsteroidal anti-inflammatory drugs during early pregnancy in South Korea: A nationwide cohort study

BACKGROUND

Existing data on the use of nonsteroidal anti-inflammatory drugs (NSAIDs) during late pregnancy is well established, providing assurance. However, the use of NSAIDs during early pregnancy remains inconclusive owing to conflicting findings on adverse neonatal outcomes as well as the limited data on adverse maternal outcomes. Therefore, we sought to investigate whether early prenatal exposure to NSAIDs was associated with neonatal and maternal adverse outcomes.

METHODS AND FINDINGS

We conducted a nationwide, population-based cohort study using Korea's National Health Insurance Service (NHIS) database with a mother-offspring cohort constructed and validated by the NHIS to include all live births in women aged 18 to 44 years between 2010 and 2018. We defined exposure to NSAIDs as at least two records of NSAID prescriptions during early pregnancy (first 90 days of pregnancy for congenital malformations and first 19 weeks for nonmalformation outcomes) and compared against three distinct referent groups of (1) unexposed, no NSAID prescription during the 3 months before pregnancy start to end of early pregnancy; (2) acetaminophen-exposed, at least two acetaminophen prescriptions during early pregnancy (i.e., active comparator); and (3) past users, at least two NSAID prescriptions before the start of pregnancy but no relevant prescriptions during pregnancy. Outcomes of interest were adverse birth outcomes of major congenital malformations and low birth weight and adverse maternal outcomes of antepartum hemorrhage and oligohydramnios. We estimated relative risks (RRs) with 95% CIs using generalized linear models within a propensity score (PS) fine stratification weighted cohort that accounted for various potential confounders of maternal sociodemographic characteristics, comorbidities, co-medication use, and general markers of burden of illness. Of 1.8 million pregnancies in the PS weighted analyses, exposure to NSAIDs during early pregnancy was associated with slightly increased risks for neonatal outcomes of major congenital malformations (PS-adjusted RR, 1.14 [CI, 1.10 to 1.18]) and low birth weight (1.29 [1.25 to 1.33]), and for maternal outcome of oligohydramnios (1.09 [1.01 to 1.19]) but not antepartum hemorrhage (1.05 [0.99 to 1.12]). The risks of overall congenital malformations, low birth weight, and oligohydramnios remained significantly elevated despite comparing NSAIDs against acetaminophen or past users. Risks of adverse neonatal and maternal outcomes were higher with cyclooxygenase-2 selective inhibitors or use of NSAIDs for more than 10 days, whereas generally similar effects were observed across the three most frequently used individual NSAIDs. Point estimates were largely consistent across all sensitivity analyses, including the sibling-matched analysis. Main limitations of this study are residual confounding by indication and from unmeasured factors.

CONCLUSIONS

This large-scale, nationwide cohort study found that exposure to NSAIDs during early pregnancy was associated with slightly higher risks of neonatal and maternal adverse outcomes. Clinicians should therefore carefully weigh the benefits of prescribing NSAIDs in early pregnancy against its modest, but possible, risk of neonatal and maternal outcomes, where if possible, consider prescribing nonselective NSAIDs for <10 days, along with continued careful monitoring for any safety signals.

A Systematic Review of the Safety of Blocking the IL-1 System in Human Pregnancy

Blockade of the interleukin-1 (IL-1) pathway has been used therapeutically in several inflammatory diseases including arthritis and cryopyrin-associated periodic syndrome (CAPS). These conditions frequently affect women of childbearing age and continued usage of IL-1 specific treatments throughout pregnancy has been reported. IL-1 is involved in pregnancy complications and its blockade could have therapeutic potential. We systematically reviewed all reported cases of IL-1 blockade in human pregnancy to assess safety and perinatal outcomes. We searched several databases to find reports of specific blockade of the IL-1 pathway at any stage of pregnancy, excluding broad spectrum or non-specific anti-inflammatory intervention. Our literature search generated 2439 references of which 22 studies included, following extensive review. From these, 88 different pregnancies were assessed. Most (64.8%) resulted in healthy term deliveries without any obstetrical/neonatal complications. Including pregnancy exposed to Anakinra or Canakinumab, 12 (15.0%) resulted in preterm birth and one stillbirth occurred. Regarding neonatal complications, 2 cases of renal agenesis (2.5%) were observed, and 6 infants were diagnosed with CAPS (7.5%). In conclusion, this systematic review describes that IL-1 blockade during pregnancy is not associated with increased adverse perinatal outcomes, considering that treated women all presented an inflammatory disease associated with elevated risk of pregnancy complications.

