Drug use during pregnancy
Drug Use During Pregnancy
Drug use during pregnancy is an issue of concern due to the associated effects of the drugs. Drug use during pregnancy ranges from the usual medical drugs to illicit/illegal drugs. The illicit drugs have a higher potential to interfere with the developmental process due to its nature and behavioral traits of the abusers. All in all, the use of non-monitored and unprescribed drugs results in various detrimental effects to both the woman and the fetus. The effects of drug use can be manifested immediately upon exposure or manifested at a later point in life. These effects range from functional impairment to carcinogenic outcomes.
The thalidomide disaster in the 1960s was the reason for the current precautions associated with drug use during pregnancy; thalidomide led to development of phocomelia. Drug use during pregnancy is a sensitive area due to the effects of pharmacokinetics of medications; these medications can have a potentially harmful effect on the growing fetus. However, all medications cannot be restricted during pregnancy; otherwise, there would be a high burden of disease among pregnant women. Most women are already having medical issues by the time they are getting pregnant; hence, the objective for drug use during pregnancy should be in alignment with safety. Several medications cause congenital abnormalities in fetuses, and these are attributed to the ingredients constituting the drugs. The discussion on drug use is quite broad, but this paper aims to give insight into the use of drugs during pregnancy so that one can understand safe and unsafe drugs and associated practices during this sensitive period.
There are different types of drugs: the typical medications, illegal drugs (what is deemed drug abuse), over-the-counter drugs, and occupational and environmental exposures. All these forms of drug use are not acceptable unless approved by a physician. According to the current statistics, the use of medical drugs is inevitable, even though it is considered a desirable move. Most women get pregnant when they already have pre-existing medical conditions that require ongoing management, for example, epilepsy, hypertension, asthma. Lack of healthcare management of such conditions may lead to adverse health effects to both the mother and fetus. Some drugs such as vitamins, minerals and dietary supplements are paramount. Sachdeva, Patel, and Patel (2009) indicate reports of more than 8% pregnant women require drug treatment in the course of their pregnancy. 59% of women are on prescribed medication while 13% pregnant women take herbal dietary supplements. 90% of pregnant women are either on illicit drugs, over-the-counter drugs, or other forms of social drugs. Due to paucity in scientific evidence and unreliability of animal studies, healthcare workers are somewhat hesitant about using drugs during pregnancy. Otherwise, the safest forms of drug are used in the management of an already prevailing condition, or in the management of newly developing ones.
Physiological Changes during Pregnancy Influencing Drug Use
The effects of drugs on pregnancy are dependent on the stage of the pregnancy. However, due to dearth literature on the effects of drugs during conception and implantation, it is recommendable that women trying to get pregnant or at risk of unexpected pregnancies should refrain from drug use 3-6 months prior to conception (Sachdeva et al., 2009). The use of drugs between the 15th and 21st days after fertilization may result in holistic effects by killing the fetus or have no effect whatsoever. After the 3rd week till the 8th week, the fetus is regarded to be highly susceptible to birth defects, and drug use during this time may cause a lifetime, but subtle defect noticed as the child grows older, miscarriage, or obvious birth defect. After the 9th week, exposure to drugs is not associated with major birth defects, but these drugs may interfere with the growth and functionality of organs and tissues formed in a normal way. The dose that reaches the fetus determines the magnitude of the effect.
This knowledge is beneficial but it is impractical because in most cases, a woman gets to know about her pregnancy when the first two stages of development that are deemed critical have already begun, and sometimes, they have already completed. Aware of the adverse effects associated with drug use during pregnancy, 60% of pregnant women will still use medication during their pregnancy. Studies have indicated that the drugs mainly used over the counter antinauseants, sleep medications, and analgesics (Chasnoff, 2012). According to Cragan (2014), the use of prescribed drugs including vitamins and minerals range from 33% to 69% in developed countries. Over the counter and prescription drug use increased almost twofold in the United States in three decades. This behavior alongside the use of illicit drugs discussed are practices that should be regulated to avoid the adverse effects resulting from such malpractice.
