Prenatal Care Initiation and Exposure to Teratogenic Medications

Abstract

ImportanceWith new legal abortion restrictions, timing of prenatal care initiation is critical to allow for discussion of reproductive options among pregnancies exposed to teratogenic medications.ObjectiveTo investigate the prevalence of prenatal exposure to teratogenic medications and prenatal care initiation across gestational weeks.Design, Setting, and ParticipantsThis descriptive, population-based cross-sectional study used health encounter data from a national sample of individuals with employer-sponsored health insurance. A validated algorithm identified pregnancies among persons identifying as female that ended with a live or nonlive outcome between January 2017 and December 2019. Data were analyzed from December 2022 to December 2023.ExposuresPrenatal exposure to any of 137 teratogenic medications, measured via pharmacy and medical claims. Measurement of prenatal care initiation was adapted from the Children’s Health Care Quality Measures.Main Outcomes and MeasuresPrevalence of prenatal exposure to teratogens and prenatal care initiation by gestational week. Timing of prenatal teratogenic exposure was compared with timing of prenatal care initiation and legal abortion cutoffs.ResultsAmong 639 994 pregnancies, 472 472 (73.8%; 95% CI, 73.7%-73.9%) had a live delivery (mean [SD] age, 30.9 [5.4] years) and 167 522 (26.2%; 95% CI, 26.1%-26.3%) had a nonlive outcome (mean [SD] age, 31.6 [6.4] years). Of pregnancies with live deliveries, 5.8% (95% CI, 5.7%-5.8%) were exposed to teratogenic medications compared with 3.1% (95% CI, 3.0%-3.2%) with nonlive outcomes. Median time to prenatal care was 56 days (IQR, 44-70 days). By 6 weeks’ gestation, 8186 pregnancies had been exposed to teratogenic medications (25.2% [95% CI, 24.7%-25.7%] of pregnancies exposed at any time during gestation; 1.3% [95% CI, 1.3%-1.3%] of all pregnancies); in 6877 (84.0%; 95% CI, 83.2%-84.8%), prenatal care was initiated after 6 weeks or not at all. By 15 weeks, teratogenic exposures had occurred for 48.9% (95% CI, 48.4%-49.5%) of all teratogen-exposed pregnancies (2.5% [2.4-2.5] of all pregnancies); prenatal care initiation occurred after 15 weeks for 1810 (16.8%; 95% CI, 16.1%-17.5%) with live deliveries and 2975 (58.3%; 95% CI, 56.9%-59.6%) with nonlive outcomes. Teratogenic medications most used within the first 15 gestational weeks among live deliveries included antiinfectives (eg, fluconazole), anticonvulsants (eg, valproate), antihypertensives (eg, lisinopril), and immunomodulators (eg, mycophenolate). For nonlive deliveries, most antihypertensives were replaced by vitamin A derivatives.Conclusions and RelevanceIn this cross-sectional study, most exposures to teratogenic medications occurred in early pregnancy and before prenatal care initiation, precluding prenatal risk-benefit assessments. Prenatal care commonly occurred after strict legal abortion cutoffs, prohibiting consideration of pregnancy termination if concerns about teratogenic effects arose.

EMR-Documented Contraception for Patients Prescribed Medications With Adverse Perinatal Outcomes

“…Furthermore, treatment planning may be influenced by the fluidity of the political impact on health care. 3 Strategies to mitigate the risk of potential teratogenic exposures could involve harmonization across EMR versions or health care systems, including linkage of EMR alerts and hard stops to use up-to-date safety data to enhance clinician education and potentially reduce risk. Although such measures add to clinician burden, safeguarding fetal development is invaluable.…”

“…The reproductive safety for medications may not be well delineated when the medication is first approved for use and may change with postmarketing surveillance. Furthermore, treatment planning may be influenced by the fluidity of the political impact on health care . Strategies to mitigate the risk of potential teratogenic exposures could involve harmonization across EMR versions or health care systems, including linkage of EMR alerts and hard stops to use up-to-date safety data to enhance clinician education and potentially reduce risk.…”

“… 2 Such medication exposures occur during organogenesis, and treatment options and/or interventions are subject to availability that is influenced by each state’s political landscape. 3 Modifications to the EMR could reduce risk and enhance clinician engagement. Previous research has shown that rates of MCD and counseling for women taking teratogenic medications increase significantly after educating clinicians about how to properly document this information in the EMR.…”

“…Many women in their reproductive years may receive treatment with medications associated with adverse perinatal outcomes in the absence of method of contraception documentation (MCD) in the electronic medical record (EMR) . Such medication exposures occur during organogenesis, and treatment options and/or interventions are subject to availability that is influenced by each state’s political landscape . Modifications to the EMR could reduce risk and enhance clinician engagement.…”