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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 247-254

Perception of benefits and risks by clinical pharmacists regarding utilization of drugs during pregnancy: A narrative review


Department of Pharmacy Practice, P Rami Reddy Memorial College of Pharmacy, Kadapa, Andhra Pradesh, India

Date of Submission07-May-2020
Date of Decision28-May-2020
Date of Acceptance27-Jun-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Miss Mohammad Ahmadi Tabassum
Department of Pharmacy Practice, P Rami Reddy Memorial College of Pharmacy, Kadapa, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_88_20

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  Abstract 


Pregnancy is a happy and positive experience for women because pregnancy in addition, having a baby is a life-changing event: the body undergoes major changes. There may be considerable discomfort or ill health takes place during pregnancy. Therefore, they face problems about taking medicines. All the illicit drugs are associated with medical complications, but some may lead to severe damage and increases the risk of serious harm to both fetus and for the mother. Drugs have shown to pass into breast milk, so advice the mothers to avoid breastfeeding when using it. There is a need to be cautious in using medication during pregnancy. However, women with lower levels of education tend to use more prescription or illicit drugs, as they do not understand the proper use of medications, which were associated with several adverse teratogenic outcomes. According to World Health Organization, therapeutic use of medication does not cause developmental abnormalities in the fetus or newborns, but abuse does pose risks to the fetus. The provision of health education during pregnancy to be an important aspect of prenatal care. Indulging effective knowledge and counseling impact of clinical pharmacist activities tends to be promoting awareness to all patients receiving drugs during pregnancy as well as providing information on the consequences and potential harm or effects for mothers and for foetuses based on their need. Communicate with the nearby pharmacists, while using medications to avoid accidental damage during pregnancy.

Keywords: Clinical pharmacist, education and counseling, illicit drugs, pregnancy


How to cite this article:
Tabassum MA, Alishar S, Kumar S N, Subbiah MV. Perception of benefits and risks by clinical pharmacists regarding utilization of drugs during pregnancy: A narrative review. Arch Med Health Sci 2020;8:247-54

How to cite this URL:
Tabassum MA, Alishar S, Kumar S N, Subbiah MV. Perception of benefits and risks by clinical pharmacists regarding utilization of drugs during pregnancy: A narrative review. Arch Med Health Sci [serial online] 2020 [cited 2021 Apr 11];8:247-54. Available from: https://www.amhsjournal.org/text.asp?2020/8/2/247/304731




  Introduction Top


Pregnancy

Pregnancy is known as gestation. Pregnancy is a dynamic process, which involves a series of changes that take place from fertilization to birth in woman's organs, which takes an average of 270 days, or about 9 months, from the start of last menstrual period.[1]

Clinical pharmacist

Clinical pharmacists are licensed practitioners with advanced education and training who practice in all types of patient care settings with a focus on achieving optimal use of medications, emphasizing dosing, monitoring, identification of adverse effects, and economic efficiency to achieve optimal patient outcomes.[2]

Clinical pharmacist activities

A clinical pharmacist typically provides the following pharmaceutical care:

  • Providing information to patients, which may include the information leaflet, name of the medicine, its purpose, potential interactions, and side effects, as well as correct usage and storage[3]
  • Educating the patients on medication (by focusing on the drug administration and precautions) taken during hospitalization and upon discharge[4]
  • Providing and sharing general as well as specific medicine-related necessary information to the physicians and advice to the public and health-care practitioners regarding the concerned drug use that general practitioners are not familiar with a focus on off-label drug use and the interactions associated between herbal and ayurvedic medications with allopathic medicines[4],[5]
  • Performing medication reconciliation in order to avoid duplication and interactions so as to confirm the safe transition of care among the patients[4]
  • Participating in multi-disciplinary teams concerning complex pharmacological treatment in collaboration with physicians and other health-care providers, typically in a hospital setting
  • Reporting adverse reactions to medicines and then discussing with the prescribing physician and health authorities in accordance with national legislation
  • Maintaining a high level of knowledge of pharmacological treatment through continuing professional development[4]
  • Ensuring safe procurement, adequate storage, and dispensing of medicines in compliance with the relevant regulations
  • Reviewing prescriptions to find allergic reactions, contraindications, and therapeutic duplications that should be discussed with the prescribing physician, but the pharmacist should not change the prescription without consulting the prescriber[3]
  • Pharmacists should also aid the physicians in monitoring the patient's mental health well-being when there is a severe shortage of front-line physicians
  • Providing effective counseling to patients and follow certain precautions on the spread of infection such as not to use unnecessary medications as it may lead to further infections. Avoid unnecessary visits to the hospital as it may increase the chances of cross-infection. Consult the physician only when the person is suspected with the symptoms of fever, cough, cold, and breathlessness.



