COVID-19 and pregnancy: A European study on pre- and post-infection medication use

PURPOSE

The COVID-19 pandemic has impacted medication needs and prescribing practices, including those affecting pregnant women. Our goal was to investigate patterns of medication use among pregnant women with COVID-19, focusing on variations by trimester of infection and location.

METHODS

We conducted an observational study using six electronic healthcare databases from six European regions (Aragon/Spain; France; Norway; Tuscany, Italy; Valencia/Spain; and Wales/UK). The prevalence of primary care prescribing or dispensing was compared in the 30-day periods before and after a positive COVID-19 test or diagnosis.

RESULTS

The study included 294,126 pregnant women, of whom 8943 (3.0%) tested positive for, or were diagnosed with, COVID-19 during their pregnancy. A significantly higher use of antithrombotic medications was observed particularly after COVID-19 infection in the second and third trimesters. The highest increase was observed in the Valencia region where use of antithrombotic medications in the third trimester increased from 3.8% before COVID-19 to 61.9% after the infection. Increases in other countries were lower; for example, in Norway, the prevalence of antithrombotic medication use changed from around 1-2% before to around 6% after COVID-19 in the third trimester. Smaller and less consistent increases were observed in the use of other drug classes, such as antimicrobials and systemic corticosteroids.

CONCLUSION

Our findings highlight the substantial impact of COVID-19 on primary care medication use among pregnant women, with a marked increase in the use of antithrombotic medications post-COVID-19. These results underscore the need for further research to understand the broader implications of these patterns on maternal and neonatal/fetal health outcomes.

COVID-19 vaccine uptake among children and adolescents in Norway: A comprehensive registry-based cohort study of over 800,000 individuals

Factors related with COVID-19 vaccine uptake in children and adolescents in Norway remain unclear, despite this being useful knowledge for future pandemic preparedness. This study aimed to comprehensively examine individual and familial factors associated with vaccine uptake in children and adolescents in Norway. We utilized nationwide registry-data from various health registries and Statistics Norway, encompassing all children and adolescents living in Norway during the pandemic, until 31-Dec-2022. Vaccine uptake is defined as receiving at least one dose of COVID-19 vaccine. We employed a forward stepwise logistic regression model and a random forest machine-learning algorithm to explore the relationship between vaccine uptake and socio-cultural, demographic, and health-related factors. We included 423,548 5-11-year-olds, 269,830 12-15-year-olds, and 120,854 16-17-year-olds. Vaccine uptake in these three groups was respectively 2.6 %, 73.3 %, and 87.3 %. Factors associated with vaccine uptake varied by age group. In youngest children, immigrant background (Odds-ratio (OR) = 1.58, 95 % confidence interval (CI) (1.14-2.19)), born extremely preterm (OR = 2.38, 95 % CI (1.60-3.54)), having risk of severe COVID-19 (OR = 5.40, 95 % CI (4.69-6.23) and maternal COVID-19 vaccination (OR = 6.34, 95 % CI (5.35-7.53)) were positively associated with vaccine uptake. The latter two factors were also strongly, positively associated with vaccine uptake in 12-15-year-olds, while previous SARS-CoV-2 infection was negatively associated (OR = 0.12, 95 % CI (0.11-0.14). Similar findings were observed in 16-17-year-olds. COVID-19 vaccine uptake differed markedly by age group, and major associated factors included socio-demographics and parental COVID-19 vaccination status, prior SARS-CoV-2 infection, but also being born premature and having moderate or high risk of severe COVID-19.

Impact of genetic, sociodemographic, and clinical features on antidepressant treatment trajectories in the perinatal period

Pregnant women on antidepressants must balance potential fetal harm with the relapse risk. While various clinical and sociodemographic factors are known to influence treatment decisions, the impact of genetic factors remains unexplored. We conducted a cohort study among 2,316 women with diagnosed affective disorders who had redeemed antidepressant prescriptions six months before pregnancy, identified from the Danish Integrated Psychiatric Research study. We calculated polygenic risk scores (PGSs) for major depression (MDD), bipolar disorder (BD), and schizophrenia (SCZ) using individual-level genetic data and summary statistics from genome-wide association studies. We retrieved data on sociodemographic and clinical features from national registers. Applying group-based trajectory modeling, we identified four treatment trajectories across pregnancy and postpartum: Continuers (38.2 %), early discontinuers (22.7 %), late discontinuers (23.8 %), and interrupters (15.3 %). All three PGSs were not associated with treatment trajectories; for instance, the relative risk ratio for continuers versus early discontinuers was 0.93 (95 % CI: 0.81-1.06), 0.98 (0.84-1.13), 1.09 (0.95-1.27) for per 1-SD increase in PGS for MDD, BD, and SCZ, respectively. Sociodemographic factors were generally not associated with treatment trajectories, except for the association between primiparity and continuing antidepressant use. Women who received ≥2 classes or a higher dose of antidepressants had a higher probability of being late discontinuers, interrupters, and continuers. The likelihood of continuing antidepressants or restarting antidepressants postpartum increased with the previous antidepressant treatment duration. Our findings indicate that continued antidepressant use during pregnancy is influenced by the severity of the disease rather than genetic predisposition as measured by PGSs.

Impact of the early COVID-19 pandemic on adult mental health-related dispensed medications, hospitalizations and specialist outpatient visits in Norway and Sweden: Interrupted time series analysis

AIMS

Norway and Sweden had different early pandemic responses that may have impacted mental health management. The aim was to assess the impact of the early COVID-19 pandemic on mental health-related care.

METHODS

We used national registries in Norway and Sweden (1 January 2018-31 December 2020) to define 2 cohorts: (i) general adult population; and (ii) mental health adult population. Interrupted times series regression analyses evaluated step and slope changes compared to prepandemic levels for monthly rates of medications (antidepressants, antipsychotics, anxiolytics, hypnotics/sedatives, lithium, opioid analgesics, psychostimulants), hospitalizations (for anxiety, bipolar, depressive/mood, eating and schizophrenia/delusional disorders) and specialist outpatient visits.

RESULTS

In Norway, immediate reductions occurred in the general population for medications (-12% antidepressants to -7% hypnotics/sedatives) except for antipsychotics; and hospitalizations (-33% anxiety disorders to -17% bipolar disorders). Increasing slope change occurred for all medications except psychostimulants (+1.1%/month hypnotics/sedatives to +1.7%/month antidepressants); and hospitalization for anxiety disorders (+5.5%/month), depressive/mood disorders (+1.7%/month) and schizophrenia/delusional disorders (+2%/month). In Sweden, immediate reductions occurred for antidepressants (-7%) and opioids (-10%) and depressive/mood disorder hospitalizations (-11%) only with increasing slope change in psychostimulant prescribing of (0.9%/month). In contrast to Norway, increasing slope changes occurred in specialist outpatient visits for depressive/mood disorders, eating disorders and schizophrenia/delusional disorders (+1.5, +1.9 and +2.3%/month, respectively). Similar changes occurred in the pre-existing mental health cohorts.

CONCLUSION

Differences in early COVID-19 policy response may have contributed to differences in adult mental healthcare provision in Norway and Sweden.

Does preterm birth increase the initiation of antidepressant use during the postpartum? A population-based investigation

Background

Preterm birth may affect maternal mental health. We explored the relationship between preterm birth and the risk of initiating antidepressant use during the year after birth.

Methods

We conducted a population-based investigation using regional healthcare utilization databases. The exposure considered was preterm birth. The outcome was having at least one prescription for antidepressant medications during the year after birth. We used a log-binomial regression model including terms for maternal age at birth, nationality, educational level, parity, modality of conception, modality of delivery, use of other psychotropic drugs, and diabetes to estimate relative risk (RR) and 95% confidence intervals (CI) for the association between preterm birth and the initiation of antidepressant use. In addition, the absolute risk differences (ARD) were also computed according to the timing of birth.

Results

The cohort included 727,701 deliveries between 2010 and 2020 in Lombardy, Northern Italy. Out of these, 6,522 (0.9%) women had at least one prescription for antidepressant drugs during the year after birth. Preterm births were related to a 38% increased risk of initiation of antidepressant use during the year after birth (adjusted RR = 1.38; 95% CI: 1.25-1.52) for moderate to late preterm and to 83% (adjusted RR = 1.83; 95% CI: 1.46-2.28) for extremely and very preterm. Excluding women with only one antidepressant prescription, the association was consistent (adjusted RR = 1.41, 95%CI: 1.23-1.61 for moderate to late preterm and adjusted RR = 1.81, 95% CI: 1.31-2.49 for extremely and very preterm). Also, excluding women who used other psychotropics, the association remained consistent (adjusted RR = 1.39, 95%CI: 1.26-1.54 and adjusted RR = 1.91, 95% CI: 1.53-2.38, respectively for moderate to late and extremely and very preterm).