Pharmacokinetics of Drugs During Pregnancy
It is necessary to understand the pharmacokinetics of drugs during pregnancy so that the underlying rationale for no or minimal, if necessary, drug use is understood. Pregnancy is associated with a 30 to 50% increase in plasma volume. This increase is associated with the development of a favorable environment to distribute drugs (Sachdeva et al., 2009). Drugs taken through oral means are metabolized by the liver to either an ionized or a non-ionized form. The non-ionized form has a much higher ability to pass the liver while the ionized form is excreted through urine. Drugs that are administered intramuscularly, intravenously or through inhalation directly cross the placenta. Pregnancy is a physiological state that alters the woman’s response to some drugs. Changes in venous pressure in the late stages of pregnancy thwart the absorption process of intramuscularly administered drugs. In addition, there is reduced protein binding due to a decrease in plasma protein levels. Albumin, for example, binds to acidic drugs and chemicals such as aspirin and phenytoin; hence, the outcome is an increase in free drugs that easily cross the placenta and reach the fetus. On the other hand, the due to the high rates of cardiac output and glomerular filtration, excretion by the kidney and the liver counteract the high levels of free drugs in the plasma. In addition, the high levels of female hormones activate maternal enzymes in a way that leads to a modified inactivation of medicinal and environmental agents (Schaefer, Peters, & Miller, 2015). Combined-drug therapy is not recommended because common drugs during pregnancy such as vitamin and mineral supplements may bind or inactivate some drugs. These events indicate that, contrary to highly held beliefs, the placenta does not block and prevent drugs from crossing over to the fetus.
Medical Drug Use and Associated Effects
In as far as 1957, the thalidomide was considered a mild sedative until it caused reduction deformities of the limbs that ranged from hypoplasia to total lack of limbs. Apparently, there has been increased drug exposure during pregnancy, and it is impossible to rule out chemical exposure from the environment; yet, indicate a plateaued prevalence of birth defects: 3-4%. These statistics are debatable, but, unfortunately, there are not statistics to back up or refute the observed prevalence of birth defects. However, one thing that makes these figures inaccurate are the unreported congenital abnormalities that appear later in life, for example, diethylstilbestrol that results in cancer of the uterus. Literature indicates that autism is linked to exposure to thalidomide (Schaefer et al., 2015). The embryonic and fetal responses to drug exposure depend on dosage of a particular drug, genetic disposition of the fetus, stage of fetal development, and mode of action of the drugs. Environmental chemical compounds may have carcinogenic effects and the fetus is highly vulnerable due to the high rate of cellular proliferation. Hence, interference with genetic make-up will result in mutations that will lead to carcinogenic outcomes.
Unfortunately, there are no holistic details about the use of drugs during pregnancy due to the limitations of not including pregnant women in drug trials. The Centers for Disease Control and Prevention (2014) indicate that information on drug use during pregnancy is only available for less than 10% of all medications that have been approved by the U.S. Food and Drug Administration (FDA) since 1980. Medications such as thalidomide (Thalamid®) and isotretinoin (Accutane®) are strongly prohibited during pregnancy. However, clinicians and the medical fraternity still lack adequate information to act as guidelines for drug use during pregnancy.
During the late 20th century, methadone was a common drug used in the management of opiate-dependent women. Quinine or procaine were also used to ax use of heroin, yet these drugs had teratogenic effects. Hence, low dosages were used to avoid the development of these effects. Due to a dearth in information, the medical intervention that replaced this early intervention is lacking. However, it is evidently clear that behavioral therapy and counseling are major interventions. Since there is inadequate information to guide the use of methadone, clinicians use a detailed history of the client’s heroin intake in the previous 24 hours. Women who already have existing medical conditions, for example, asthma, high blood pressure, epilepsy, or depression, continuing with the medication is important to prevent harmful effects on the pregnant women and her fetus. A perfect example is that of HIV pregnant women who have to continue using the antiretroviral drugs throughout pregnancy.
