Interventions to enhance medication adherence in pregnancy- a systematic review.

BACKGROUND: Sub-optimal medication adherence in pregnant women with chronic disease and pregnancy-related indications has the potential to adversely affect maternal and perinatal outcomes. Adherence to appropriate medications is advocated during and when planning pregnancy to reduce risk of adverse perinatal outcomes relating to chronic disease and pregnancy-related indications. We aimed to systematically identify effective interventions to promote medication adherence in women who are pregnant or planning to conceive and impact on perinatal, maternal disease-related and adherence outcomes. METHODS: Six bibliographic databases and two trial registries were searched from inception to 28th April 2022. We included quantitative studies evaluating medication adherence interventions in pregnant women and women planning pregnancy. Two reviewers selected studies and extracted data on study characteristics, outcomes, effectiveness, intervention description (TIDieR) and risk of bias (EPOC). Narrative synthesis was performed due to study population, intervention and outcome heterogeneity. RESULTS: Of 5614 citations, 13 were included. Five were RCTs, and eight non-randomised comparative studies. Participants had asthma (n = 2), HIV (n = 6), inflammatory bowel disease (IBD; n = 2), diabetes (n = 2) and risk of pre-eclampsia (n = 1). Interventions included education +/- counselling, financial incentives, text messaging, action plans, structured discussion and psychosocial support. One RCT found an effect  of the tested intervention on self-reported antiretroviral adherence but not objective adherence. Clinical outcomes were not evaluated. Seven non-randomised comparative studies found an association between the tested intervention and at least one outcome of interest: four found an association between receiving the intervention and both improved clinical or perinatal outcomes and adherence in women with IBD, gestational diabetes mellitus (GDM), and asthma. One study in women with IBD reported an association between receiving the intervention and maternal outcomes but not for self-reported adherence. Two studies measured only adherence outcomes and reported an association between receiving the intervention and self-reported and/or objective adherence in women with HIV and risk of pre-eclampsia. All studies had high or unclear risk of bias. Intervention reporting was adequate for replication in two studies according to the TIDieR checklist. CONCLUSIONS: There is a need for high-quality RCTs reporting replicable interventions to evaluate medication adherence interventions in pregnant women and those planning pregnancy. These should assess both clinical and adherence outcomes.

Smoking alters hydroxyprostaglandin dehydrogenase expression in fetal membranes.

INTRODUCTION: The way in which tobacco smoking increases the risk of preterm labor remains uncertain. Altered prostaglandin metabolism is one potential mechanism. METHODS: Proteins in fetal membrane samples (amniochoriodecidua) from 20 women were relatively quantified using Tandem Mass Tagging nano-liquid chromatography mass spectrometry. RESULTS: Prostaglandin synthases and two enzymes involved in prostaglandin degradation, hydroxyprostaglandin dehydrogenase (HPGD) and CBR1, were detected by the mass spectrometer. The expression of HPGD was significantly lower in smokers relative to non-smokers (0.43 fold, p = 0.016). There was no effect of labor, inflammatory status or gestational age on the HPGD levels. DISCUSSION: We describe for the first time an association between maternal smoking and HPGD expression. We propose that reduced expression of HPGD is one mechanism through which smoking may contribute to preterm labor. Lower levels of this enzyme, key to metabolising prostaglandins, may result in higher levels of prostaglandins and therefore precipitate labor prematurely.

Smoking and Preterm Birth.

Premature birth is a significant global problem and the leading cause of newborn deaths. Tobacco smoking has been associated with premature birth for over 50 years. The mechanisms through which smoking exerts its effects on pregnancy outcomes remain unclear. In this review, we discuss rates of prematurity and smoking in pregnancy, the evidence of a causal relationship between tobacco and preterm birth, and proposed biochemical pathways through which the interaction is mediated. The suggested mechanisms include nicotine-induced vasoconstriction, carbon monoxide-induced fetal hypoxia, cadmium disruption of calcium signaling, altered steroid hormone production, disruption of prostaglandin synthesis, and changed responses to oxytocin. The relative importance of each of these pathways is yet to be ascertained. Further research is necessary to explore the mechanisms through which smoking exerts its effect on gestational length and the process of parturition. Moreover, the risks of nicotine replacement in pregnancy should be investigated further.

Environmental Tobacco Smoke Exposure in Pregnancy is Associated With Earlier Delivery and Reduced Birth Weight.

The association between maternal smoking and preterm birth (PTB) has been known for more than 50 years but the effect of passive smoking is controversial. This retrospective cohort study in Bristol, United Kingdom, examines the effect of environmental tobacco smoke exposure (ETSE) on gestational age at delivery, birth weight, PTB, and being small-for-gestational age (SGA). Environmental tobacco smoke exposure was defined by either self-report or exhaled carbon monoxide (eCO) levels, and exposed women were compared with unexposed controls. Two models were used: The first included all women with adjustment for maternal smoking, and the second considered nonsmokers alone. Both models were further adjusted for maternal age, body mass index, parity, ethnicity, employment status, socioeconomic position, asthma, preeclampsia, and offspring sex. Logistic regression and likelihood ratio tests were used to test for any association between exposure and the binary outcomes (PTB and SGA), while linear regression and F tests were used to test for associations between exposure and the continuous outcomes. There were 13 359 deliveries in 2012 to 2014, with complete data for 5066 and 4793 women in the self-reported and eCO-measured exposure groups, respectively. Self-reported exposure was associated with earlier delivery (-0.19 weeks; 95% confidence interval [CI]: -0.32 to -0.05) and reduced birth weight (-56 g, 95% CI: -97 to -16 g) but no increase in the risk of PTB or SGA. There was no evidence for an association between eCO-measured exposure and any of the outcome measures. This information is important when advising women and their families and adds further support to continued public health efforts to reduce exposure to tobacco smoke.

Current pregnancy outcomes in women with cystic fibrosis.

OBJECTIVES: Women with cystic fibrosis (CF) now achieve a greater life expectancy and therefore have greater expectations from life. Literature reporting pregnancy outcomes in CF is still sparse. There remains a legacy of advising women with significant disease to avoid pregnancy. We aimed to assess current maternal and fetal outcomes in women with CF with varied pre-pregnancy lung function. STUDY DESIGN: Retrospective case note review of data from 15 pregnancies in 12 women with CF receiving care at a specialist centre between 2003 and 2011. Descriptive statistics were used for the quantitative data. The forced expiratory volume (FEV1) and forced vital capacity (FVC) were calculated and shown as the percentage of their predicted values for BMI, height and age. Changes in lung function pre, 6, and 24 months post delivery were calculated with the paired t-test. RESULTS: Mean maternal age was 28.9 (range 21-36, CI 26.8-31). Maternal FEV1 at booking ranged from 27 to 80% predicted (mean=63.6%, CI 54.62-71.38%). Cystic fibrosis-related diabetes (CFRD) was present in 8 of 14 (live birth) pregnancies. Average gestation at delivery was 38 weeks. There was a 100% vaginal delivery rate (11 spontaneous vertex, 2 ventouse, 1 forceps). Average fetal birth weight was 2.97 kg (range 2.2-3.83 kg, CI 2.72-3.23). The differences between the maternal pre- and 6 months post-pregnancy mean FEV1 (p=0.136) and FVC (p=0.225) were not statistically significant. CONCLUSION: With careful multidisciplinary antenatal and intrapartum management, successful outcomes have been obtained in this group of women with CF.