Conclusion

Women who delivered preterm may have an excess risk of initiation of antidepressant consumption during the first year after birth.

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.

Drug utilisation in children and adolescents before and after the start of the COVID-19 pandemic: Interrupted time-series analyses in three European countries

BACKGROUND

The COVID-19 pandemic has affected children and adolescents in several ways, including worsened mental health, improvement of asthma, and increases in diabetes ketoacidosis. Less is known about how medication use in children and adolescents has been affected by the pandemic.

OBJECTIVES

To explore how the COVID-19 pandemic affected drug utilisation in children and adolescents in Norway, Sweden, and Italy, by child age.

METHODS

We conducted a longitudinal drug utilisation study among all children and adolescents (<18 years old) in Norway and Sweden and a nationwide paediatric database covering 3% of the paediatric population in Italy. We conducted an interrupted time-series analysis from January 2018 to December 2021, with March 2020 as the interruption point. Dispensing or prescription rates of antidepressants, anxiolytics, sleep medications, attention-deficit/hyperactivity disorder (ADHD) medications, insulin, and asthma medications were examined.

RESULTS

The study population in January 2018 consisted of 3,455,521 children and adolescents (136,188 from Italy, 1,160,431 from Norway, and 2,158,902 from Sweden). For sleep medications and insulin, there were only minor changes in level or trend in some age groups after March 2020. For asthma medications, the pandemic was associated with an immediate decrease in dispensing in Norway and Sweden (range of change in level: -19.2 to -3.7 dispensings per 1000 person-months), and an increasing trend in all countries afterward (range of change in trend: 0.3-6.4 dispensings per 1000 person-months), especially for the youngest age groups. Among adolescents, the pandemic was associated with an increased trend for ADHD medications, antidepressants, and anxiolytics in Norway and Sweden, but not in Italy.

CONCLUSIONS

The increasing trend of psychotropic medication dispensing, especially among adolescents after the start of the pandemic, is concerning and should be investigated further. Aside from a temporary effect on asthma medication dispensing, the pandemic did not greatly affect the dispensing of the medications investigated.

Machine learning-driven development of a disease risk score for COVID-19 hospitalization and mortality: a Swedish and Norwegian register-based study

Aims

To develop a disease risk score for COVID-19-related hospitalization and mortality in Sweden and externally validate it in Norway.

Method

We employed linked data from the national health registries of Sweden and Norway to conduct our study. We focused on individuals in Sweden with confirmed SARS-CoV-2 infection through RT-PCR testing up to August 2022 as our study cohort. Within this group, we identified hospitalized cases as those who were admitted to the hospital within 14 days of testing positive for SARS-CoV-2 and matched them with five controls from the same cohort who were not hospitalized due to SARS-CoV-2. Additionally, we identified individuals who died within 30 days after being hospitalized for COVID-19. To develop our disease risk scores, we considered various factors, including demographics, infectious, somatic, and mental health conditions, recorded diagnoses, and pharmacological treatments. We also conducted age-specific analyses and assessed model performance through 5-fold cross-validation. Finally, we performed external validation using data from the Norwegian population with COVID-19 up to December 2021.

Results

During the study period, a total of 124,560 individuals in Sweden were hospitalized, and 15,877 individuals died within 30 days following COVID-19 hospitalization. Disease risk scores for both hospitalization and mortality demonstrated predictive capabilities with ROC-AUC values of 0.70 and 0.72, respectively, across the entire study period. Notably, these scores exhibited a positive correlation with the likelihood of hospitalization or death. In the external validation using data from the Norwegian COVID-19 population (consisting of 53,744 individuals), the disease risk score predicted hospitalization with an AUC of 0.47 and death with an AUC of 0.74.

Conclusion

The disease risk score showed moderately good performance to predict COVID-19-related mortality but performed poorly in predicting hospitalization when externally validated.

Comparative study showed that children faced a 78% higher risk of new-onset conditions after they had COVID-19

AIM

Children have largely been unaffected by severe COVID-19 compared to adults, but data suggest that they may have experienced new conditions after developing the disease. We compared outcomes in children who had experienced COVID-19 and healthy controls.

METHODS

A retrospective nested cohort study assessed the incidence rate of new-onset conditions after COVID-19 in children aged 0-14 years. Data were retrieved from an Italian paediatric primary care database linked to Veneto Region registries. Exposed children with a positive nasopharyngeal swab were matched 1:1 with unexposed children who had tested negative. Conditional Cox regression was fitted to estimate the adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for the exposure and outcome associations after adjusting for covariates.

RESULTS

We compared 1656 exposed and 1656 unexposed children from 1 February 2020 to 30 November 2021. The overall excess risk for new-onset conditions after COVID-19 was 78% higher in the exposed than unexposed children. We found significantly higher risks for some new conditions in exposed children, including mental health issues (aHR 1.8, 95% CI 1.1-3.0) and neurological problems (aHR 2.4, 95% CI 1.4-4.1).

CONCLUSION

Exposed children had a 78% higher risk of developing new conditions of interest after COVID-19 than unexposed children.

Antidepressant continuation and adherence in pregnancy, and risk of antenatal hospitalization for unipolar major depressive and/or anxiety disorders

BACKGROUND

Knowledge about the effectiveness of antidepressants in pregnancy is limited. We aimed to evaluate the association of antidepressant continuation in pregnancy and adherence with the risk of antenatal hospitalization for depression/anxiety.

METHODS

In a population-based study based on the healthcare databases of the Lombardy region, Italy (2010-2020), we included 17,033 live-birth pregnancies within 16,091 women with antidepressant use before pregnancy. Antidepressant exposure was classified as continued in pregnancy versus discontinued proximal to pregnancy. Outcome measure was antenatal hospitalization for depression/anxiety. Propensity score matching analysis was performed to control for measured confounding. Stratification by pre-pregnancy antidepressant adherence based on the proportion of days covered (PDC) with antidepressants served to address confounding by disease severity. We applied 60 days lag-time for antidepressant exposure to minimize the risk of protopathic bias.

RESULTS

There were 362 (2.1 %) antenatal hospitalizations for depression/anxiety. Among the matched pairs, the cumulative incidence was 3.5 (continued antidepressant) versus 2.1 (discontinued antidepressant) per 1000 person-months, yielding a hazard ratio (HR) of 1.76 (95 % confidence interval (CI): 1.34-2.33)). The HR declined to the null (1.02, 95 % CI: 0.62-1.69) in the stratified analysis of pregnancies with moderate-high adherence pre-pregnancy. Moderate-high adherence in pregnancy was associated with 85 % greater risk of the antenatal outcome, but the HR decreased with the 60 days lag-time (HR: 1.40, 95 % CI: 0.79-2.50).

LIMITATIONS

Lack of information regarding antidepressant dosage.

CONCLUSION

We found no difference in risk for antenatal hospitalization for depression/anxiety with antidepressant continuation or higher adherence in pregnancy, relative to discontinuation or lower adherence.

Associations of periconceptional oral contraceptive use with pregnancy complications and adverse birth outcomes

BACKGROUND

Periconceptional use of oral contraceptives (OCs) has been reported to increase risks of pregnancy complications and adverse birth outcomes, but risks are suggested to differ depending on the timing of discontinuation, amount of oestrogen and progestin content.

METHODS

Prospective cohort study among 6470 pregnancies included in the PRegnancy and Infant DEvelopment (PRIDE) Study in 2012-19. Exposure was defined as any reported use of OCs within 12 months pre-pregnancy or after conception. Outcomes of interest were gestational diabetes, gestational hypertension, pre-eclampsia, pre-term birth, low birthweight and small for gestational age (SGA). Multivariable Poisson regression using stabilized inverse probability weighting estimated relative risks (RRs) with 95% CIs.

RESULTS

Any periconceptional OC use was associated with increased risks of pre-eclampsia (RR 1.38, 95% CI 0.99-1.93), pre-term birth (RR 1.38, 95% CI 1.09-1.75) and low birthweight (RR 1.45, 95% CI 1.10-1.92), but not with gestational hypertension (RR 1.09, 95% CI 0.91-1.31), gestational diabetes (RR 1.02, 95% CI 0.77-1.36) and SGA (RR 0.96, 95% CI 0.75-1.21). Associations with pre-eclampsia were strongest for discontinuation 0-3 months pre-pregnancy, for OCs containing ≥30 µg oestrogen and for first- or second-generation OCs. Pre-term birth and low birthweight were more likely to occur when OCs were discontinued 0-3 months pre-pregnancy, when using OCs containing <30 µg oestrogen and when using third-generation OCs. Associations with SGA were observed for OCs containing <30 µg oestrogen and for third- or fourth-generation OCs.

CONCLUSIONS

Periconceptional OC use, particularly those containing oestrogen, was associated with increased risks of pre-eclampsia, pre-term birth, low birthweight and SGA.