The Safety of Medications During Pregnancy and Lactation in Patients with Inflammatory Rheumatic Diseases

The advances in treatments, including disease-modifying anti-rheumatic drugs and biologic agents, have significantly improved the management of inflammatory rheumatic diseases, allowing females with severe disease to become pregnant and lactate, previously considered as prohibited. Maintaining low disease activity with medications known to be safe from pre-conception to post-partum is a key point in reducing adverse pregnancy outcomes. Numerous observational and case studies have provided a growing amount of evidence on the use of safe anti-rheumatic medications in patients during pregnancy and lactation. Based on this information, this review discusses the safety of medications for patients with inflammatory rheumatic diseases during pregnancy and lactation. Among these, hydroxychloroquine, sulfasalazine, azathioprine, low-dose glucocorticoids, and low-dose aspirin are considered compatible with pregnancy, while methotrexate, cyclophosphamide, mycophenolate mofetil, and leflunomide are contraindicated. Non-steroidal anti-inflammatory drugs are only recommended for use early in pregnancy, as they are reported to cause rare but serious kidney problems in the fetus after 20 weeks or later. Cyclosporin, tacrolimus, and anti-TNF agents can be continued throughout pregnancy if the benefit is greater than the potential risk for the individual patient. Physicians should carefully weigh the risks and benefits of medications in patients with inflammatory rheumatic diseases considering pregnancy.

[Pain management during pregnancy : An expert-based interdisciplinary consensus recommendation]

Hintergrund

Schwangerschaft und Schmerzen unterschiedlicher Herkunft sind eine ungünstige Kombination, die alle BehandlerInnen vor besondere Herausforderungen stellt. Schmerzen beeinflussen die Homöostase des Menschen negativ. Compliance der Patientin und fundiertes Wissen über Fetotoxizität und Teratogenität von Analgetika sind nötig, um die Balance zwischen Therapie der Mutter und Sicherheit des Ungeborenen zu wahren.

Ziel der Arbeit

ExpertInnen verschiedener Disziplinen, die mit der Betreuung von schwangeren Schmerzpatientinnen betraut sind, haben sich zusammengeschlossen, um medikamentöse und nichtmedikamentöse Therapiekonzepte zu erstellen, mit dem Ziel, eine suffiziente Analgesie von schwangeren Schmerzpatientinnen zu ermöglichen.

Material und Methode

Relevante Fragestellungen wurden durch ExpertInnen formuliert und einer Literatursuche unterzogen. Kombiniert mit weiteren nationalen und internationalen Empfehlungen wurden Behandlungskonzepte entwickelt, interdisziplinär diskutiert und im Anschluss Kernaussagen erstellt, die mit Empfehlungsgraden abgestuft wurden.

Ergebnisse

Abhängig vom Trimenon können bei Schmerzen Paracetamol, Ibuprofen, Diclofenac, Metamizol und Opioide wohlüberlegt verabreicht werden, besondere Vorsicht ist bei nichtsteroidalen Antirheumatika (NSAR) im letzten Trimenon geboten. COX-2-Hemmer werden nicht empfohlen. Bei neuropathischen Schmerzen gelten Amitriptylin, Duloxetin, Venlafaxin als sicher. Bei starker Migräne kann Sumatriptan zum Einsatz kommen. Nichtmedikamentöse Therapien wie transkutane elektrische Nervenstimulation (TENS-Therapie), Kinesio-Tapes und Akupunktur gelten als sicher. Lymphdrainagen werden bei Ödemen empfohlen, sofern sie nicht durch eine Präeklampsie bedingt sind.

Schlussfolgerung

Die Therapie sollte mit einer nichtmedikamentösen Behandlung beginnen und eskalierend in einer Kombination aus medikamentösen und nichtmedikamentösen Konzepten enden.

Exposure of human fetal kidneys to mild analgesics interferes with early nephrogenesis

Acetaminophen, aspirin, and ibuprofen are mild analgesics commonly used by pregnant women, the sole current recommendation being to avoid ibuprofen from the fifth month of gestation. The nephrotoxicity of these three analgesics is well documented in adults, as is their interference with prostaglandins biosynthesis. Here we investigated the effect of these analgesics on human first trimester kidneys ex vivo. We first evaluated prostaglandins biosynthesis functionality by performing a wide screening of prostaglandin expression patterns in first trimester human kidneys. We demonstrated that prostaglandins biosynthesis machinery is functional during early nephrogenesis. Human fetal kidney explants aged 7-12 developmental weeks were exposed ex vivo to ibuprofen, aspirin or acetaminophen for 7 days, and analyzed by histology, immunohistochemistry, and flow cytometry. This study has revealed that these analgesics induced a spectrum of abnormalities within early developing structures, ranging from cell death to a decline in differentiating glomeruli density. These results warrant caution for the use of these medicines during the first trimester of pregnancy.

First trimester naproxen exposure and outcome of pregnancy - A German case series

In contrast to other non-steroidal anti-inflammatory drugs (NSAIDs), naproxen use during pregnancy is not well studied. The objective of this analysis was to assess negative effects on pregnancy outcomes following naproxen exposure in the first trimester of pregnancy. Out of 121 exposed pregnancies prospectively recorded by two German teratology information services (TIS) 15 ended as spontaneous abortion and ten were electively terminated; in one case for prenatal diagnosis of anencephaly. Four pregnancies were stillborn, in these cases naproxen was discontinued more than two months before the event. Of 95 live-born infants, including three pairs of twins, two were born with major birth defects: one with dysmelia of the left hand and foot and another with a complex congenital heart defect, esophageal atresia with tracheoesophageal fistula, and choanal stenosis. The results of this case series do not suggest that naproxen has a significant teratogenic effect. However, due to the limited cohort size and lack of comparable reference group results should be interpreted with caution and better studied NSAIDs such as ibuprofen should be preferred in the first and second trimester of pregnancy. This work was supported by the German Federal Institute for Drugs and Medical Devices (BfArM).