  Retraining Knowledge on Use of Stimulant Top


Stimulant is the most common type of medication prescribed for attention deficit hyperactivity disorder[6] used in children and adults. This is usually a type of medication that has been used for a long time and helps the brain control impulses, behavior, and attention[7] by increasing dopamine levels in the brain. Dopamine is a neurotransmitter associated with motivation, pleasure, attention, and movement.[6]

Example includes: Amphetamine, dextroamphetamine, dexmethylphenidate, lisdexamfetamine, and methylphenidate.[7]

Effect on the usage of stimulants in pregnancy

The stimulant used in late pregnancy, which has the potential to negatively affect fetal growth, could affect infant growth after conceivable exposure via breast milk and have adverse effects on appetite and sleep.[8] Stimulant effects are likely related to placental abruption. These are associated with higher risk of preterm delivery, premature birth, low birth weight, growth retardation, neonatal withdrawal symptoms, and increased maternal and fetal morbidity and neonatal mortality.[9] Several adverse teratogenic outcomes were associated while using the stimulants, which include higher rates of preterm birth, placental vasoconstriction, cardiac anomalies, smaller head circumference, fetal distress, and fetal growth restriction.[10]

Epidemiology of stimulants

In the USA, pregnant women consistently increase the using of stimulant nationwide. In 2015, 1.38 million women used stimulant. The lifetime prevalence among adults for stimulant use is 29.2%, second only to marijuana 46.9%.[11] Stimulants are legally prescribed for medical reasons, and for the nonmedical users. The prevalence of use, whether legal or illicit, is a substantial global problem.[12]

Contraindications

According to the International Programme on Chemical Safety (IPCS) and the United States Food and Drug Administration (USFDA), human studies indicate that therapeutic use of stimulant does not cause developmental abnormalities in the fetus or newborns, but abuse does pose risks to the fetus.[13] Stimulants have also been shown to pass into breast milk, so the IPCS and the USFDA advise mothers to avoid breastfeeding when using it.[14]

Counseling on the usage of stimulants

It is important to take the drug, as per doctor and pharmacist's instructions, that will help to maximize the effectiveness and minimize the side effects and risks upon usage of the medication during pregnancy.

The following are some instructions for safe use:

Learn about the prescribed medication such as how often to take it, potential side effects, special warnings, and other substances that should be avoided. Start with a low dose and work up from there. Be patient while finding the right medication and dose because it will take some experimenting, as well as open, honest communication with your doctor. Monitor and observe the drug's effects as how well the medication is working to reduce symptoms. Consult the doctor for guidance on gradually decreasing the dose, if wants to stop taking medication. Sudden stoppage of medication can lead to unpleasant withdrawal symptoms such as irritability, fatigue, depression, and headaches.

Not all stimulants are equal, and patient response also varies considerably. Abuse and addiction to stimulants is a major health concern in pregnancy. During pregnancy, balancing of the risk and benefits has an important challenge for the clinicians.