Assessing decisional conflict and challenges in decision-making among perinatal women using or considering using antidepressants during pregnancy-a mixed-methods study

This study aims to investigate decisional conflict and elucidate challenges in decision-making among perinatal women using or considering using antidepressant (AD) during pregnancy. A sequential, mixed-methods study was employed among pregnant and postnatal women in Norway who had been offered ADs in the last 5 years. Quantitative data were obtained through an electronic questionnaire. Decisional conflict in pregnancy was assessed using the Decisional Conflict Scale (DCS) defined as either low (< 25) or moderate-high ( ≥ 25) (evaluated retrospectively for postnatal women). Logistic regression was used to identify factors associated with moderate-high decisional conflict. Qualitative data were collected through focus groups with pregnant and postnatal women, and an inductive approach was used for data analysis. Among 174 pregnant and 102 postnatal women, 67.8% and 69.6%, respectively, reported moderate-high decisional conflict during pregnancy. Unsatisfactory doctor-patient relationship was associated with greater likelihood of having moderate-high decisional conflict in pregnancy, both in pregnant (aOR = 1.20, 95% CI: 1.00-1.44) and postnatal women (aOR = 1.40, 95% CI: 1.08-1.82). Reported barriers to decision-making regarding AD use in pregnancy encompassed five DCS subscales: uninformed knowledge following contradictory research and unfamiliarity with authorised resources, unclear values due to emotional blunting and fear associated with AD use, inadequate support, uncertainty in decisions and ineffective decisions due to difficulty in finding personalised treatment, and diverging recommendations by the healthcare providers (HCPs). The quality of the interaction with the HCP plays a crucial role in managing decisional conflict and supporting informed decisions in the management of perinatal mental illness. This study highlights the need for increased provision of clear, evidence-based information by HCPs to facilitate shared decision-making and create personalised treatments for perinatal women considering AD use during pregnancy.

Antidepressant treatment in pregnancy: a Danish registry linkage study in pregnant women with pre-existing obsessive-compulsive disorder

The association between antidepressant continuation during pregnancy and postpartum mental health in women with obsessive-compulsive disorder (OCD) is uncertain. We identified 1317 women with live-birth singleton pregnancies and having outpatient/inpatient visits for OCD in the 4 years pre-pregnancy from the Danish registries. We defined three groups based on antidepressant prescriptions filled in the 2 years before pregnancy to delivery: (i) unexposed (n = 449); (ii) discontinuers (n = 346), i.e., with pre-pregnancy antidepressant fills only; (iii) continuers (n = 522), i.e., with antidepressant fills before and during pregnancy. We estimated crude and propensity score weighted hazard ratio (HRs) of postpartum visit for OCD and mood/anxiety disorders using Cox proportional hazard models. In weighted analyses, we found no difference in the probability of a postpartum visit for OCD or MADs with antidepressant continuation compared to unexposed and discontinuers. The likelihood of a postpartum OCD visit was higher in pregnancies having only one prescription fill during pregnancy compared to unexposed (HR = 3.44, 95% CI: 1.24, 9.54) or discontinuers (HR = 2.49, 95% CI: 0.91, 6.83). Continuers in pregnancy without antidepressant fill in the first three months postpartum had higher probability for postpartum visit for mood/anxiety disorders compared to discontinuers (HR = 3.84, 95% CI: 1.49, 9.92). Among pregnant women with pre-existing OCD, we found similar probabilities of a postpartum visit for OCD or mood/anxiety disorders in antidepressant continuers compared to unexposed and discontinuers. Continuers with a single prescription fill during pregnancy or no fill postpartum may have higher risks for these outcomes. Our findings highlight the importance of continuity of treatment throughout the perinatal period.

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.

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.

Timing of Antidepressant Discontinuation During Pregnancy and Postpartum Psychiatric Outcomes in Denmark and Norway

Importance

Approximately one-half of women treated for affective disorders discontinue antidepressant use during pregnancy, yet this discontinuation could lead to relapse post partum.

Objective

To investigate the associations between longitudinal antidepressant fill trajectories during pregnancy and postpartum psychiatric outcomes.

Design, Setting, and Participants

This cohort study used nationwide registers in Denmark and Norway. The sample included 41 475 live-born singleton pregnancies in Denmark (1997-2016) and 16 459 in Norway (2009-2018) for women who filled at least 1 antidepressant prescription within 6 months before pregnancy.

Exposures

Antidepressant prescription fills were obtained from the prescription registers. Antidepressant treatment during pregnancy was modeled using the k-means longitudinal method.

Main Outcomes and Measures

Initiation of psycholeptics, psychiatric emergencies, or records of self-harm within 1 year post partum. Between April 1 and October 30, 2022, hazard ratios (HRs) for each psychiatric outcome were estimated using Cox proportional hazards regression models. Inverse probability of treatment weighting was used to control for confounding. Country-specific HRs were pooled using random-effects meta-analytic models.

Results

Among 57 934 pregnancies (mean [SD] maternal age, 30.7 [5.3] years in Denmark and 29.9 [5.5] years in Norway), 4 antidepressant fill trajectories were identified: early discontinuers (31.3% and 30.4% of the included pregnancies in Denmark and Norway, respectively), late discontinuers (previously stable users) (21.5% and 27.8%), late discontinuers (short-term users) (15.9% and 18.4%), and continuers (31.3% and 23.4%). Early discontinuers and late discontinuers (short-term users) had a lower probability of initiating psycholeptics and having postpartum psychiatric emergencies vs continuers. A moderately increased probability of initiation of psycholeptics was found among late discontinuers (previously stable users) vs continuers (HR, 1.13; 95% CI, 1.03-1.24). This increase in late discontinuers (previously stable users) was more pronounced among women with previous affective disorders (HR, 1.28; 95% CI, 1.12-1.46). No association between antidepressant fill trajectories and postpartum self-harm risk was found.

Conclusions and Relevance

Based on pooled data from Denmark and Norway, a moderately elevated probability of initiation of psycholeptics in late discontinuers (previously stable users) vs continuers was found. These findings suggest that women with severe mental illness who are currently on stable treatment may benefit from continuing antidepressant treatment and personalized treatment counseling during pregnancy.

Psychiatric visits during the postpartum year in women with eating disorders who continue or discontinue antidepressant treatment in pregnancy

OBJECTIVE

To determine the association between continued antidepressant use in pregnancy and postpartum psychiatric visits for eating (ED) or mood/anxiety disorders in women with preexisting ED.

METHOD

Using Danish health registry data (1998-2015), we identified 3529 pregnancies in women with ED prepregnancy: (i) 564 with continued antidepressant use before and during pregnancy; (ii) 778 with discontinued antidepressants before pregnancy; (iii) 2137 unexposed. Outpatient and inpatient postpartum visits for an ED or a mood/anxiety disorder constituted the outcome measures. We estimated hazard ratios (HRs) and 95% confidence intervals (CI) using Cox regression with inverse probability of treatment weighting, and performed stratified analyses by antidepressant prescription filling in the first 3 months postpartum.

RESULTS

The weighted cumulative incidence for an ED visit at end of follow-up was 4.5% (continued) and 4.8% (discontinued). We found no association between continued antidepressant and postpartum ED visit, relative to discontinued (HR: 0.89, 95% CI: 0.52-1.52). The HR for postpartum mood/anxiety disorder visit was 1.27 (95% CI: 0.68-2.36) with continued antidepressants versus discontinued but decreased if more than two antidepressant prescriptions were refilled. Continued antidepressant use was associated with a 57% reduced likelihood of a postpartum ED visit versus discontinued use in pregnancies with antidepressant prescription refills in the early postpartum.

CONCLUSION

Among women with preexisting ED, there was no association between continued antidepressant use during pregnancy and the likelihood of postpartum psychiatric visits, relative to discontinued antidepressants before pregnancy. Continuation of treatment into the early postpartum is associated with reduced likelihood of postpartum ED visit.

PUBLIC SIGNIFICANCE

Based on data from the Danish registries, we identified 3529 pregnancies among women with preexisting eating disorders before pregnancy. Women with continued antidepressant treatment both before and during pregnancy did not have a lower probability of having postpartum psychiatric visits for an eating disorder or for mood/anxiety disorders (often coexisting with eating disorders), relative to those who discontinued antidepressants before pregnancy. Further continuation of antidepressant treatment into the early postpartum is associated with improved maternal postpartum outcomes. However, residual confounding by disease severity limits confidence in this conclusion.

Mental health of pregnant and postpartum women during the third wave of the COVID-19 pandemic: a European cross-sectional study

OBJECTIVE

To describe the mental health of perinatal women in five European countries during the third pandemic wave and identify risk factors related to depressive and anxiety symptoms.

DESIGN

A cross-sectional, online survey-based study.

SETTING

Belgium, Norway, Switzerland, the Netherlands and the UK, 10 June 2021-22 August 2021.

PARTICIPANTS

Pregnant and up to 3 months postpartum women, older than 18 years of age.