Safety considerations when using drugs in pregnant patients with systemic lupus erythematosus

Introduction: Systemic lupus erythematosus (SLE) mainly affects young females during childbearing age; therefore, reproductive issues are of major interest.Areas covered: Pregnancy planning is crucial to adjust the treatment toward drugs that are safe throughout pregnancy and breastfeeding. The evidence about drug safety is limited to post-marketing surveillance, registries, case series, and case reports, as pregnant patients are excluded from randomized clinical trials. The aim of this review is to report the safety considerations when treating pregnant SLE patients. Regarding maternal side effects of drugs, we focused on metabolic, infectious, and hemorrhagic complications. Fetal safety was analyzed looking at drugs teratogenicity, their possible effects on immune system, and on the long-term neuropsychological development of children.Expert opinion: The management of pregnancy in SLE has changed when knowledge about the safety of drugs has become available. Keeping SLE disease activity under control before, during and after pregnancy is of fundamental importance to ensure the best possible outcomes for mother and child. All these issues must be discussed with the patient and her family during preconception counseling. International efforts in terms of pregnancy registries and reproductive health guidelines help physicians improve their communication with SLE patients.

An Update on Biologic Agents During Pregnancy

Most biological agents are safe to use in pregnancy. Biologic agents may be divided into 4 risk categories: minimal, uncertain, moderate, and high. Treatment options should be individualized to each patient's disease activity, response to medication, and adverse effects. Hydroxychloroquine, sulfasalazine, azathioprine, cyclosporine A, and low-dose aspirin are considered safe. Glucocorticoids may increase the risk of gestational diabetes and gestational hypertension/preeclampsia. Nonsteroidal medication should only be used during the first trimester and for a short period during the second trimester. Limited experience with tumor necrosis factor-α inhibitor medications suggests minimal risk. Methotrexate, mycophenolate, and leflunomide are contraindicated during pregnancy.

[Systemic drug treatment during pregnancy]

In clinical routine, treatment of pregnant women is a recurring challenge. The frequent opacity of current studies, lack of reliable sources of information and the general insecurity of pregnant women towards systemic drug treatment leads to difficult clinical decision making. Potent therapies with sufficient clinical experience in terms of safety of application are available for most diseases seen in pregnancy. After careful evaluation of potential benefits and risks of a therapy, not only the optimal choice of a medical treatment, but also adequate control of clinical symptoms and interdisciplinary care are crucial for a safe pregnancy.

Medication Use and Pain Management in Pregnancy: A Critical Review

BACKGROUND

Pain during pregnancy is common, and its management is complex. Certain analgesics may increase the risk for adverse fetal and pregnancy outcomes, while poorly managed pain can result in adverse maternal outcomes such as depression and hypertension. Guidelines to assist clinicians in assessing risks and benefits of exposure to analgesics for the mother and unborn infant are lacking, necessitating evidence-based recommendations for managing pain in pregnancy.

METHODS

A comprehensive literature search was conducted to assess pregnancy safety data for pharmacological and nonpharmacological pain management methods. Relevant clinical trials and observational studies were identified using multiple medical databases, and included studies were evaluated for quality and possible biases.

RESULTS

Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) are appropriate for mild to moderate pain, but NSAIDs should be avoided in the third trimester due to established risks. Short courses of weaker opioids are generally safe in pregnancy, although neonatal abstinence syndrome must be monitored following third trimester exposure. Limited safety data for pregabalin and gabapentin indicate that these are unlikely to be major teratogens, and tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors have limited but overall reassuring safety data. Many of the included studies were limited by methodological issues.

CONCLUSIONS

Findings from this review can guide clinicians in their decision to prescribe analgesics for pregnant women. Treatment should be tailored to the lowest therapeutic dose and shortest possible duration, and management should involve a discussion of risks and benefits and monitoring for response. Further research is required to better understand the safety profile of various analgesics in pregnancy.

