Medication Safety During Pregnancy: Improving Evidence‐Based Practice

Nearly 90% of women in the United States have taken medications during pregnancy. Medication exposures during pregnancy can result in adverse pregnancy and neonatal outcomes including birth defects, fetal loss, intrauterine growth restriction, prematurity, and longer‐term neurodevelopmental outcomes. Advising pregnant women about the safety of medication use during pregnancy is complicated by a lack of data necessary to engage the woman in an informed discussion. Routinely, health care providers turn to the package insert, yet this information can be incomplete and can be based entirely on animal studies. Often, adequate safety data are not available. In a busy clinical setting, health care providers need to be able to quickly locate the most up‐to‐date information in order to counsel pregnant women concerned about medication exposure. Deciding where to locate the best available information is difficult, particularly when the needed information does not exist. Pregnancy registries are initiated to obtain more data about the safety of specific medication exposures during pregnancy; however, these studies are slow to produce meaningful information, and when they do, the information may not be readily available in a published form. Health care providers have valuable data in their everyday practice that can expand the knowledge base about medication safety during pregnancy. This review aims to discuss the limitations of the package insert regarding medication safety during pregnancy, highlight additional resources available to health care providers to inform practice, and communicate the importance of pregnancy registries for expanding knowledge about medication safety during pregnancy.     

Negative impact of non-evidence-based information received by women taking antidepressants during pregnancy from health care providers and others

ObjectivesThe use of antidepressants by women during pregnancy continues to be a controversial subject, with conflicting information regarding the safety of this group of drugs. We sought (1) to determine the impact of information, advice, and comments women received from health care providers, family, and media about use of antidepressants during pregnancy, and (2) to compare experiences regarding the psychosocial impact of women who continued and discontinued antidepressant therapy during pregnancy.MethodsWomen who had taken an antidepressant at some point during pregnancy were interviewed. The responses of women who continued antidepressant therapy throughout pregnancy were compared with those of women who discontinued therapy at some point in the pregnancy. A questionnaire with questions pertaining to information women had received from various individuals regarding the use of an antidepressant while pregnant was administered to both groups.ResultsNinety-four interviews were completed; 78 were with women who continued antidepressant therapy throughout pregnancy, and 16 were with women who discontinued therapy. The small number of women in the discontinuation group was a result of many women declining to participate. More than one half of the women who continued the medication throughout pregnancy had frequently considered discontinuing, despite reassurance that continuation would cause no harm to their baby. Negative information was recalled far more often than reassuring information.ConclusionInformation from friends, family, and health care providers can have a negative impact on decision-making regarding pharmacotherapy for depression during pregnancy. Health care providers should be cognizant of this when counselling patients who require antidepressant therapy during pregnancy.     

Referrals for dental care during pregnancy

Oral health is essential to overall health in the prenatal period. Pregnancy is not a time to delay dental care. Several studies have shown an association between periodontal disease and poor pregnancy outcomes including preterm birth. Interventions to provide periodontal treatment to pregnant women yield inconsistent results regarding preterm birth but have established the safety of periodontal therapy during pregnancy. Postpartum women in poor dental health readily transmit the tooth decay pathogen Streptococcus mutans from their saliva to their infants, resulting in increased risk of early childhood caries. Preventive services and treatment for acute problems should be recommended, fears allayed, and women referred. Dental radiographs may be performed safely with the use of appropriate shielding. Nonemergent interventions are best provided between 14 and 20 weeks' gestation for comfort and optimal fetal safety. Most gravid women do not seek dental care. Increased interprofessional communication to encourage dentists to treat pregnant women will reduce the number of women without care. In states where it is available, Medicaid coverage of dental services for pregnant women is typically allowed during pregnancy and for 2 months postpartum. Women's health providers should understand the importance of protecting oral health during pregnancy and educate their patients accordingly.     