PRIMARY OUTCOME MEASURE

The Edinburgh Depression Scale (EDS) and the Generalised Anxiety Disorder scale (GAD-7) were used to assess mental health status. Univariate and multivariate generalised linear models were performed to identify factors associated with poor mental health.

RESULTS

5210 women participated (including 3411 pregnant and 1799 postpartum women). The prevalence of major depressive symptoms (EDS ≥13) was 16.1% in the pregnancy group and 17.0% in the postpartum . Moderate to severe generalised anxiety symptoms (GAD ≥10) were found among 17.3% of the pregnant and 17.7% of the postpartum women. Risk factors associated with poor mental health included having a pre-existing mental illness, a chronic somatic illness, having had COVID-19 or its symptoms, smoking, unplanned pregnancy and country of residence. Among COVID-19 restrictive measures specific to perinatal care, pregnant and postpartum women were most anxious about not having their partner present at the time of delivery, that their partner had to leave the hospital early and to be separated from their newborn after the delivery.

CONCLUSION

Approximately one in six pregnant or postpartum women reported major depression or anxiety symptoms during the third wave of the pandemic. These findings suggest a continued need to monitor depression and anxiety in pregnancy and postpartum populations throughout and in the wake of the pandemic. Tailored support and counselling are essential to reduce the burden of the pandemic on perinatal and infant mental health.

Antidepressant Fill and Dose Trajectories in Pregnant Women with Depression and/or Anxiety: A Norwegian Registry Linkage Study

Background

Few studies investigated longitudinal antidepressant exposure during pregnancy and included dosage in the assessment.

Methods

We conducted a nationwide, registry-linkage study in Norway using data on antidepressant prescription fills in pregnancies lasting ≥32 weeks in women with a delivery between 2009 and 2018 who had a depression/anxiety diagnosis and antidepressant fills prior to pregnancy. Information on antidepressant exposure by week (measured by filled prescriptions) and prescribed average daily dose was used in longitudinal k-means trajectory modelling for a 108-week time window from six months prior to pregnancy to one year after delivery. Factors associated with trajectory group membership were examined using multinomial logistic regression models.

Results

We included 8,460 pregnancies in 8,092 women. Four antidepressant fill trajectories were identified based on filled antidepressant prescriptions: two distinct discontinuing patterns, one at around the start of pregnancy (30.4%) and one around the end of pregnancy (33.8%); one continuing pattern (20.6%); and one interrupting pattern (15.2%). Using average usual daily dose, we identified low dose discontinuing (60.3%), medium dose reducing (20.6%) and high dose continuing (15.2%) patterns. The multinomial logistic regressions showed that the fill trajectory group membership was strongly associated with: antidepressant type and dose prior to pregnancy and co-medication prior to pregnancy, maternal age, marital status, parity, previous pregnancy loss, and pregnancy planning.

Conclusion

Longitudinal trajectory modelling revealed distinct antidepressant fill and dosage patterns in the period around pregnancy. Knowledge about factors associated with utilization trajectories might be useful for health-care personnel counselling women about antidepressant use in pregnancy.

Clinical practice guidelines with recommendations for peripartum depression: A European systematic review

OBJECTIVE

This study aims to systematically review all Clinical Practice Guidelines (CPGs) with recommendations for peripartum depression in European countries.

METHODS

A systematic review according to the PRISMA statement was conducted. CPGs focussing on peripartum depression or with at least one specific recommendation for peripartum depression from European countries were selected. Searching was conducted in electronic databases (MEDLINE and PsycINFO), and by contacting professional societies and international experts until November 24th, 2021. Characteristics of the included CPGs and their recommendations were extracted. A methodological quality assessment was conducted using the AGREE-II tool.

RESULTS

A total of 239 records were identified after duplicate removal. Of these, 54 were examined for full-text inspection. The final selection yielded 14 CPGs from 11 European countries in 10 languages. Of them, 11 provided recommendations on pharmacological treatments, 10 on psychological treatment (e.g., cognitive-behavioural therapy), 10 on screening, 8 on diagnosis, 6 on other treatments (e.g., physical exercise), 5 on prevention, and 5 other recommendations (e.g., provide information). Regarding the overall methodological quality, only five (35.7%) guidelines were rated as of adequate quality, reaching a score ≥ 70% in the overall assessment of the AGREE-II instrument. Of the six AGREE-II domains, applicability scored the lowest and clarity of presentation scored the highest.

CONCLUSION

The absence of CPGs in most European countries, the discrepancy in recommendations and the low methodological quality of the guidelines may lead to disparities and inequalities in peripartum depression management in Europe. The COST Action Riseup-PPD highlights key considerations for future guideline developers.

Perceived risk of neurodevelopmental outcomes in offspring related to psychotropic and mental illness exposures in pregnancy and breastfeeding: a cross-sectional survey of women with past or current mental illness

OBJECTIVES

To investigate the perceived risk of psychotropic and mental illness exposures (1) during pregnancy or (2) while breastfeeding on offspring neurodevelopment, and factors associated with this perception in women with past/current mental illness.

DESIGN

Cross-sectional, web-based study.

SETTING

Nationwide in Norway, June 2020-June 2021.

PARTICIPANTS

Women aged 18-55 years who were pregnant, recent mothers or planning a pregnancy, and had been offered antidepressants in the last 5 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Perceived risk of prenatal and breastmilk exposure to psychotropic medications and maternal mental illness on offspring neurodevelopmental outcomes.

RESULTS

We included 448 women: 234 pregnant, 146 mothers and 68 planning a pregnancy. On a 0-10 scale, women perceived antidepressants as least harmful both (1) in pregnancy (mean score 4.2, 95% CI 3.6 to 4.8) and (2) while breastfeeding (mean score 3.8, 95% CI 3.3 to 4.4), relative to antipsychotics, anxiety/sleeping medication or antiepileptics (mean score range: 6.3-6.5 during pregnancy, 5.5-6.2 while breastfeeding). Many participants were unfamiliar with psychotropics other than antidepressants. The perceived risk of mental illness exposure exceeded that of antidepressants (mean score range 5.6-5.9) in both exposure periods. Using general linear models, factors associated with greater antidepressant risk perception in both exposure periods included having lower education, non-Norwegian native language, and employment status (range mean score difference (β): 2.07-6.07). For pregnant women and mothers, there was an inverse association between perceived risk and the perceived antidepressant effectiveness in both exposure periods (range of β: -0.18 to -0.25).

CONCLUSIONS

In women with past/current mental illness, the perceived risk of antidepressant exposure on child neurodevelopment was lower than that for maternal mental illness. Other psychotropic medications were perceived as more harmful. As medication risk perception influences the decision-making regarding treatment of mental illness, pre- and pregnancy counselling should target women with characteristics associated with higher perceived risk.

Antidepressant and mental health care utilization in pregnant women with depression and/or anxiety: An interrupted time-series analysis

BACKGROUND

Little is known about mental health care utilization patterns in pregnant women with depression/anxiety in Norway according to antidepressant fill trajectories in pregnancy.

METHOD

We conducted a registry-linkage cohort study of pregnancies within women having outpatient visit for depression/anxiety and antidepressant fills prior to pregnancy identified from four national registries of Norway (2009-2018). Number of consultations for depression/anxiety per 100 pregnancies as proxy of mental health care utilization was modelled using interrupted time-series analysis with first month into pregnancy and first month after delivery as interruption points. We investigated the time window spanning from six months prior to one year postpartum. Antidepressant fill trajectories in the corresponding time window were identified using longitudinal k-means trajectory modelling.

RESULTS

The cohort included 8460 pregnancies within 8062 women with depression/anxiety. We observed reduced mental health care utilization when pregnant women entered the course of pregnancy (negative slopes during pregnancy for psychiatric specialists and psychologists). The declines were observed for all antidepressant fill trajectories (i.e., discontinuers and continuers) except interrupters (i.e., discontinued then resumed treatment). We found increased mental health care utilization in the postpartum year, notably in interrupters (positive slopes in consultation rates with specialists of outpatient clinics and public-contracted psychiatrists).

LIMITATIONS

It was not possible to measure directly the use of psychosocial interventions and psychotherapy.

CONCLUSIONS

Pregnancy was associated with reduced mental health care utilization regardless of whether antidepressant treatment was maintained during pregnancy or not. Increases in mental health care utilization were observed in the postpartum year, especially in interrupters.

Analysis of Prenatal Exposure to Opioid Analgesics and Scholastic Skills in Children in Fifth Grade in Norway

IMPORTANCE

Few studies have examined the neurodevelopmental consequences of prenatal exposure to opioid analgesics. Therefore, it is necessary to gain knowledge to inform clinical decisions for pregnant women with moderate to severe pain.

OBJECTIVE

To investigate fifth-grade scholastic skills in children with prenatal exposure to opioid analgesics.