Momordica charantia (bitter melon) modulates adipose tissue inflammasome gene expression and adipose-gut inflammatory cross talk in high-fat diet (HFD)-fed mice

Systemic and tissue-specific inflammation has a profound influence on regulation of metabolism, and therefore, strategies to reduce inflammation are of special interest in prevention and treatment of obesity and type 2 diabetes (T2D). Antiobesity and antidiabetic properties of Momordica charantia (bitter melon, BM) have been linked to its protective effects on inflammation and gut microbial dysbiosis. We investigated the mechanisms by which freeze-dried BM juice reduces adipose inflammation in mice fed a 60% high-fat diet (HFD) for 16 weeks. Although earlier studies indicated that BM inhibited recruitment of macrophages (Mφ) infiltration in adipose tissue of rodents and reduced NF-kB and IL-1β secretions, the mechanisms remain unknown. We demonstrate that freeze-dried BM juice inhibits recruitment of Mφ into adipose tissue and its polarization to inflammatory phenotype possibly due to reduction of sphingokinase 1 (SPK1) mRNA in HFD-fed mice. Furthermore, reduction of IL-1β secretion by freeze-dried BM juice in the adipose tissue of HFD-fed mice is correlated to alleviation of NLRP3 inflammasome components and their downstream signaling targets. We confirm previous observations that BM inhibited inflammation of colon and gut microbial dysbiosis in HFD-fed mice, which in part may be associated with the observed anti-inflammatory effects in adipose tissue if HFD-fed mice. Overall, functional foods such as BM may offer potential dietary interventions that may impact sterile inflammatory diseases such as obesity and T2D.

Seasonality of birth affects paediatric coeliac disease

AIM

This study investigated the seasonality of birth in children diagnosed with coeliac disease (CD) at a tertiary University hospital in Southern Israel.

METHODS

This was a population-based retrospective time series analysis study from January 1988 to December 2014. There were 308 903 live births at Soroka University Medical Centre during the study period and 699 were diagnosed with CD. We combined three databases covering births, CD diagnoses and weather indices. The daily proportion of births that resulted in CD for the different four seasons and high seasons were compared to the weather indices on the day of birth using negative binomial regression.

RESULTS

Statistically significant associations were found between the season of birth and the rate of CD, with autumn births being associated with a higher risk for the development of CD than births during the summer, with an incidence ratio of 1.22. The association was further increased when the defined summer and autumn high seasons were used, with an incidence ratio of 1.40. No association was found between CD and the mean temperature and global radiation.

CONCLUSION

Coeliac disease was associated with birth during the autumn and the autumn high season posed an even more significant risk factor.

Pharmacological Approach to Managing Childhood-Onset Systemic Lupus Erythematosus During Conception, Pregnancy and Breastfeeding

Pediatric patients often have poor pregnancy outcomes. Systemic lupus erythematosus predominantly impacts women in their second to fourth decade of life, with childhood-onset disease being particularly aggressive. Reproductive issues are an important clinical consideration for pediatric patients with systemic lupus erythematosus (SLE), as maintaining good disease control and planning a pregnancy are important for maternal and fetal outcomes. In this clinical review, we will consider the safety of medications in managing childhood-onset SLE during conception, pregnancy, and breastfeeding. The developing fetus is at highest risk for teratogenicity from maternal medications during the period of critical organogenesis, which occurs between the first 3-8 weeks following conception. Medications known to be teratogenic, leading to a specific pattern of malformations, include mycophenolic acid, methotrexate, and cyclophosphamide. These should be discontinued prior to a planned pregnancy or as soon as pregnancy is suspected. Hydroxychloroquine is safe and should be continued throughout pregnancy and breastfeeding in those without contraindications to it. Azathioprine and calcineurin inhibitors are felt to be compatible with pregnancy in usual doses and may be used prior to and throughout pregnancy and lactation. Non-fluorinated corticosteroids including methylprednisolone and prednisone are inactivated by the placenta and can be used if needed for maternal indication during gestation. Addition of aspirin may be considered around the 12th week of gestation for prevention of pre-eclampsia. Illustrative cases are presented that demonstrate management of adolescents with childhood-onset SLE through conception, pregnancy, and breastfeeding.

Hormonal Regulation of Physiology, Innate Immunity and Antibody Response to H1N1 Influenza Virus Infection During Pregnancy

In 2009, the H1N1 swine flu pandemic highlighted the vulnerability of pregnant women to influenza viral infection. Pregnant women infected with influenza A virus were at increased risk of hospitalization and severe acute respiratory distress syndrome (ARDS), which is associated with high mortality, while their newborns had an increased risk of pre-term birth or low birth weight. Pregnant women have a unique immunological profile modulated by the sex hormones required to maintain pregnancy, namely progesterone and estrogens. The role of these hormones in coordinating maternal immunotolerance in uterine tissue and cellular subsets has been well researched; however, these hormones have wide-ranging effects outside the uterus in modulating the immune response to disease. In this review, we compile research findings in the clinic and in animal models that elaborate on the unique features of H1N1 influenza A viral pathogenesis during pregnancy, the crosstalk between innate immune signaling and hormonal regulation during pregnancy, and the role of pregnancy hormones in modulating cellular responses to influenza A viral infection at mid-gestation. We highlight the ways in which lung architecture and function is stressed by pregnancy, increasing baseline inflammation prior to infection. We demonstrate that infection disrupts progesterone production and upregulates inflammatory mediators, such as cyclooxygenase-2 (COX-2) and prostaglandins, resulting in pre-term labor and spontaneous abortions. Lastly, we profile the ways in which pregnancy alters innate and adaptive cellular immune responses to H1N1 influenza viral infection, and the ways in which these protect fetal development at the expense of effective long-term immune memory. Thus, we highlight advancements in the field of reproductive immunology in response to viral infection and illustrate how that knowledge might be used to develop more effective post-infection therapies and vaccination strategies.

