June 1, 2006 • www.familypracticenews.com Women’s Health 39

D RUGS, PREGNANCY, C-Section Ups Placenta A ND L ACTATION Previa, Abruption Risk Gastrointestinal Agents: Part III he final part of this series covers nancy or breast-feeding. BY KATE JOHNSON from the Missouri longitudinally linked Tthe use of infliximab, anticholin- In contrast, another GI stimulant, Montreal Bureau live birth and fetal death data files. Sin- ergics/antispasmodics, gastrointestinal metoclopramide (Reglan, Maxolon), gleton births were analyzed for 156,475 stimulants, and anorectal preparations has substantial human pregnancy ex- T ORONTO — Women whose first ba- women whose first two consecutive births in pregnant and lactating women. perience, primarily as an antiemetic. Al- bies are delivered by cesarean section face occurred within the study period of 1989- Ǡ Infliximab (Remicade): Infliximab is though it is considered compatible with an elevated risk of placenta previa and pla- 1997, and 31,102 women whose first three a monoclonal antibody used to treat se- pregnancy, its use during breast-feeding cental abruption in their second pregnan- consecutive births occurred within that pe- vere Crohn’s disease and autoimmune is controversial. It has been successful- cies. And with two previous cesarean de- riod. diseases such as ankylosing spondylitis, ly used as a lactation stimulant at dos- liveries the risk of placenta previa is Among 40,472 women whose first de- rheumatoid arthritis, and psoriasis. It es of 20-45 mg/day. The drug is ex- increased further in the third pregnancy, livery was by cesarean section, the relative binds to and inhibits human tumor creted into milk, but the estimated dose according to a study by Dr. Darios risk of placenta previa was 1.5, and that of necrosis factor–α (TNF-α). Animal re- ingested by a nursing infant from milk Getahun of the Robert Wood Johnson placental abruption was 1.3 in the second production studies have not been con- is much lower than the therapeutic in- Medical School in New Brunswick, N.J., pregnancy, compared with women whose ducted with the agent be- fant dose. However, mild and his colleagues. first delivery was vaginal. cause it does not react intestinal discomfort has The study, which was recently published There was a dose response noted for the with animal TNF-α. Hu- been observed in two in- (Obstet. Gynecol. 2006;107:771-8), was risk of placenta previa, but not for pla- man pregnancy exposure fants. Because of its presented as a poster at the annual meet- cental abruption risk. Therefore, when consists of about 30 cases, dopaminergic blocking ing of the Society for Gynecologic Inves- both the first and second deliveries were which are limited to case action, the American tigation. by cesarean section, the risk of placenta reports and observational Academy of Pediatrics “Although cesarean section has previ- previa doubled in the third pregnancy, but studies. The drug does classifies metoclo- ously been reported as a risk factor for pla- the risk of placental abruption did not in- not appear to represent a pramide as a drug of po- centa previa, it has not been previously as- crease further, compared with women significant risk for devel- tential concern during sociated with abruption,” Dr. Getahun whose first two deliveries were vaginal. opmental toxicity. Still, if breast-feeding. said in an interview at the meeting. “Ce- The interval between pregnancies also possible, the best course is Ǡ Anorectal prepara- sarean section causes scarring of the uter- was analyzed, and the study found that for to avoid its use in preg- BY GERALD G. tions: These include a ine wall, with the result that placentation cesarean deliveries, but not vaginal ones, an nancy. If pregnancy expo- BRIGGS, B.PHARM. large group of agents may not be optimal. That’s why it may be interval of less than 1 year was associated sure does occur, health that are available in vari- leading to abruption,” he explained. with a relative risk of 1.7 for placenta pre- care providers are encouraged to reg- ous topical formulations such as The study included a cohort of women via and 1.5 for placental abruption. ■ ister these patients in the Organization creams, ointments, foams, lotions, tis- of Teratology Information Specialists sues and pads, and suppositories. With (OTIS) Autoimmune Diseases in Preg- the exception of the hydrocortisone nancy study by calling the toll-free products, all are available over the Ultrasound’s Value for Diagnosing number, 877-311-8972. counter, so you might not know that Ǡ Anticholinergics/antispasmodics: your patient is using them unless a These agents have been used for years for careful history is taken. The OTC Abnormal Placentation Confirmed peptic ulcer and functional GI disorders preparations are formulated with low such as diarrhea, hypermotility, neuro- concentrations of various drug mix- BY SHARON WORCESTER 35 of the 39 patients for a sensitivity of 0.90, genic colon, irritable bowel syndrome, ul- tures, such as local anesthetics, vaso- Southeast Bureau and ruled