DESIGN, SETTING, AND PARTICIPANTS

A cohort study was conducted based on data from the Norwegian Mother, Father, and Child Cohort (1999-2008). These data were linked to the Medical Birth Registry of Norway, and data from Statistics Norway included 64 256 live-born singletons, born to 54 568 mothers who reported pain during pregnancy, were analyzed. The study was conducted from July 1 to December 15, 2021.

EXPOSURES

Self-reported exposure to opioid analgesics during pregnancy, characterized in terms of any exposure, the exposure timing, and the exposure duration.

MAIN OUTCOMES AND MEASURES

Scores from 3 national tests for children in fifth grade. The tests measured scholastic skills in literacy, numeracy, and the English language. Test scores were standardized to z scores. Differences in z scores were compared between children of mothers exposed to opioid analgesics during pregnancy and children of mothers with only prepregnancy opioid exposure.

RESULTS

Of the 64 256 children included, 32 521 were boys (50.6%), and 1483 children (2.3%) were exposed to an opioid analgesic at least once during gestation. All test scores were similar between children with any exposure to opioid analgesics in utero and children with only prepregnancy exposure. Children exposed in the first trimester and those exposed in two or three 4-week intervals during pregnancy scored lower than children of mothers with only prepregnancy exposures on tests in literacy (weighted β [wβ], -0.13; 95% CI, -0.25 to -0.01 and wβ, -0.19; 95% CI, -0.35 to -0.04) and numeracy (wβ, -0.14; 95% CI, -0.25 to -0.04 and wβ, -0.19; 95% CI, -0.34 to -0.05). These differences were small and may not be clinically relevant.

CONCLUSIONS AND RELEVANCE

In this large birth cohort, prenatal exposure to opioid analgesics had no substantial negative association with fifth-grade scholastic skills. However, adequate pain management in pregnancy may be addressed on an individual patient level, bearing in mind the benefits and risks of different analgesic therapies.

Longitudinal Methods for Modeling Exposures in Pharmacoepidemiologic Studies in Pregnancy

In many perinatal pharmacoepidemiologic studies, exposure to a medication is classified as "ever exposed" versus "never exposed" within each trimester or even over the entire pregnancy. This approach is often far from real-world exposure patterns, may lead to exposure misclassification, and does not to incorporate important aspects such as dosage, timing of exposure, and treatment duration. Alternative exposure modeling methods can better summarize complex, individual-level medication use trajectories or time-varying exposures from information on medication dosage, gestational timing of use, and frequency of use. We provide an overview of commonly used methods for more refined definitions of real-world exposure to medication use during pregnancy, focusing on the major strengths and limitations of the techniques, including the potential for method-specific biases. Unsupervised clustering methods, including k-means clustering, group-based trajectory models, and hierarchical cluster analysis, are of interest because they enable visual examination of medication use trajectories over time in pregnancy and complex individual-level exposures, as well as providing insight into comedication and drug-switching patterns. Analytical techniques for time-varying exposure methods, such as extended Cox models and Robins' generalized methods, are useful tools when medication exposure is not static during pregnancy. We propose that where appropriate, combining unsupervised clustering techniques with causal modeling approaches may be a powerful approach to understanding medication safety in pregnancy, and this framework can also be applied in other areas of epidemiology.

Association between antidepressant use in pregnancy and gestational diabetes mellitus: Results from the Norwegian Mother, Father and Child Cohort Study

PURPOSE

This study sought to determine the association between gestational diabetes mellitus (GDM) and antidepressant exposure during early-mid pregnancy, overall and according to antidepressant affinity to the histamine-1 (H₁ ) receptor.

METHODS

Data originate from the nation-wide, Norwegian Mother, Father and Child Cohort Study conducted in 1999-2008, linked to the national Medical Birth Registry. The study included 6647 pregnancies within women with depressive/anxiety disorders during and/or 6 months prior to pregnancy. Pregnancies exposed in early-mid gestation to antidepressants having low (group 1, n = 814) or high (group 2, n = 77) affinity to the H₁ receptor were compared to non-medicated (n = 5756). We fit crude and weighted modified Poisson regression models using inverse probability of treatment weighting (IPTW).

RESULTS

Overall, 84 (1.3%) of the pregnancies developed GDM. Relative to non-medicated pregnancies, the risk of GDM was slightly lower in antidepressant group 1 exposed (1.3% vs 1.1%), but more elevated in those exposed to group 2 antidepressants (3.9%). In the weighted analysis, there was no evidence for an association between antidepressant group 1 exposure in early-mid pregnancy and risk of GDM [relative risk (RR): 0.69, 95% confidence interval: 0.31-1.51].

CONCLUSIONS

Gestational use of antidepressants with low H₁ receptor affinity, mainly SSRIs and SNRIs, does not pose a substantial risk of GDM in women with depressive/anxiety disorders in pregnancy, compared to no use.

Antihistamine use during breastfeeding with focus on breast milk transfer and safety in humans: A systematic literature review

Current data on use of antihistamines during breastfeeding and risks to the breastfed infant are insufficient. The aim of this systematic review was to provide an overview of studies measuring the levels of antihistamines in human breast milk, estimating the exposure for breastfed infants and/or reporting possible adverse effects on the breastfed infant. An additional aim was to review the antihistamine product labels available in the European Union (EU) and the United States. We searched seven online databases and identified seven human lactation studies that included 25 mother-infant pairs covering cetirizine, clemastine, ebastine, epinastine, loratadine, terfenadine and triprolidine. In addition, one study investigated the impact of chlorpheniramine or promethazine on prolactin levels among 17 women, and one study investigated possible adverse drug reactions in 85 breastfed infants exposed to various antihistamines. The relative infant dose was below 5% for all antihistamines, ranging from 0.3% for terfenadine to 4.5% for clemastine. Most product labels of the 10 antihistamines with available information in both the EU and the United States reported lack of evidence and recommended to avoid use during breastfeeding. The knowledge gap on antihistamines and lactation is extensive, and further human studies are warranted to ensure optimal treatment of breastfeeding women with allergy.

Association of Timing and Duration of Prenatal Analgesic Opioid Exposure With Attention-Deficit/Hyperactivity Disorder in Children

IMPORTANCE

Prior studies have reported that the use of illicit opioids during pregnancy is associated with increased risk of attention-deficit/hyperactivity disorder (ADHD) in offspring; however, evidence regarding the association of analgesic opioids is limited.

OBJECTIVE

To examine the association of timing and duration of prenatal analgesic opioid exposure with ADHD in children.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study uses data from the Norwegian Mother, Father and Child Cohort study (1999-2008), a nationwide birth cohort study linked to national health registries, with a mean (SD) follow-up of 10.8 (2.2) years. A total of 73 784 live-born singleton children born to 62 013 mothers who reported a pain-related condition before and/or during pregnancy were included, with 2 comparator groups: (1) mothers who did not use any opioids and (2) mothers who used opioids before pregnancy only. Data were analyzed from June to December 2020.

EXPOSURES

Maternal self-report of analgesic opioid use during pregnancy, by timing (early and middle and/or late) and duration (≥5 weeks vs ≤4 weeks).

MAIN OUTCOMES AND MEASURES

Diagnosis of ADHD or filled prescription for ADHD medication in children and symptoms of ADHD at child age 5 years, measured by Conners' Parent Rating Scale-Revised. Inverse probability of treatment weights were used to control for measured confounding. Cox regression was used to estimate hazard ratios (HRs) and 95% CIs.

RESULTS

The analyses of ADHD diagnosis and ADHD symptoms included 73 480 children (35 996 [49.0%] girls; mean [SD] maternal age, 30.0 [4.6] years) and 31 270 children (15 377 [49.2%] girls; mean [SD] maternal age, 30.5 [4.4] years), respectively. Overall, 1726 children in the ADHD diagnosis sample (2.3%) and 667 children in the ADHD symptom sample (2.1%) were exposed to an analgesic opioid at least once during gestation. No associations between timing of prenatal analgesic opioid exposure and ADHD diagnosis or symptoms was found. Exposure for 5 or more weeks was associated with an increased risk of ADHD diagnosis (HR, 1.60, 95% CI, 1.04-2.47) compared with exposure for 4 weeks or less; however, there was no such association for the risk of ADHD symptoms.

CONCLUSIONS AND RELEVANCE

In this cohort study, a slightly elevated risk of ADHD diagnosis after prenatal analgesic opioid exposure for 5 or more weeks was found compared with exposure for 4 weeks or less. This result may be driven by longer duration of use; however, the role of residual or unmeasured confounding cannot be excluded. This finding needs to be replicated in other studies.

Perinatal use of triptans and other drugs for migraine-A nationwide drug utilization study

OBJECTIVE

To characterize nationwide utilization patterns of migraine pharmacotherapy before, during, and after pregnancy in women with triptan use.