Use of Nimesulide During Early Pregnancy and the Risk of Congenital Malformations: A Population-Based Study from Italy

INTRODUCTION

Nimesulide is the most prescribed non-steroidal anti-inflammatory drug in Italy, and it is currently marketed in about 50 countries worldwide. The association between the use of nimesulide in early pregnancy and the risk of birth defects was investigated in a large cohort of pregnant women from Italy.

METHODS

Data were from the healthcare utilization databases of the Italian region of Lombardy. The cohort of 353,081 newborns occurring in Lombardy during the period 2005-2010 was investigated. Exposure to nimesulide during the first trimester of pregnancy, and congenital malformations detected at presentation and within 90 days after birth (outcome), were investigated. Exposure-outcome association was measured by the ratio between the prevalence of congenital malformations among users and non-users of nimesulide. Propensity score stratification was used to control for potential confounders, including maternal medical comorbidities, concomitant medications and sociodemographic characteristics.

RESULTS

The 627 (0.18%) women who filled prescriptions for nimesulide in the first trimester of pregnancy had a 2.6-fold risk of having children with congenital urinary tract anomalies compared to those who did not (adjusted prevalence ratio 2.6; 95% CI 1.2-5.7). Weaker and non-significant evidence for congenital malformations as a whole was found (adjusted prevalence ratio 1.2, 95% CI 0.9-1.6).

CONCLUSION

Our study suggests that the use of nimesulide in early pregnancy may result in a greater risk of having births with congenital urinary tract anomalies.

FUNDING

This study was funded by grants from the Italian Ministry of the Education, University and Research ('Fondo d'Ateneo per la Ricerca' portion, year 2015).

[Analgesic drugs during pregnancy]

Some important limitations must be taken into consideration for analgesic therapy during pregnancy. Paracetamol is the agent of choice for mild to moderate pain in any stage of pregnancy. Ibuprofen is the non-steroidal anti-inflammatory drug (NSAID) of choice; however, these substances are contraindicated after 28 weeks of gestation due to the increasing risk of premature closure of the ductus arteriosus and impairment of fetal kidney function. Even opioids can be used for severe pain but peripartum administration can lead to neonatal respiratory depression and adaptation disorders and long-term therapy up to the end of pregnancy can lead to neonatal withdrawal symptoms. Migraine can also be treated with sumatriptan. Antiepileptic drugs should not be taken during pregnancy as a teratogenic risk mostly cannot be excluded; however, well studied antidepressants, such as amitriptyline can be used for chronic pain with the appropriate indications.

Leflunomide use during pregnancy and the risk of adverse pregnancy outcomes

Objectives

Leflunomide is known to be embryotoxic and teratogenic in rodents. However, there is less evidence in humans. We quantified the risk of major congenital malformation (MCM), prematurity, low birth weight (LBW) and spontaneous abortion associated with leflunomide exposure during pregnancy in humans.

Methods

From a cohort of 289 688 pregnancies in Montreal, Quebec, Canada, from 1998 to 2015, first-trimester leflunomide exposure and other antirheumatic drug exposures were studied for their association with MCM and spontaneous abortions. Also second or third-trimester leflunomide exposures were examined for associations with prematurity and LBW. Logistic regression model-based generalised estimating equations were used.

Results

51 pregnancies were exposed to leflunomide during the first trimester, and 21 during the second/third trimesters. Adjusting for potential confounders, use of leflunomide during the first trimester of pregnancy was not associated with the risk of MCM (adjusted OR (aOR) 0.97, 95% CI 0.81 to 1.16; 5 exposed cases). No association was found between second/third-trimester exposure to leflunomide and the risk of prematurity (aOR 4.03, 95% CI 0.91 to 17.85; 7 exposed cases) nor LBW (aOR 1.06, 95%CI 0.90 to 1.25; 8 exposed cases). Pregnancy exposure to leflunomide was also not associated with the risk of spontaneous abortion (aOR 1.09, 95% CI 0.90 to 1.32; 11 exposed cases).

Conclusions

Maternal exposure to leflunomide during pregnancy was not associated with statistically significant increased risk of MCMs, prematurity, LBW or spontaneous abortions. However, given that relatively few women were exposed to leflunomide during pregnancy in this cohort, caution remains warranted.

Association of Prenatal Ibuprofen Exposure with Birth Weight and Gestational Age: A Population-Based Sibling Study

OBJECTIVES

Three studies so far have investigated the effect of prenatal non-steroidal anti-inflammatory drug (NSAID) exposure on birth weight and gestational age. The aim in this study was to evaluate the association of prenatal ibuprofen with birth weight and gestational age at birth, using a sibling design in an attempt to adjust for the possibility of familial confounding.