In a study cited by Schaefer et al. (2015), the use of paracetamol during the first trimester was not associated with birth defects. As a matter of fact, the use of paracetamol for febrile disorders was associated with reduced risk of birth defects, including orofacial clefts, neural tube defects, microtia, and anotia. However, contradictory results from experimental studies indicate that the use of paracetamol is associated with reduced testosterone synthesis. The result would be an impairment of reliant testosterone activities. Exposure to paracetamol for at least four weeks between the eighth and fourteenth weeks resulted in cryptorchidism. On the other hand, the same is not the case when pregnant women in need of operative treatment were exposed to paracetamol. The administration of aspirin is beneficial in the management of hypertension and preeclampsia. However, the effectiveness of the drug is dependent on the dosage and time of administration. Studies indicate that the drug should be administered in low dosages and its administration should be initiated at least 16 weeks prior to gestation. Aspirin is not the ideal analgesic or anti-inflammatory first line of drugs for use during pregnancy. Paracetamol is the most preferred choice. Alternatively, ibuprofen or diclofenac can be used instead of paracetamol. It is, nonetheless, important to note that non-steroidal anti-inflammatory drugs, including aspirin should not be routinely used in the third trimester because it may lead to closure of the fetal ductus arteriosus. Subsequently, these may have detrimental renal effects. The list of drugs is endless, but a thorough examination of the ingredients is imperative especially with newly developed drugs.
Illicit Drug Use
Illegal drugs are unacceptable because they have no benefit (American Pregnancy Association, 2015). The dosage for alcohol in relation to adverse effects on the fetus is still unknown, but, according to the National Health Service (2015), if it is necessary one should have a cheat drink of no more than two small glasses of wine weekly or biweekly. Alcohol metabolism takes place in the liver, yet the liver is one of the last organs to develop during the last trimester. Hence, exposure to alcohol reaches the baby’s system in a non-refined form that affects development. Current research correlates drinking during the first trimester with premature birth and low birth-weight. Other effects of excessive alcohol intake include, but not limited to miscarriage, poor cognitive development.
Substance abuse and dependence are a major problem among women of reproductive age. The drugs that are commonly used include marijuana, cocaine, and methamphetamine. Young women in the adolescence indulge in binge drinking and inhalant abuse. This behavior continues during adulthood and child-bearing age due to the strong correlation between drug abuse during adolescence and during adulthood. Women are aware of the repercussions associated with substance abuse during pregnancy; hence, most of them seek prenatal care during the last stages of pregnancy to avoid conflict with the law. Illicit drugs have low molecular weight; hence are readily transferred across the placenta (Pillitteri, 2014).
Environmental and Occupational Exposure
Apparently, assessment of drugs associated with occupational exposure is rather difficult due to lack of information necessary for evaluation. In reference to environmental exposure, recommendations on management of inadvertent exposure should be followed. Otherwise, environmental exposure to chemicals should be maintained at limit threshold levels.
In conclusion, medication is important for a woman who already has a known medical condition such as asthma. Drugs have a vital role of alleviating suffering and promoting individual’s general health. Therefore, it is imperative to ensure that drugs used during pregnancy are safe, effective, and their rationale for usage is explicitly understood. However, it is necessary that the intake of these drugs is made known to one’s doctor so that necessary adjustments are made in relation to the safest medications to use at the time. As far as illicit drugs are concerned, pregnant women should totally avoid consumption of alcohol and associated illegal/illicit drugs. Nowadays, there is the increase in the use of over-the-counter drugs, but the intake of such drugs should be closely monitored by a physician because some of them are unsafe. All in all, there is a call for more initiatives aimed at gathering information from hospital records. This information is meant to guide practice using daily effective practices since drug trials cannot be conducted in a cohort of pregnant women.
American Pregnancy Association. (2015). Using Illegal Drugs During Pregnancy. Retrieved Oct. 25, 2015, from http://americanpregnancy.org/pregnancyhealth/illegal-drugs-during-pregnancy/.
Centers for Disease Control and Prevention. (2014). Medications and Pregnancy. Retrieved Oct. 23, 2015, from http://www.cdc.gov/pregnancy/meds/.
Cragan, J. (2014). Medication use during pregnancy: Evaluating risk is an ongoing challenge. BMJ, 349, g5252. doi: http://dx.doi.org/10.1136/bmj.g5252.
National Health Service. (2015). Alcohol in Pregnancy. Retrieved Oct. 24, 2015, from http://www.nhs.uk/conditions/pregnancy-and-baby/pages/alcohol-medicines-drugs-pregnant.aspx#close.
Pillitteri, A. (2014). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family (7th ed.). Sydney: Wolters Kluwer.
Sachdeva, P., Patel, B. G., & Patel, B. K. (2009). Drug use in pregnancy: a point to ponder! Indian Journal of Pharmaceutical Sciences, 71(1), 1-7.
Schaefer, C., Peters, P., & Miller, R. (Eds.). (2015). Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment (3rd ed.). Oxford: Elsevier B. V.