  Retraining Knowledge on the Use of Over-the-Counter Medication Top


Over-the-counter drugs

Medications which can be directly available to the consumer for the treatment of common ailments, without a prescription from health-care professionals, are known as over-the-counter (OTC) or nonprescription medications.[15]

Use of over-the-counter medications

Pregnant women commonly use OTC medications[16] as a self-medication for many years, in the treatment of pregnancy-related health problems. However “not all OTC medications are safe to be taken during pregnancy.”[17] Even though most of the drugs have an excellent safety profile, some of the OTC drugs are known to cause serious adverse effects to the fetus with unproven safety profiles.[16],[17] All the drugs are associated with medical complications, but some may lead to severe damage to both fetus and mother. The use of OTC drugs increases the risk of serious harm to their health and pregnancy. With these drugs, adverse drug interactions may not occur in non-pregnant women, but may occur in pregnant women, which causes serious harm to their health and pregnancy.[18]

Epidemiology

More than 80% of the pregnant women use medications which are sold as OTC.[19] Women who were pregnant are about twice and thrice risk of practicing self-medication with OTC drugs compared to employed pregnant women. On the other hand, the presence of comorbid conditions was found to have a 60% protective effect against self-medications with OTC drugs. This may be due to frequent counseling against OTC medication use by health care givers when the women come for regular follow-up of comorbid condition checkups.[18]

Over-the-counter medications during pregnancy

Commonly used OTC medications are analgesics, antibiotics,[20] antipyretics, cough syrups, antiemetics, herbal products, and nutritional supplements.[17],[20]

Examples: Acetaminophen, ketoprofen, ibuprofen, naproxene, aspirin, streptomycin, tetracycline, sulfonamides,[21] chlorpheniramine, pseudoephedrine hydrochloride, guaifenesin, dextromethorphan hydrobromide, diphenhydramine, clemastine fumarate, calcium, folic acid, iron, and vitamin supplements.[17],[21]

Role of calcium

Calcium plays an important role during pregnancy. In order to prevent the risks associated with hypertensive disorders (eclampsia and pre-eclampsia) and the serious consequences of preterm calcium intake is necessary. It increases the bone mineral density in the infants of supplemented mothers.[45] According to the WHO, 1.5–2.0 g of oral elemental calcium with the total dose divided into three doses per day was recommended to start at 20 weeks of gestation so as to get benefits from the supplements during the mid-pregnancy.[46] There is no limit on the duration of calcium supplementation, but in extremely low number of cases, there were found to be elevated risks of a rare syndrome (hemolysis, elevated liver enzymes, and low platelet count).[47]

Role of folic acid

Before conception and during early pregnancy, folic acid plays a vital role in preventing the infants from neural tube defects, preterm birth, low birth weight, miscarriage, and poor growth in the womb, which can occur within the first 3–4 weeks of gestation, and also reduces the risk of pregnancy complications, heart disease, stroke, and Alzheimer's disease.[48] According to the WHO, daily 400 μg of folic acid supplementation is recommended for pregnant women.[49] Excess of folic acid intake may impaired fetal growth and also slow down the brain development of the baby.[50]

Role of ferrous sulfate

During pregnancy, ferrous sulfate is required to meet the deficiencies associated with anemia, showing negative impact on the health of women, which makes them tired and faint with increased risk of infections and low birth weight. According to the WHO, 300 mg of ferrous sulfate is recommended daily for pregnant women.[45]

Consequences during pregnancy

Drugs taken by the mother may cross the placenta and reach the developing fetus and results in various consequences.[22] Hence, there is a need to be cautious in using OTC medication because of concern about the adverse effects on the developing fetus.

Salicylates are usually associated with increased perinatal mortality, neonatal hemorrhage, decreased birth weight, prolonged gestation and labor, and possible teratogenicity.[16],[23] Pain medications are usually associated with oligohydramnios, premature closure of the fetal ductus arteriosus[16],[24] with subsequent persistent pulmonary hypertension of the newborn, fetal nephrotoxicity, and periventricular hemorrhage.[16] Even cold medications such as expectorants, decongestants and anti-histamines, which may result in various consequences such as vascular disruption (gastroschisis), disruption in the flow of blood to the fetus and neural tube defects.[16],[23]