DESIGN

Using data from the Norwegian Mother and Child Cohort Study (MoBa) and the Medical Birth Registry of Norway (MBRN), we identified 28 597 siblings, of whom 1080 were prenatally exposed to ibuprofen and 26 824 were not exposed to any NSAID. Random and fixed effects models with propensity score adjustment were used to evaluate the effects of ibuprofen exposure on birth weight and gestational age.

RESULTS

Ibuprofen exposure during the first trimester was associated with a decrease in birth weight of 79 grams (95% confidence interval -133 to -25 grams). In contrast, second and/or third trimester exposure, and duration of exposure had no impact on the effect estimates. We found no association between ibuprofen exposure and gestational age at birth.

CONCLUSIONS

Our results suggest that prenatal exposure to ibuprofen during the first trimester is associated with a slight decrease in birth weight. The association does not seem to be attributable to shared genetics and family environment, and could be explained by either exposure to ibuprofen, or to non-shared confounding between pregnancies.

Recommendations for the evaluation and management of patients with rheumatic autoimmune and inflammatory diseases during the reproductive age, pregnancy, postpartum and breastfeeding

OBJECTIVE

To develop recommendations on the evaluation and management of patients with rheumatic autoimmune and inflammatory diseases during the reproductive age, pregnancy, post-partum and breastfeeding based on the best evidence and experience.

METHODS

Recommendations were generated using nominal group and Delphi techniques. An expert panel of 12 rheumatologists was established. A systematic literature review and a narrative review (websites, clinical guidelines and other relevant documentation) were performed and presented to the panel in its 1^st meeting to be discussed and to help define recommendations. A first draft of recommendations was generated and circulated for comments and wording refinement. A national survey analyzing different aspects of this topic was undertaken separately, followed by a Delphi process (2 rounds). Agreement with each recommendation was ranked on a scale of 1 (total disagreement) to 10 (total agreement), and was considered to be achieved if at least 70% voted≥7. The level of evidence and grade of recommendation were assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence.

RESULTS

A total of 14 recommendations were generated for the preconception period (oral and hormonal contraception, reproductive techniques), pregnancy (planning, treatment and follow-up), and breastfeeding (treatment and follow-up). High-risk situations such as lupus or antiphospholipid syndrome were included. A consensus>90% was reached for all but one recommendation.

CONCLUSIONS

These recommendations are intended to provide rheumatologists, patients, families and other stakeholders with a consensus on the evaluation and management of patients with autoimmune and inflammatory diseases during the reproductive age, pregnancy, postpartum and breastfeeding.

Safety of anti-rheumatic drugs for rheumatoid arthritis in pregnancy and lactation

Women with rheumatoid arthritis (RA) are often of childbearing age and therefore questions regarding reproductive health and the use of medications, including disease-modifying anti-rheumatic drugs (DMARDs) may arise during the clinical consultation. Each patient requires individual assessment in order to effectively manage the disease while minimizing any treatment-associated risks to the fetus. Although good-quality controlled trials are lacking, there is an increasing volume of evidence surrounding the use of immunosuppressive therapies in pregnancy and lactation. This review summarizes the currently available information which can be of benefit to clinicians guiding patients and their families through the risks and benefits of continuing RA therapy during pregnancy and lactation. Further studies and ongoing surveillance of drug safety in pregnancy are required to resolve the uncertainties that remain regarding synthetic and biologic DMARDs.

Pharmacological treatment of migraine during pregnancy and breastfeeding

Migraine affects up to 25% of women of reproductive age. In the majority of these women, migraine improves progressively during pregnancy, but symptoms generally recur shortly after delivery. As suboptimally treated migraine in pregnancy could have negative consequences for both mother and fetus, the primary aim of clinicians should be to provide optimal treatment according to stage of pregnancy, while minimising possible risks related to drug therapy. Nonpharmacological approaches are always first-line treatment, and should also be used to complement any required drug treatment. Paracetamol is the preferred drug for acute treatment throughout pregnancy. If paracetamol is not sufficiently effective, sporadic use of sumatriptan can be considered. NSAIDs such as ibuprofen can also be used under certain circumstances, though their intake in the first and third trimesters is associated with specific risks and contraindications. Preventive treatment should only be considered in the most severe cases. In women contemplating pregnancy, counselling is essential to promote a safe and healthy pregnancy and postpartum period for the mother and child, and should involve a dialogue addressing maternal concerns and expectations about drug treatment. This Review summarizes current evidence of the safety of the most common antimigraine medications during pregnancy and breastfeeding, and provides treatment recommendations for use in clinical practice.

Safety of Drugs during Pregnancy and Breastfeeding in Cystic Fibrosis Patients

Health management of cystic fibrosis (CF) patients should be maximized during pregnancy and breastfeeding because of its significant impact on the maternal and newborn outcomes. Thus, numerous drugs will have to be continued during pregnancy and lactation. Most of the drugs representing CF treatment lines cross the placenta or are excreted into human milk. Research addressing the risks and benefits of drugs used in CF patients during pregnancy and lactation is often incomplete or challenged by limited methodology, which often leads to conflicting or inconclusive results. Yet, potential treatment benefits for CF pregnant patients most often outbalance potential risks for the unborn child.