out the condition in the remain- cerative colitis, and biliary tract spasm. constrictors, astringents, antiseptics, ing 19 patients for a specificity of 1. The agents—available under numerous emollients/protectants, counterirri- M IAMI B EACH — Pelvic ultrasound is Information for the study was obtained trade names—include atropine, bel- tants, keratolytics, and wound healing accurate for ruling out placenta accreta, from a perinatal database for patients ladonna, dicyclomine, glycopyrrolate, L- agents. Only a few of these products and should be used as the primary screen- screened by ultrasound between January hyoscyamine, mepenzolate, methscopo- and drugs have been studied in human ing tool in patients at high risk for this con- 2000 and June 2005 and for patients lamine, propantheline, and scopolamine. pregnancy or lactation, but these prepa- dition, Dr. Carri Warshak said at the an- screened by MRI between January 1992 Only atropine, scopolamine, and dicy- rations are used for their local effects nual meeting of the Society for and June 2005. clomine have sufficient data in preg- and clinically significant systemic levels Maternal-Fetal Medicine. The findings are impor- nancy. There are no reports suggesting are not expected. Magnetic resonance imag- The 10-fold tant because they confirm that these agents cause birth defects. About 26% of the corticosteroid is ab- ing also should be consid- the accuracy of ultrasound However, an excessive dose of scopo- sorbed from hydrocortisone supposito- ered in the evaluation of all increase in the and MRI for detecting a con- lamine in labor has been associated with ries, but the maximum strength of these suspected cases, she added. incidence of dition that requires accurate newborn toxicity. The other drugs are products is only 30 mg, so the amount A historical cohort study prenatal diagnosis for opti- also probably low risk, but cannot be reaching the circulation is clinically in- of 433 patients with placen- abnormal mal management, she said. classified as such because of the very significant. Therefore, at recommended ta previa who underwent ul- placentation is Furthermore, the inci- limited or complete lack of human preg- doses, the use of anorectal prepara- trasound showed that this dence of abnormal placen- nancy experience. However, anticholin- tions during pregnancy or breast-feed- screening modality accu- largely due to the tation has increased 10-fold ergic combinations formulated with ing can be considered low risk. rately predicted placenta acc- increased over the past decade, largely phenobarbital or other sedatives should Of the drugs covered in this series, reta (which for the purposes due to the increased cesare- be avoided in pregnancy and lactation. misoprostol and tetracycline cause of this study also included cesarean section an section rate. An estimat- Although the data are very limited, all structural defects, castor oil can induce placenta increta and percre- rate; about 9% of ed 9% of pregnancies are af- anticholinergics, except dicyclomine, ap- labor, and mesalamine-containing ta) in 25 of the 32 women fected, she noted. pear to be compatible with breast-feed- agents and dicyclomine have caused whose diagnosis was con- pregnancies are The findings confirm ing. Dicyclomine is concentrated in milk toxicity in nursing infants. Most GI firmed by pathologic exam- affected. those from the three largest and has been associated with apnea in agents are safe in pregnancy and lacta- ination, for a sensitivity of studies of ultrasound diag- one nursing infant. tion, but many have insufficient data to 0.78. Ultrasound ruled out the condition in nosis for placenta accreta; pooled data Ǡ GI stimulants: Dexpanthenol judge their risk. 397 of 401 patients, for a specificity of 0.99; from those studies and the current study (Ilopan) is given by intramuscular in- MRI ruled out the condition in the re- show pelvic ultrasound is 81% sensitive jection to prevent paralytic ileus after MR. BRIGGS is a pharmacist clinical maining 4 patients, said Dr. Warshak of the and 98% specific for diagnosis, she said. abdominal surgery. Although the drug specialist, Women’s Pavilion, Miller University of California, San Diego. MRI has been less well studied, and re- has been promoted for constipation in Children’s Hospital, Long Beach, Calif.; Of an additional 58 women who were re- sults have been conflicting, but the find- pregnant women, there are no reports clinical professor of pharmacy, University ferred for MRI based on equivocal ultra- ings of this study suggest it has an impor- of its use or studies in pregnant or lac- of California, San Francisco; and adjunct sound findings, 39 were shown on patho- tant role in optimizing diagnostic accuracy, tating animals or humans. Thus, the professor of pharmacy, University of logic examination to have placenta accreta. particularly in patients with equivocal find- drug should not be given during preg- Southern California, Los Angeles. MRI accurately predicted the condition in ings on ultrasound, she concluded. ■