Pregnant Canadians’ Perceptions About the Transmission of Cannabis in Pregnancy and While Breastfeeding and the Impact of Information From Health Care Providers on Discontinuation of Use

ObjectiveRates of cannabis use during pregnancy and while breastfeeding are increasing in Canada. Some observational studies have found associations between cannabis use in pregnancy and low birthweight, preterm labour, and admission to the intensive care unit. This study aimed to evaluate women's perceptions about transmission of cannabis to the fetus, and whether receiving information from a health care provider influenced their decision to stop using cannabis during pregnancy.MethodsPregnant women presenting to obstetrical, midwifery, and family practice clinics in the greater Hamilton, Ontario area were asked to complete an anonymous survey. Chi-square tests were used to investigate whether patient knowledge was influenced by health care providers or by self-directed learning and if this information influenced their decision to discontinue cannabis use.ResultsOf the 478 women surveyed, the vast majority perceived that cannabis is transmitted to the fetus during pregnancy and to the infant while breastfeeding (94.3% and 91.2%, respectively). The majority of women (99%) indicated that the advent of cannabis legalization did not influence their choice to use cannabis in pregnancy. Women who continued to use cannabis during pregnancy were more likely to report receiving information on cannabis from a health care provider (52%) than those who chose to discontinue use in pregnancy (35%) (P = 0.035).ConclusionsIn our study, the proportion of pregnant women who understood that cannabis could be transmitted to the fetus in utero and to the infant via breastmilk was high. Despite this, 4.2% of women reported that they continued to use cannabis in pregnancy. More work is needed to understand why some women continue to use cannabis in pregnancy despite being informed of its risks.     

Abused pregnant women's interactions with health care providers during the childbearing year

OBJECTIVE: To explore how intimate partner abuse during pregnancy influences women's decisions about seeking care and disclosing abuse and their preferences for health care professionals' responses. DESIGN: A qualitative, grounded theory approach using dimensional analysis. Data were collected via 21 interviews. SETTING: Participants were interviewed in their homes, at their prenatal clinic, at a hospital, and at the investigator's office. PARTICIPANTS: A convenience sample of 12 English-speaking women abused during pregnancy. Five participants were recruited from two prenatal clinics in the Pacific Northwest; 7 were recruited via snowball sampling. RESULTS: The grounded theory "living two lives: women's experiences of intimate partner abuse during pregnancy" emerged from the investigation. Abused pregnant women engaged in a process of guarding and revealing their public and private lives. This process affects how women seek and attend prenatal care, their perceptions of health care providers' interventions, and abuse disclosure. CONCLUSIONS: Intimate partner abuse profoundly affects women's pregnancies and pregnancy-related decisions. Embarrassment, shame, and fear are common emotions. Pregnant, abused women want health care providers to treat them respectfully and empathetically, to recognize the conflict between their public and private lives, to support their decisions, and to be available to help them. They do not expect or want health care providers to fix their situation.     

Spectrum of anxiety disorders: diagnosis and pharmacologic treatment

Nearly 30% of women experience an anxiety disorder at some time during their lives, and there is increasing evidence that anxiety disorders are associated with adverse pregnancy outcomes. Despite increased media coverage regarding anxiety disorders, women are reluctant to discuss signs and symptoms of anxiety with family or health care providers. Additionally, despite ongoing research and improved educational curricula, primary care and women's health care providers find diagnosis and treatment of mental health disorders challenging. This article reviews the diagnostic features and pharmacologic treatment options for the most common anxiety disorders including generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, and posttraumatic stress disorder. The impact of anxiety disorders on pregnancy and guidelines for management are presented.     

Group Prenatal Care for Women Receiving Medication‐Assisted Treatment for Opioid Use Disorder in Pregnancy: An Interprofessional Approach

Opioid use disorder among pregnant women is common and rapidly increasing nationwide. Group prenatal care is an innovative alternative to individual care for pregnant women and has been shown to improve women's and health care providers’ satisfaction and adherence to care. We describe a novel group prenatal care program colocated in an opioid treatment program that integrates prenatal care, substance use disorder counseling, and medication‐assisted treatment. Our interprofessional model draws on the unique contributions of physicians, midwives, nurses, and mental health professionals to address the complex needs of pregnant women with opioid use disorder. Participants reported increased trust and engagement with health care providers and peers, improved prenatal care and birth experience, and increased resilience for relapse prevention. Group prenatal care is an accepted and promising model for women with opioid use disorder in pregnancy and has the potential to improve outcomes for women and newborns.     