The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation

A European League Against Rheumatism (EULAR) task force was established to define points to consider on use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Based on a systematic literature review and pregnancy exposure data from several registries, statements on the compatibility of antirheumatic drugs during pregnancy and lactation were developed. The level of agreement among experts in regard to statements and propositions of use in clinical practice was established by Delphi voting. The task force defined 4 overarching principles and 11 points to consider for use of antirheumatic drugs during pregnancy and lactation. Compatibility with pregnancy and lactation was found for antimalarials, sulfasalazine, azathioprine, ciclosporin, tacrolimus, colchicine, intravenous immunoglobulin and glucocorticoids. Methotrexate, mycophenolate mofetil and cyclophosphamide require discontinuation before conception due to proven teratogenicity. Insufficient documentation in regard to fetal safety implies the discontinuation of leflunomide, tofacitinib as well as abatacept, rituximab, belimumab, tocilizumab, ustekinumab and anakinra before a planned pregnancy. Among biologics tumour necrosis factor inhibitors are best studied and appear reasonably safe with first and second trimester use. Restrictions in use apply for the few proven teratogenic drugs and the large proportion of medications for which insufficient safety data for the fetus/child are available. Effective drug treatment of active inflammatory rheumatic disease is possible with reasonable safety for the fetus/child during pregnancy and lactation. The dissemination of the data to health professionals and patients as well as their implementation into clinical practice may help to improve the management of pregnant and lactating patients with rheumatic disease.

Pain Management in Pregnancy: Multimodal Approaches

Nonobstetrical causes of pain during pregnancy are very common and can be incapacitating if not treated appropriately. Recent reports in the literature show that a significant percentage of pregnant women are treated with opioids during pregnancy. To address common pain conditions that present during pregnancy and the available pharmacological and nonpharmacological treatment options, for each of the pain conditions identified, a search using MEDLINE, PubMed, Embase, and Cochrane databases was performed. The quality of the evidence was evaluated in the context of study design. This paper is a narrative summary of the results obtained from individual reviews. There were significant disparities in the studies in terms of design, research and methodology, and outcomes analyzed. There is reasonable evidence available for pharmacological approaches; however, these are also associated with adverse events. Evidence for nonpharmacological approaches is limited and hence their efficacy is unclear, although they do appear to be primarily safe. A multimodal approach using a combination of nonpharmacological and pharmacological options to treat these pain conditions is likely to have the most benefit while limiting risk. Research trials with sound methodology and analysis of outcome data are needed.

NSAIDs and spontaneous abortions - true effect or an indication bias?

AIM

The aim of the study was to characterize the extent of indication bias resulting from the excessive use of NSAIDs on the days preceding a spontaneous abortion to relieve pain.

METHODS

We used data from a retrospective cohort study assessing the risk for spontaneous abortions following exposure to NSAIDs. Three definitions of exposure for cases of spontaneous abortions were compared, from the first day of pregnancy until the day of spontaneous abortion and until 3 and 2 days before a spontaneous abortion. Statistical analysis was performed using multivariate time programmed Cox regression.

RESULTS

A sharp increase was observed in the dispensation of indomethacin, diclofenac and naproxen, and a milder increase was found in the use of ibuprofen during the week before a spontaneous abortion. Non- selective COX inhibitors in general and specifically diclofenac and indomethacin were found to be associated with spontaneous abortions when the exposure period was defined until the day of spontaneous abortion (hazard ratio (HR) 1.15, 95% confidence interval (CI) 1.04, 1.28; HR 1.31, 95% CI 1.08, 1.59 and HR 3.33, 95% CI 2.09, 5.29, respectively). The effect disappears by excluding exposures occurring on the day before the spontaneous abortion for non-selective COX inhibitors and on the last week before the spontaneous abortion for indomethacin. In general, decreasing HRs were found with the exclusion of exposures occurring on the days immediately before the spontaneous abortion.

CONCLUSIONS

The increased use of NSAIDs during the last few days that preceded a spontaneous abortion to relieve pain associated with the miscarriage could bias studies assessing the association between exposure to NSAIDs and spontaneous abortions.