Use of magnesium trisilicate may lead to fetal nephrolithiasis, hypotonia, and respiratory distress.[16] Usage of sodium bicarbonate may cause metabolic acidosis and fluid overload.[16],[21] Use of antidiarrheal medication may increase the chances of developing iron deficiency anemia and possible fetal cardiac malformations.[16] Prolonged usage of antacids may sometimes result in fetal development and injury, fetal death, and spontaneous abortion.[16] Nonsteroidal anti-inflammatory drugs (NSAIDs) and bismuth subsalicylate may cause premature closure of the fetal ductus arteriosus and may lead to subsequent persistent pulmonary hypertension of the newborn.[25] Usage of antibiotics (streptomycin, tetracycline, and sulfonamides) may result in hearing loss in the baby, jaundice in the newborn, and discoloration of teeth.[21]

Counseling to compete against the usage of over-the-counter medications

  • Avoid the usage of OTC medications unless it is necessary. Encourage the pregnant woman to go for nonpharmacological treatment through hydration, rest, vaporizers or humidifiers, nasal irrigation, and saline nasal sprays in case of cough and cold.[23] Proper attention needs to be taken while using OTC medications during the first trimester, as it is the period of organogenesis and the drug may interfere with the fetal development.[25] Always communicate with the nearby physician or pharmacists while using OTC medications to avoid accidental damage to the fetus and the mother
  • Avoid usage of salicylates at high doses mainly aspirin during the third trimester as it may cause bleeding problems in mother and baby at delivery.[16] Avoid the usage of NSAIDs during the third trimester as it may slow down the blood flow to the baby and the mother.[23] Avoid using medications in combination that treat many symptoms at once because a number of drugs may cause harm to the baby.[25] Avoid taking anabolic steroids.[21]



  Retraining Knowledge on the Use of Prescription Drugs Top


Prescription drugs

Safe and effective medications, which are prescribed under the doctor's care for the treatment of a patient's disease/ailment, which were bought at the pharmacy.[26]

Usage of prescription drugs in pregnancy

Most of the pregnant women used to take at least one prescription drug during pregnancy to treat their health condition such as diabetes, hypertension, and depression. However, not all the prescription drugs are safe to use during pregnancy.[27] These medications are less risky because they perceived more physician oversight, had undergone many clinical trials, and included more specific directions,[28] even though these drugs may lead to increase the potential risk to the fetus and the mother.

Examples include opioids, tranqulizers, stimulants, antibiotics, anti-asthmatic drugs, analgesics [Table 1].
Table 1: Safe medications during pregnancy

Click here to view


Epidemiology

Prescription use during pregnancy is prevalent, with estimates of approximately 44%–99%.[26] About nine in ten women take at least one medicine during pregnancy and seven in ten take at least one prescription medicine.[30] Women from lower level of education tend to use more prescription drugs than that of women from a higher level of education. Women with chronic health condition such as gestational diabetes, a prenatal hospitalization, a history of infertility, or symptoms of acid reflux were more likely to use prescription drugs than that of women without these conditions.[31]

Consequences on using prescription drugs[32]

Contraction of the uterus may affect the fetal blood supply or cause preterm labor and birth. Interference with normal prenatal development can lead to birth defects or fetal demise. prescription drugs also interfere with the function of the placenta, which supplies oxygen and nutrients to the baby, causing babies to be underdeveloped and underweight.

Potential harm to the fetus and the mother[33]

Upon intake of opiates, it may lead to preterm birth, low birth weight, or fetal death in the fetus and symptoms of slow breathing, nausea, constipation, and drowsiness in the mother. Birth defects caused by opiates include spina bifida, heart defects, and glaucoma. Tranquilizers may increase the risk of fetal death, birth defects in the fetus, and slowed breathing, heartbeat, drowsiness, and dizziness in the mother. Stimulants may result in rise in body temperature, seizures, irregular heartbeat, high or irregular blood pressure, sleep problems, tremors, weight loss, and panic attacks in mother. In addition, they cause fetal defect or preterm birth and can increase the blood pressure, risk of brain and heart defects, and risk of cleft lip/palate in the fetus. Antibiotics such as chloramphenicol may lead to gray baby syndrome in the fetus.

Counseling to compete against these consequences[32]

  • Avoid consuming larger doses than prescribed and avoid using prescription drugs more frequently than prescribed
  • Avoid taking medication for reasons other than originally prescribed and avoid taking medications which are prescribed for someone else. Attention should be needed for using medications with other addictive substances .