METHODS

Population-based data were obtained by linking the Medical Birth Registry of Norway and the Norwegian Prescription Database from 2006 to 2017. We included 22,940 pregnancies among 19,669 women with at least one filled triptan prescription, a proxy for migraine, in the year before pregnancy or during pregnancy. The population was classified into four groups: i) continuers; ii) discontinuers; iii) initiators, and vi) post-partum re-initiators. Participant characteristics and prescription fills for other drugs such as analgesics, antinauseants, and preventive drugs among the groups were examined, along with an array of triptan utilization parameters.

RESULTS

In total, 20.0% of the women were classified as triptan continuers, 54.1% as discontinuers, 8.0% as initiators, and 17.6% as re-initiators. Extended use of triptans (≥15 daily drug doses/month) occurred among 6.9% of the continuers in the first trimester. The top 10% of triptan continuers and initiators accounted for 41% (95% CI: 39.2% - 42.5%) and 33% (95% CI: 30.3% - 35.8%) of the triptan volume, respectively. Triptan continuers and initiators had similar patterns of acute co-medication during pregnancy, but use of preventive drugs was more common among the continuers before, during, and after pregnancy.

CONCLUSION

Among women using triptans before and during pregnancy, one in four continued triptan treatment during pregnancy, and extended triptan use was relatively low. Triptan discontinuation during and in the year after pregnancy was common. Use of other acute migraine treatments was higher among both continuers and initiators of triptans. Women using preventive migraine treatment were most commonly triptan continuers and re-initiators after pregnancy. Prescribing to and counseling of women with migraine should be tailored to the condition severity and their information needs to promote optimal migraine management in pregnancy.

Medical care contact for infertility and related medication use during pregnancy – a European, cross-sectional web-based study

Aims: The aim of the study was two-fold: i) to determine the prevalence of medical care contact for infertility in European countries; ii) to map overall and long-term/chronic medication use during pregnancy in women who sought medical care due to infertility.Methods: This is a sub-study of the Multinational Medication Use in Pregnancy Study, a cross-sectional, web-based study conducted from October 2011 to February 2012. We included 8097 participants from Europe who were pregnant or new mothers. We collected data on overall and long-term/chronic medication use, medical care seeking due to infertility, and whether women eventually conceived spontaneously or with the aid of infertility treatment.Results: Medical care contact for infertility was lower in Western Europe (prevalence estimate: 10.0-15.3%), compared with Northern (15.2-17.5%) or Eastern (17.4-20.9%), but Poland had the lowest estimate (8.0%). Overall, 660 (8.2%) women sought medical care due to infertility but conceived spontaneously; 548 (6.8%) conceived aided by fertility treatment, and 6889 (85.0%) women did not seek help. Use of any medication was comparable across the three groups (range 80.4-82.5%), but women seeking help for infertility (21.8-24.6%) took more often long-term/chronic medications than women who did not (14.8%).Conclusion: Medical care contacts for infertility varies greatly across European countries. Women who had medical contact due to infertility used more often chronic medications in pregnancy than women who did not, pointing to more co-morbidities and risk pregnancies.

The Norwegian Society for Pharmacoepidemiology

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Antithyroid drug treatment and pregnancy outcomes among women with hyperthyroidism in pregnancy: A Norwegian population-based registry-linkage study

Aims: The aim of this study was two-fold: i) to describe factors associated with antithyroid drug (ATD) treatmentduring gestation among women with hyperthyroidism in pregnancy, ii) to investigate the impact of ATDtreatment during gestation on pregnancy outcomes.Methods: Women with hyperthyroidism in pregnancy and ATD treatments were identified through linkage ofthree national registries (2008-2018): The Medical Birth Registry of Norway, the Norwegian PrescriptionRegistry and the Norwegian Patient Registry. Pregnancies were categorized as ATD treated or untreated basedon filled prescriptions indicating ATD exposure during pregnancy. ATD treatment was examined by trimester(T1, T2/T3) and by substance carbimazole (CMZ), propylthiouracil (PTU) and by both CMZ/PTU. Generalizedestimating equations analysis with a robust variance estimator was used to estimate adjusted odds ratio (aOR)and adjusted standardized mean difference (aSMD) with 95% confidence interval (CI).Results: We identified 1699 pregnancies with hyperthyroidism during gestation. Hyperthyroidism was treatedwith ATD in 44.4% of the pregnancies, while 55.6% were untreated. Pregnant women treated with ATD hadmore often asthma compared to untreated women. Prenatal exposure to CMZ was associated with increased riskof preterm birth (aOR 1.8, 95% CI 1.1-2.8) whereas PTU exposure in the first trimester was associated with anincreased risk of cardiac malformations (aOR 9.0, 95% CI 1.8-44.7). There was no association between ATDtreatment in pregnancy and maternal preeclampsia (aOR 0.8, 95% CI 0.4-1.3) and gestational hypertension (aOR0.9, 95% CI 0.5-1.8).Conclusion: This nationwide registry study found an association between treatment with carbimazole and increasedrisk of preterm birth. Exposure to propylthiouracil in the first trimester was associated with an increasedrisk of cardiac malformations. These findings should be interpreted in light of international findings on the riskof untreated hyperthyroidism and the potential risk of ATD treatment for the mother and child.

Attention-deficit/hyperactivity disorder in children following prenatal exposure to antidepressants: results from the Norwegian mother, father and child cohort study

OBJECTIVE

To determine the association between child attention-deficit/hyperactivity disorder (ADHD) and prenatal exposure to selective serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitor antidepressants, by timing and duration, with quantification of bias due to exposure misclassification.

DESIGN

Norwegian Mother, Father and Child Cohort Study and national health registries.

SETTING

Nationwide, Norway.

POPULATION

A total of 6395 children born to women who reported depression/anxiety in pregnancy and were either medicated with SSRI/SNRI in pregnancy (n = 818) or non-medicated (n = 5228), or did not report depression/anxiety but used antidepressants 6 months before pregnancy (discontinuers, n = 349).

MAIN OUTCOME MEASURE

Diagnosis of ADHD or filled prescription for ADHD medication in children, and mother-reported symptoms of ADHD by child age 5 years.

RESULTS

When the hazard was averaged over the duration of the study follow up, there was no difference in ADHD risk between ever in utero SSRI/SNRI-exposed children and comparators (weighted hazard ratio [wHR] 1.07, 95% CI 0.76-1.51 versus non-medicated; wHR 1.53, 95% CI 0.77-3.07 versus discontinuers). Underestimation of effects due to exposure misclassification was modest. In early childhood, the risk for ADHD was lower with prenatal SSRI/SNRI exposure compared with no exposure, and so were ADHD symptoms (weighted β -0.23, 95% CI -0.39 to -0.08); this risk became elevated at child age 7-9 years (wHR 1.93, 95% CI 1.22-3.05). Maternal depression/anxiety before pregnancy was independently associated with child ADHD.

CONCLUSION

Prenatal SSRI/SNRI exposure is unlikely to considerably increase the risk of child ADHD beyond that posed by maternal depression/anxiety. The elevated risk at child age 7-9 years needs to be elucidated.

TWEETABLE ABSTRACT

Women with depression who use antidepressants in pregnancy do not have greater risk of having children with ADHD. Findings in school-age children needs follow up.

Prenatal exposure to non-steroidal anti-inflammatory drugs and risk of attention-deficit/hyperactivity disorder: A follow-up study in the Norwegian mother, father and child cohort

PURPOSE

To estimate the association between Attention-Deficit/Hyperactivity Disorder (ADHD) in children in preschool and primary school, and prenatal exposure to non-steroidal anti-inflammatory drugs (NSAIDs) by timing and duration.

METHODS

This study was based on the Norwegian Mother, Father and Child Cohort Study linked to the Medical Birth Registry of Norway, the Norwegian Patient Registry (NPR) and the Norwegian Prescription Database (NorPD). NSAID exposure was identified by maternal self-report in pregnancy. Child diagnosis of ADHD was obtained from NPR and NorPD. Symptoms of ADHD at age 5 years were measured using Conners' Parent Rating Scale-Revised, where higher scores correspond to more symptoms. To account for time-varying exposure and confounders, marginal structural models were fitted to estimate hazard ratios and mean difference in z-scores.

RESULTS

The analyses on ADHD diagnosis and ADHD symptoms included 56 340 and 34 961 children respectively. Children exposed to NSAIDs prenatally had no increased risk of ADHD diagnosis (first trimester: HR 1.12, 95% CI 0.86;1.45, second trimester: HR 0.98, 95% CI 0.69;1.38, third trimester: HR 0.68, 95% CI 0.31; 1.46) or ADHD symptoms (first trimester: standardized mean difference 0.03, 95% CI -0.03;0.09, second trimester: standardized mean difference 0.03, 95% CI -0.04;0.11, third trimester: standardized mean difference 0.11, 95% CI -0.03; 0.25). There was no duration-response relationship for either outcome.