[Prevalence of the use of nonsteroidal anti-inflammatory drugs in pregnant women in Lubumbashi (Democratic Republic of Congo)]

Malgré l'importance de leurs effets secondaires sur la femme enceinte et le fœtus, les anti-inflammatoires non stéroïdiens (AINS) continuent à être largement utilisés par les femmes enceintes. Leur rapport bénéfice-risque n'est pas toujours bien évalué en pratique courante. L'objectif de ce travail est d’évaluer l'usage des AINS chez la femme enceinte, de discuter les risques potentiels encourus aussi bien par la mère que par le fœtus, et enfin d'en tirer des recommandations éventuelles à la femme enceinte. Du 22 août au 11 septembre 2012, une enquête a été menée auprès de 145 femmes enceintes suivies en consultation prénatale à l'Hôpital Sendwe. Un formulaire reprenant les informations sur les AINS consommés a été remis à chacune d'elle. Les résultats montrent que 75% des femmes interrogées reconnaissent avoir consommé des AINS surtout en automédication et principalement pendant les deux derniers trimestres de la grossesse pour soulager des douleurs d'origines diverses. Cette étude montre que des efforts restent encore à déployer à Lubumbashi afin de combattre l'utilisation des AINS surtout en automédication chez la femme enceinte.

Renal teratogens

In utero exposure to certain drugs early in pregnancy may adversely affect nephrogenesis. Exposure to drugs later in pregnancy may affect the renin-angiotensin system, which could have an impact on fetal or neonatal renal function. Reduction in nephron number and renal function could have adverse consequences for the child several years later. Data are limited on the information needed to guide decisions for patients and providers regarding the use of certain drugs in pregnancy. The study of drug nephroteratogenicity has not been systematized, a large, standardized, global approach is needed to evaluate the renal risks of in utero drug exposures.

Fetal exposure to nonsteroidal anti-inflammatory drugs and spontaneous abortions

BACKGROUND

Spontaneous abortion is the most common complication of pregnancy. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used during pregnancy. Published data are inconsistent regarding the risk of spontaneous abortion following exposure to NSAIDs.

METHODS

We performed a historical cohort study involving all women who conceived between January 2003 and December 2009 and who were admitted for delivery or spontaneous abortion at Soroka Medical Center, Clalit Health Services, Israel. A computerized database of medication dispensation was linked with 2 computerized databases containing information on births and spontaneous abortions. We constructed time-varying Cox regression models and adjusted for maternal age, diabetes mellitus, hypothyroidism, obesity, hypercoagulation or inflammatory conditions, recurrent miscarriage, in vitro fertilization of the current pregnancy, intrauterine contraceptive device, ethnic background, tobacco use and year of admission.

RESULTS

The cohort included 65,457 women who conceived during the study period; of these, 58,949 (90.1%) were admitted for a birth and 6508 (9.9%) for spontaneous abortion. A total of 4495 (6.9%) pregnant women were exposed to NSAIDs during the study period. Exposure to NSAIDs was not an independent risk factor for spontaneous abortion (nonselective cyclooxygenase [COX] inhibitors: adjusted hazard ratio [HR] 1.10, 95% confidence interval [CI] 0.99-1.22; selective COX-2 inhibitors: adjusted HR 1.43, 95% CI 0.79-2.59). There was no increased risk for specific NSAID drugs, except for a significantly increased risk with exposure to indomethacin (adjusted HR 2.8, 95% CI 1.70-4.69). We found no dose-response effect.

INTERPRETATION

We found no increased risk of spontaneous abortion following exposure to NSAIDs. Further research is needed to assess the risk following exposure to selective COX-2 inhibitors.

Effects of ibuprofen, diclofenac, naproxen, and piroxicam on the course of pregnancy and pregnancy outcome: a prospective cohort study

OBJECTIVE

To investigate the individual effects of ibuprofen, diclofenac, naproxen, and piroxicam on pregnancy outcome.

DESIGN

Cohort study.

SETTING

Norwegian population.

POPULATION

A total of 90 417 women and singleton child pairs.

METHODS

The Norwegian Mother and Child Cohort Study and Medical Birth Registry of Norway data sets were used.

MAIN OUTCOME MEASURES

Infant survival, congenital malformations, structural heart defects, neonatal complications, haemorrhage during pregnancy and postpartum, asthma at age of 18 months.

RESULTS

One or more of the four nonsteroidal anti-inflammatory drugs (NSAIDs) were used by 6511 pregnant women (7.2%). No effect on rates of infant survival, congenital malformation, or structural heart defects was found. The use of ibuprofen in the second trimester was significantly associated with low birthweight (adjusted OR 1.7, 95% CI 1.3-2.3), and ibuprofen use in the second and third trimesters was significantly associated with asthma in 18-month-old children (adjusted OR 1.5, 95% CI 1.2-1.9; adjusted OR 1.5, 95% CI 1.1-2.1). The use of diclofenac in the second trimester was significantly associated with low birthweight (adjusted OR 3.1, 95% CI 1.1-9.0), whereas diclofenac use in the third trimester was significantly associated with maternal vaginal bleeding (adjusted OR 1.8, 95% CI 1.1-3.0). No associations with other neonatal complications were found.

CONCLUSIONS

The lack of associations with congenital malformations is reassuring. The significant association between diclofenac and ibuprofen use late in pregnancy, and maternal bleeding and asthma in the child, respectively, is consistent with their pharmacological effects. The increased risk of low birthweight may partly have been caused by underlying inflammatory conditions, and was reassuringly similar to the expected baseline risk of low birthweight.