Screening for Substance Abuse in Women's Health: A Public Health Imperative

Alcohol and drug use is a significant public health problem with particular implications for the health and safety of women. Women who abuse these substances are more likely to have untreated depression and anxiety and are at higher risk for intimate partner violence, homelessness, incarceration, infectious disease, and unplanned pregnancy. Substance abuse during pregnancy places both mother and fetus at risk for adverse perinatal outcomes. Data regarding the prevalence of substance abuse in women are conflicting and difficult to interpret. On the clinical level, strong arguments exist against routine urine drug testing and in favor of the use of validated instruments to screen women for drug and alcohol use both in primary women's health care and during pregnancy. A number of sex‐specific screening tools are available for clinicians, some of which have also been validated for use during pregnancy. Given the risks associated with untreated substance abuse and dependence in women, the integration of drug and alcohol screening into daily clinical practice is imperative. This article reviews screening tools available to providers in both the prenatal and primary women's health care settings and addresses some of the challenges raised when women screen positive for drug and alcohol abuse.     

Desistance,Self‐treatment,or Substitution: Decisions about Cannabis Use During Pregnancy

Cannabis is the most commonly used drug during pregnancy in the United States and Canada, and the American College of Obstetricians and Gynecologists recommends that all pregnant individuals be screened for cannabis use and counseled regarding potential adverse health impacts of use. However, those considering or using cannabis during pregnancy report experiencing stigma and lack of information from health care providers and, thus, frequently rely on friends, family, and the internet for information. This article describes 3 types of decisions individuals may be making about cannabis use during pregnancy and suggests approaches health care providers may take to minimize judgment and provide optimal support for informed cannabis use decisions among pregnant individuals. Desistance decisions involve consideration of whether and how to reduce or stop using during pregnancy. Self‐treatment decisions are made by those exploring cannabis to help alleviate troublesome symptoms such as nausea or anxiety. Substitution decisions entail weighing whether to use cannabis instead of another substance with greater perceived harms. Health care providers should be able to recognize the various types of cannabis use decisions that are being made in pregnancy and be ready to have a supportive conversation to provide current and evidence‐based information to individuals making desistance, self‐treatment, and substitution decisions. Individuals making desistance decisions may require support with potential adverse consequences such as withdrawal or return of symptoms for which cannabis was being used, as well as potentially navigating social situations during which cannabis use is expected. Those making self‐treatment decisions should be helped to fully explore treatment options for their symptoms, including evidence on risks and benefits. Regarding substitution decisions, health care providers should endeavor to help pregnant individuals understand the available evidence regarding risks and benefits of available options and be open to revisiting the topic over time.     

Lesbian experiences and needs during childbirth: guidance for health care providers

OBJECTIVE: To provide an overview of the literature regarding lesbian experiences of childbirth and to offer health care providers guidance in supporting the childbearing lesbian couple. DATA SOURCES: A search of the literature from 1980 through 2004 was conducted using PsycINFO, Ovid, PubMed, Ebscohost, and Cinahl, and the key words, lesbian, childbirth, parenting health care providers, pregnancy, artificial insemination, parental rights. DATA EXTRACTION: A critical review of all articles from relevant journals was included with attention to the needs of lesbian women concerning childbirth and implications for health care provider care. DATA SYNTHESIS: The four areas of concern identified for lesbians considering parenting were (a) the pros and cons of disclosing sexual orientation to caregivers and finding lesbian-sensitive caregivers, (b) the options available when deciding how to conceive, (c) assurance of the desired level of partner involvement, and (d) the legal considerations for the conception process and for the protection of both parents as well as the child. Methods and strategies to assist health care providers to meet the needs of lesbian clients were gleaned from the literature. CONCLUSION: A growing numbers of lesbian women are becoming consumers of childbirth health care. Health care outcomes of lesbian women and their infants are affected by experiences during pregnancy and childbirth and by the attitudes and actions of health care providers. Evidence exists that health care outcomes for lesbians are improved when health care providers are knowledgeable about and sensitive to the unique needs of lesbian clients.     