CONCLUSION

Though non-differential misclassification of the exposure may have attenuated results, these findings are reassuring and suggest no substantially increased risk of ADHD diagnosis or symptoms in children prenatally exposed to NSAIDs, regardless of timing or duration.

Thyroid hormone replacement therapy in pregnancy and motor function, communication skills, and behavior of preschool children: The Norwegian Mother, Father, and Child Cohort Study

PURPOSE

Limited research has focused on the association between prenatal thyroid hormone replacement therapy (THRT) and motor function, communication skills, and behavior in preschool children. Here, we estimated the association between THRT during pregnancy and the first trimester and these developmental outcomes.

METHODS

This study was based on the Norwegian Mother, Father, and Child Cohort Study (MoBa) and other national registries. We included mother-child pairs exposed to THRT during pregnancy (n = 663), after delivery (n = 728), or unexposed (n = 28 040). Exposure to THRT was defined according to filled prescriptions. Child outcomes, presented as T-score differences, were parent-reported using the Ages and Stages Questionnaire, Strengths and Difficulties Questionnaire, and Child Behavior Checklist.

RESULTS

Of 29 431 mother-child pairs, 2.3% were prenatally exposed to THRT. We found no difference between prenatally exposed and unexposed children in regards to gross motor function (β: 0.17, 95% CI -1.19, 1.54), fine motor function (β: -0.17, 95% CI -1.14, 0.80), communication (β: -0.31, 95% CI -1.58, 0.96), externalizing (β: -0.03, 95% CI -1.07, 1.01), internalizing (β: 0.89, 95% CI -0.20, 1.97), or social behaviors (β: -0.04, 95% CI -0.92, 0.84). Somatic complaints were higher in THRT-exposed children (β: 0.98, 95% CI 0.08, 1.87), and children whose mothers were exposed after delivery had more sleep problems than unexposed children (β: 0.99, 95% CI 0.24, 1.74).

CONCLUSIONS

Children prenatally exposed to THRT have developmental outcomes as positive as unexposed children on motor function, communication, and behavior. The association with somatic complaints and sleep were not clinically relevant.

Emerging issues and questions on peripartum depression prevention, diagnosis and treatment: a consensus report from the cost action riseup-PPD

BACKGROUND

Peripartum depression [PPD] is a public health problem which has been widely studied. Nonetheless, study findings and clinical guidelines for PPD treatment differ among countries and the condition is still underdiagnosed and undertreated, suggesting the importance of a global understanding of PPD. The Riseup-PPD Cost Action aims to establish a Pan-European and multidisciplinary network of researchers dedicated to the global understanding of PPD.

METHODS

A literature search was performed in different databases (e.g., Medline, PsychInfo) including a combination of terms related with PPD diagnosis, prevention, treatment and cost-effectiveness of its management. A narrative synthesis of the literature, together with a critical overview of the current issues/questions to be addressed within the topic of PPD were performed.

RESULTS

Emerging issues include challenges regarding definition and timing of PPD; heterogeneity in severity, timing of onset and assessment tools; comparative effectiveness of preventive and treatment interventions; help seeking for PPD; improving health professional's awareness of PPD; and cost-effectiveness of PPD management.

LIMITATIONS

The main limitation is the non-systematic nature of the literature search.

CONCLUSIONS

The Riseup-PPD network will deal with these challenges through four lines of action: (1)provide an updated and comprehensive synthesis of existing knowledge that can contribute to inform clinical recommendations and guidelines for PPD management; (2) clarify inconsistent findings concerning diagnosis, prevention and treatment of PPD; (3) develop new lines of research in the field of PPD; and (4) develop international recommendations for PPD diagnosis, prevention and treatment, ultimately influencing maternal mental health policymaking at global and local levels.

Prenatal paracetamol exposure and neurodevelopmental outcomes in preschool-aged children

BACKGROUND

Recent studies have suggested an association between prenatal paracetamol exposure and adverse neurodevelopmental outcomes in children. However, these findings may be confounded by unmeasured factors related to maternal use of paracetamol and child outcomes.

OBJECTIVE

To examine the association between duration and timing of prenatal paracetamol exposure on parent-reported communication skills, behaviour, and temperament in preschool-aged children, with focus on the role of unmeasured confounding.

METHODS

We used data from the Norwegian Mother and Child Cohort Study. Linear and generalised linear models with inverse probability weights and robust standard errors were used to quantify the association between prenatal paracetamol exposure and continuous and categorical outcomes.

RESULTS

Of the 32 934 children included in our study, 8374 (25.4%), 4961 (15.1%), and 1791 (5.4%) were prenatally exposed to paracetamol in one, two, and three trimesters, respectively. Children exposed to paracetamol in two trimesters scored lower on shyness compared with unexposed children (β -0.62, 95% confidence interval [CI] -1.05, -0.19). Children exposed to paracetamol in three trimesters had a moderate increased risk of internalising behaviour problems (relative risk (RR) 1.36, 95% CI 1.02, 1.80) and borderline externalising behaviour problems (RR 1.22, 95% CI 0.93, 1.60) compared with unexposed children. Children exposed to paracetamol in 2nd/3rd trimester scored lower on shyness (β -0.32, 95% CI -0.66, 0.02) compared with unexposed children. Sensitivity analyses indicated that unmeasured confounders play an important role and may potentially bias the effect estimates away from the null.

CONCLUSIONS

Timing of exposure and short-term use of paracetamol during pregnancy do not seem to pose any substantial risk of the outcomes examined. Although we found an association between paracetamol use in multiple trimesters and lower shyness and greater internalising behaviour in preschool-aged children, we cannot rule out chance or unmeasured confounding as possible explanations for these findings.

Women's Beliefs About Medicines and Adherence to Pharmacotherapy in Pregnancy: Opportunities for Community Pharmacists

BACKGROUND

During pregnancy, women might weigh the benefits of treatment against potential risks to the unborn child. However, non-adherence to necessary treatment can adversely affect both mother and child. To optimize pregnant women's beliefs and medication adherence, community pharmacists are ideally positioned to play an important role in primary care.

OBJECTIVE

This narrative review aimed to summarize the evidence on 1) pregnant women's beliefs, 2) medication adherence in pregnancy and 3) community pharmacists' counselling during pregnancy.

METHODS

Three search strategies were used in Medline and Embase to find original studies evaluating women's beliefs, medication adherence and community pharmacists' counselling during pregnancy. All original descriptive and analytic epidemiological studies performed in Europe, North America and Australia, written in English and published from 2000 onwards were included.

RESULTS

We included 14 studies reporting on women's beliefs, 11 studies on medication adherence and 9 on community pharmacists' counselling during pregnancy. Women are more reluctant to use medicines during pregnancy and tend to overestimate the teratogenic risk of medicines. The risk perception varies with the type of medicine, level of health literacy, education level and occupation. Furthermore, low medication adherence during pregnancy is common. Finally, limited evidence showed that the current community pharmacists' counselling is insufficient. Barriers hindering pharmacists are insufficient knowledge and limited access to reliable information.

CONCLUSION

Concerns about medication use and non-adherence are widespread among pregnant women. Community pharmacists' counselling during pregnancy is insufficient. Further education, training and research are required to support community pharmacists in fulfilling all the opportunities they have when counselling pregnant women.

Differences in medication beliefs between pregnant women using medication, or not, for chronic diseases: a cross-sectional, multinational, web-based study

OBJECTIVES

To assess whether medication beliefs differ between women who use or not use medication for their somatic chronic diseases during pregnancy and whether this association varies across diseases.

DESIGN

Cross-sectional web-based survey.

SETTING

Multinational study in Europe.

PARTICIPANTS

Pregnant women or women with children less than 1 year old from European countries and with asthma, allergy, cardiovascular, rheumatic diseases, diabetes, epilepsy and/or inflammatory bowel diseases (IBD).

PRIMARY AND SECONDARY OUTCOME MEASURE

Differences in scores of the Beliefs about Medicines Questionnaire (BMQ).

RESULTS

In total, 1219 women were included (ranging from 736 for allergy to 49 for IBD). Women using medication for their chronic disease (n=770; 63%) had higher scores on the BMQ subscales necessity (16.6 vs 12.1, p<0.001) and benefits (16.2 vs 15.4, p<0.001), and lower values on the subscales overuse (12.5 vs 13.1; p=0.005) and harm (9.8 vs 10.7, p<0.001) than women not using medication. No significant differences were shown for the concerns subscale (12.5 vs 12.3, p=0.484). Beliefs varied somewhat across diseases but in general more positive beliefs among women using medication were shown. Epilepsy was the disease where less differences were observed between women using and not using medication.

CONCLUSION

Women's beliefs were associated with medication use during pregnancy with only small differences across the diseases. Knowing pregnant women's beliefs could help identify women who are reluctant to use medication and could guide counselling to support making well-informed treatment decisions.