Some drugs in category X that are contraindicated in pregnancy and their effects on the fetus are listed in [Table 2].
Table 2: Drugs contraindicated in pregnancy

Click here to view


During the last trimester of pregnancy, drugs may interfere with the vital functions of the fetus[42] [Table 3].
Table 3: Drugs causing organ functions

Click here to view



  Discussion Top


Stimulant use in pregnancy is an underrecognized public health epidemic and has important short-term and long-term implications for maternal and neonatal health as stated by Marcela et al.[11] They describe that illicit stimulant use is likely associated with adverse perinatal outcomes including shorter gestational age and low birth weight, however less is[44] known about the prescribed stimulant use and perinatal outcomes. In general, using OTC medication during pregnancy may sometimes result in serious effects as stated by Abduelkarem and Mustafa[17] that all the OTC medications are not safe during pregnancy as these may be beneficial only for the treatment of minor ailments if, there is a sufficient knowledge regarding the use of OTC. Using OTC drugs may potentially cause effects on the fetus and the mother, and this statement correlates with a study conducted by Black et al.,[16] as they describe that almost all the OTC medications may adversely increase the risk to the fetus as well as mothers.

Imparting specific knowledge of the potential risks of using nonprescribed medication during pregnancy may help pregnant women more safely manage their OTC use as stated by Atmadani et al.[34] They describe that the significant effects of a higher level of knowledge of self-medication among women with lower income and education levels may indicate a level of their competence that is a strength upon which a provider could build. Expanding the role of health-care providers together with the provision of evidence-based information in prenatal health education is crucial to promote pregnant women's safe management of OTC. In general, using prescription drugs is more common among the pregnant women, i.e., at least 7 in 10%, and this correlates with the data provided by Chan et al.,[29] as they summarized that the usage of prescription drugs is more prevalent during pregnancy, even though there was no proper information related to teratogenic and fetotoxic effects of these drugs. Many women with lower levels of education tend to use more prescription drugs as they do not understand the proper use of medications, hence there is a need of providing guidance regarding the safety of using drugs during pregnancy. In relation to the above, these data coincide with the study conducted by Riley et al.,[31] as they concluded that there is a need to suggest pharmacists to safeguard prescribing practices for women of reproductive age, which supports the importance of expanding the evidence about the risks and benefits of using prescription drugs.

Pregnancy can be a confusing time for women facing many choices about legal drugs, such as stimulants, tobacco and alcohol, as well as prescription and OTC drugs. During that period, the pharmacist spends more time with pregnant women for personal counseling that offers better outcome to the mother and fetus because the pharmacists are capable of monitoring abuse problems, evaluate their severity, and offer proper counseling for individuals in their recovery as stated by Kenna et al.[35] Most of the OTC drugs have been linked with adverse effects during pregnancy, so pharmacist plays an important role in selecting and providing information or medication counseling regarding the safety of OTC drugs, dietary supplements, and herbal products to use in pregnancy as stated by Verstappen et al.[24] Presence of comorbid conditions was found to have a 60% protective effect against self-medications with OTC drugs. This protective effect due to frequent counseling by health care givers against OTC medications, women who has come for regular checkups of comorbid condition as stated by Mohammed et al.[18]


  Conclusion Top


This review concluded that, same as the illegal drugs, upon prolonged use some of the prescription medications and stimulants also dangerous to pregnant women and harmful or potentially fatal to fetuses. The articles included revealed that pregnancy is a confusing time, so many women with lower levels of education tend to use more prescription drugs as they do not understand the proper use of medications, hence in such circumstances, a well-qualified counselor provides information regarding the medications generally used in pregnancy, in an effort to highlight the knowledge and proper counseling or guidance during pregnancy. We believe that pharmacist provides space for pregnant women's concerns or frustrations in a safe, nonjudgmental environment and pregnant women should be counseled and educated regarding the safe and effectiveness of medication during pregnancy; this could also be a milestone to prevent medication misadventures during pregnancy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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