Breast cancer during pregnancy

The terms gestational breast cancer (GBC) and pregnancy-associated breast cancer are given to breast cancer that occurs during pregnancy and up to one year post-partum. It is an uncommon event, and for even the most experienced clinician, whether oncologist, obstetrician or primary health worker, the complex issues that surround a diagnosis of breast cancer during pregnancy make management difficult. The prognosis overall for women diagnosed with GBC is poor, possibly due to delays in diagnosis. Primary physicians and obstetricians can play an important role in the early detection of GBC by promoting breast awareness in premenopausal women, including women who are pregnant or lactating; and by undertaking prompt and appropriate referral of pregnant and lactating women with breast abnormalities. Even in pregnant or lactating women, clinicians should always investigate a breast abnormality using triple assessment--clinical assessment, imaging and tissue biopsy. Breast cancer during pregnancy requires a multidisciplinary approach to ensure optimal care for both the mother and the baby. Breast cancer management can be adapted to protect the fetus, but this will be dependent on the gestation and disease status at diagnosis. Pregnancy after breast cancer does not appear to affect either cancer prognosis or pregnancy outcome. Obstetricians have a vital role to play in the care of these women by supporting them through their pregnancy, providing reassurance of fetal health and maintaining good communication with their other health providers.     

A qualitative study of women's perspectives of antenatal care in a rural area of Zimbabwe

OBJECTIVE: To describe the perspectives and experiences of women in their use of antenatal care and in their reasoning on specific antenatal care routines. DESIGN: Two qualitative methods including focus group discussions and individual interviews were combined. SETTING:: a rural district in Zimbabwe where a randomised control trial had been undertaken to introduce a new antenatal care package. PARTICIPANTS: Forty-four women and twenty-four men participated in the study. FINDINGS: Women were observed to take actions contrary to those assumed professionally acceptable in antenatal care generally and in some specific changed routines. Visits were to be reduced and weighing was to be omitted, but women, especially younger women, said they preferred more than the stipulated five goal oriented visits. One reason for this was the importance of being assured that the fetus was growing well. They considered that visits spaced too widely would make it difficult for service providers to help, should complications develop. On the other hand, older women (above 35 years old), a group professionally considered to be at high risk, were not so concerned with the visits. All the women said they wanted to be weighed at all the visits. The antenatal care visits are simply known as 'going for scale'. The health care providers complied by weighing the women without recording. Cultural beliefs had great influence, especially on the time a pregnancy is acknowledged and reported. It is believed that pregnant women and the pregnancy are vulnerable to witchcraft during the early period of pregnancy. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: We concluded that, whether in its traditional or new form, antenatal care ignores the experiences and views of women and the way they make sense of pregnancy and the care of pregnancy. The importance of understanding the perspectives of different stakeholders as the key to effective change is underlined.     

Access and utility as reflections of cultural constructions of pregnancy

Health care providers can give their patients better care if they understand how their patients view pregnancy and birth. This article provides some examples of how women from various cultural backgrounds understand pregnancy and how these beliefs affect women’s decisions to seek prenatal care and to utilize prenatal services regularly throughout their pregnancies. These concepts—access and utility—provide the frame for this article, and the case studies from diverse ethnic groups provide examples of a variety of cultural beliefs and women’s decisions to seek and to value biomedical direction during pregnancy. The conclusion includes several recommendations that health care providers can employ to enhance the quality and effectiveness of care.     

Traditional birth attendants and birth outcomes in low-middle income countries: A review

Traditional birth attendants (TBAs) provided delivery care throughout the world prior to the development of organized systems of medical care. In 2016, an estimated 22% of pregnant women delivered with a TBA, mostly in rural or remote areas that lacked formal health services. Still active in many regions of LMICs, they provide care, including support and advice, to women during pregnancy and childbirth. Even though they generally have no formal training and are not recognized as medical practitioners, TBAs enjoy a high societal standing and many families seek them as health care providers. They are generally older women who have acquired their skills acting as apprentices of other TBAs or are self-taught.WHO and other international organizations have focused maternal mortality reduction efforts on the availability of skilled birth attendance, which excludes TBAs as providers of care. However, as countries move towards SBA, policy makers need to make the best use of TBAs while simultaneously planning for their replacement with skilled attendants. They often serve as a bridge between the community and the formal health system; once women are inside an institution, TBAs could potentially act as doulas, providing company and making women feel more comfortable in an unknown environment. In this paper, we will review who TBAs are, how many births they attend worldwide worldwide, where they provide delivery care, and finally, their relationships with the formal health care system and the communities they serve.     