Analyzing Missing Data in Perinatal Pharmacoepidemiology Research: Methodological Considerations to Limit the Risk of Bias

Pharmacoepidemiological studies on the safety of medication during pregnancy are all susceptible to missing data (ie, data that should have been recorded but for some reason were not). Missing data are ubiquitous, irrespective of the data source used. Bias can arise when incomplete data on confounders, outcome measures, pregnancy duration, or even cohort selection criteria are used to estimate prenatal exposure effects that would be obtained from the fully observed data, if these were available for each mother-child dyad. This commentary describes general missing data mechanisms and methods, and illustrates how missing data were handled in recent medication in pregnancy research, according to the utilized data source. We further present one applied example on missing data analysis within MoBa (the Norwegian Mother, Father and Child Cohort Study), and finally illustrate how the causal diagram framework can be helpful in assessing risk of bias due to missing data in perinatal pharmacoepidemiology research. We recommend that applied researchers limit missing data during data collection, carefully diagnose missingness, apply strategies for missing data mitigation under different assumptions, and finally include evaluations of robustness results under these assumptions. Following this set of recommendations can aid future perinatal pharmacoepidemiology research in avoiding the problems that result from failure to consider this important source of bias.

Maternal Thyroid Hormone Replacement Therapy Exposure and Language and Communication Skills of Offspring at 8 Years of Age

IMPORTANCE

Hypothyroidism during pregnancy is associated with neurodevelopmental delays in the offspring. However, it remains unknown whether prenatal thyroid hormone replacement therapy (THRT) has benefits regarding children's language and communication skills.

OBJECTIVE

To quantify associations between prenatal THRT exposure and risk of language impairment diagnosis and parent-reported symptoms of language and communication skill deficits in offspring at 8 years of age.

DESIGN, SETTING, AND PARTICIPANTS

The Norwegian Mother, Father and Child Cohort Study (MoBa), a nationwide population-based cohort study, recruited pregnant women from throughout Norway between June 1999 and December 2008. MoBa was linked to several nationwide registries: the Norwegian Medical Birth Registry, Norwegian Prescription Database, and Norwegian Patient Registry. For this study, the analyzed cohort was restricted to singleton pregnancies resulting in a live-born infant, enrolled in the MoBa between 2005 and 2008. Statistical analysis was performed from January 2 to May 7, 2019.

EXPOSURES

In both study samples, mother-child pairs were categorized into 3 mutually exclusive groups: THRT exposure during pregnancy, based on dispensed prescription records; unexposed to THRT during pregnancy (population comparison); and mothers initiating THRT after delivery (THRT after delivery), comprising incident postpartum THRT users.

MAIN OUTCOMES AND MEASURES

Two defined study samples were analyzed with different outcome measures. In the Norwegian Patient Registry sample, outcome was defined by a diagnosis of language and speech impairment. In the MoBa sample, children were followed up until age 8 years via parental self-completed questionnaires. Hazard ratios were calculated for language impairment diagnosis, estimated by Cox proportional hazards regression. Standardized mean score (β) was calculated for parent-reported symptoms of language and communication deficits, estimated using generalized linear models.

RESULTS

The Norwegian Patient Registry sample included 53 862 mother-child pairs (mean [SD] age, 30.4 [4.6] years; offspring, 26 145 girls and 27 717 boys; 1204 pairs exposed to THRT [2.2%]) and the MoBa sample included 23 686 mother-child pairs (mean [SD] age, 30.8 [4.4] years; offspring, 11 536 girls and 12 150 boys; 532 pairs exposed to THRT [2.2%]). Language and speech impairment diagnosis was not significantly associated with prenatal THRT exposure compared with the unexposed group (adjusted hazard ratio, 0.75; 95% CI, 0.38-1.43) or the THRT after delivery group (adjusted hazard ratio, 0.63; 95% CI, 0.26-1.53). Language outcomes also did not significantly differ between these groups.

CONCLUSIONS AND RELEVANCE

There was no significant difference in child outcomes between children exposed to THRT in the prenatal period compared with children in the population comparison group. These results support current guidelines recommending hypothyroidism treatment during pregnancy. Future research should further examine the use of THRT after delivery or a proper disease comparison group.

Use and validity of child neurodevelopment outcome measures in studies on prenatal exposure to psychotropic and analgesic medications - A systematic review

In recent years there has been increased attention to child neurodevelopment in studies on medication safety in pregnancy. Neurodevelopment is a multifactorial outcome that can be assessed by various assessors, using different measures. This has given rise to a debate on the validity of various measures of neurodevelopment. The aim of this review was twofold. Firstly we aimed to give an overview of studies on child neurodevelopment after prenatal exposure to central nervous system acting medications using psychotropics and analgesics as examples, giving special focus on the use and validity of outcome measures. Secondly, we aimed to give guidance on how to conduct and interpret medication safety studies with neurodevelopment outcomes. We conducted a systematic review in the MEDLINE, Embase, PsycINFO, Web of Science, Scopus, and Cochrane databases from inception to April 2019, including controlled studies on prenatal exposure to psychotropics or analgesics and child neurodevelopment, measured with standardised psychometric instruments or by diagnosis of neurodevelopmental disorder. The review management tool Covidence was used for data-extraction. Outcomes were grouped as motor skills, cognition, behaviour, emotionality, or "other". We identified 110 eligible papers (psychotropics, 82 papers, analgesics, 29 papers). A variety of neurodevelopmental outcome measures were used, including 27 different psychometric instruments administered by health care professionals, 15 different instruments completed by parents, and 13 different diagnostic categories. In 23 papers, no comments were made on the validity of the outcome measure. In conclusion, establishing neurodevelopmental safety includes assessing a wide variety of outcomes important for the child's daily functioning including motor skills, cognition, behaviour, and emotionality, with valid and reliable measures from infancy through to adolescence. Consensus is needed in the scientific community on how neurodevelopment should be assessed in medication safety in pregnancy studies. Review registration number: CRD42018086101 in the PROSPERO database.

Association of Maternal Use of Benzodiazepines and Z-Hypnotics During Pregnancy With Motor and Communication Skills and Attention-Deficit/Hyperactivity Disorder Symptoms in Preschoolers

IMPORTANCE

The reproductive safety of benzodiazepine/z-hypnotic exposure on child longer-term developmental risks remains unresolved.

OBJECTIVE

To quantify the association of motor, communication, and attention-deficit/hyperactivity disorder (ADHD) symptoms in preschoolers with gestational benzodiazepine/z-hypnotic exposure by timing and duration and coexposure to opioids or antidepressants.

DESIGN, SETTING, AND PARTICIPANTS

Nationwide, population-based Norwegian Mother and Child Cohort Study, recruiting pregnant women from 1999 to 2008, with child follow-up from ages 6, 18, and 36 months to ages 5, 7, and 8 years. Follow-up of teenagers is ongoing. The study included women with depressive/anxiety (n = 4195), sleeping (n = 5260), or pain-related (n = 26 631) disorders before and/or during pregnancy.

EXPOSURES

For the timing analyses, children exposed to benzodiazepines/z-hypnotics in midpregnancy (weeks 17-28) or late pregnancy (week 29 or later) vs those born to nonmedicated women. For the duration and coexposure analyses, benzodiazepine/z-hypnotic treatment for multiple 4-week intervals vs 1 and co-use of benzodiazepine/z-hypnotic with opioids or antidepressants vs sole benzodiazepine/z-hypnotic use.

MAIN OUTCOMES AND MEASURES

Parent-reported motor and communication skills (Ages and Stages Questionnaires) and ADHD symptoms (Conners' Parent Rating Scale-Revised) at child median age of 5.1 years (interquartile range, 5.0-5.3 years) as standardized mean scores. General linear propensity score-adjusted and marginal structural models were fitted. Analyses were stratified by maternal disorder.

RESULTS

Of 41 146 eligible pregnancy-child dyads, 36 086 children (18 330 boys and 17 756 girls) were included, of whom 283 (0.8%) were prenatally exposed to benzodiazepines/z-hypnotics (134 in the depressive/anxiety, 60 in the sleeping, and 89 in the pain-related disorders). There was no increased risk for greater ADHD symptoms or fine motor deficits after intrauterine benzodiazepine/z-hypnotic exposure at different time points. Children born to women with depressive/anxiety disorders who took benzodiazepines/z-hypnotics in late pregnancy had greater gross motor (weighted β, 0.67; 95% CI, 0.21-1.13) and communication (weighted β, 0.35; 95% CI, 0.04-0.65) deficits than unexposed children. There was no evidence for substantial duration or coexposure associations.

CONCLUSIONS AND RELEVANCE

These findings suggest no substantial detrimental risk on child fine motor and ADHD symptoms after prenatal benzodiazepine/z-hypnotic exposure alone or in combination with opioids or antidepressants. Residual confounding by indication and/or a higher drug dose regimen among women with anxiety/depression may explain the moderate association of gross motor and communication deficits with late-pregnancy benzodiazepine/z-hypnotic use.