Domestic violence during pregnancy in Turkey and responsibility of prenatal healthcare providers

The purpose of this study was to estimate prevalence and risk groups of domestic violence during pregnancy in Manisa, Turkey, and to determine antenatal complications or health problems and health service use. This study was a population-based, cross-sectional, and household survey. The study universe included two primary health units situated in two different socioeconomic areas (rural and urban) in the city of Manisa, Turkey, from January to June 2004; the homes of 246 women were visited and the study sample included 217 women. A questionnaire was used that comprised sociodemographic and reproductive characteristics, and the Domestic Violence Against Women Determination Scale, developed by Yanikkerem in 2002 to measure the frequencies of type and severity of violence. The Statistical Package for the Social Sciences (SPSS, version 10.0 for Windows) was used to analyze the data. Student t test and Mann-Whitney U test were used to evaluate data. Results indicated that 9.7% of women were beaten by their partner during the pregnancy (17.3% in the rural area and 2.7% in the urban area) and 14.3% of women were beaten before pregnancy. A total of 10.6% of women said they had been slapped, 9.1% reported an object was thrown at them by their partner, and 6.5% admitted to having been kicked during pregnancy. A total of 36.4% of women reported experiencing forced sexual activity. Abused pregnant women were less educated, had lower income, were unmarried, were multiparous, had more children, had a longer duration of marriage, lived rural areas, were more likely to have unplanned pregnancies, had miscarriage, had an interpregnancy interval of 2 years or less, smoked more cigarettes, did not visit a health institution for control during pregnancy and did not know the sex or knew the fetus was female when compared with nonabused women. Abused women who live with various problems during pregnancy and are victims of violence tend to feel isolated, insecure, and depressed. Our results indicate that most pregnant women do not report that their prenatal care providers discussed violence with them. Healthcare provides have an important role in this issue. Antenatal care protocols should be modified to address domestic violence and contributing factors during pregnancy so that identified women can be counseled appropriately and attempts can be made to intervene to prevent further episodes of domestic violence in primary care settings.     

Ludwig's Angina in Pregnancy: A Case Report

BackgroundPhysiologic changes in pregnancy may predispose pregnant women to oral health problems. However, most women are not counselled on oral health during pregnancy. Lack of proper oral health care predisposes pregnant women to odontogenic infections, which can lead to severe complications.CaseA 34-year-old multiparous woman presented at 40⁰ weeks gestation with a 3-day history of severe, progressive neck swelling, jaw pain, and trismus. She was diagnosed with Ludwig's angina secondary to an untreated dental cavity. She required emergency fiberoptic intubation to secure her airway, urgent delivery via cesarean section, and subsequent surgical drainage performed by otolaryngology.ConclusionLudwig's angina during pregnancy is associated with severe morbidity. Dental care should not be denied or postponed due to pregnancy, and dental infections should be treated promptly. Health care providers should counsel women on the importance of maintaining good oral health during pregnancy.     

Psychosomatic obstetrics and gynecology in the next millennium: Some thoughts and observations

While the importance of psychosocial and cultural issues in obstetric care has been increasingly acknowledged in recent decades there is still neglect and misunderstanding of what women want during pregnancy, birth and the postpartum period with regard to their care by health care providers. This paper highlights significant issues of concern which should be of value for caregivers, educators and health service planners as we move into the next millenium     

Pregnancy and alcohol use: evidence and recommendations for prenatal care

Pregnancy alcohol consumption has been linked to poor birth outcomes and long-term developmental problems. Despite this, a significant number of women drink during pregnancy. Although most prenatal care providers are asking women about alcohol use, validated screening tools are infrequently employed. Research has demonstrated that currently available screening methods and intervention techniques are effective in identifying and reducing pregnancy drinking. Implementing universal screening and appropriate intervention for pregnancy alcohol use should be a priority for prenatal care providers, as these efforts could substantially improve pregnancy, birth, and longer term developmental outcomes for those affected.