Pharmacological management of low milk supply with domperidone: separating fact from fiction

Letter to the EditorLuke E Grzeskowiak, Lisa H Ami

Off-label prescribing in pregnancy - A case of risky business or business as usual?

Editorial. Published:January 14, 2015.Luke E. Grzeskowiak, Ben W. Mo

Pharmacoepidemiology and costs of medications dispensed during pregnancy: A retrospective population‐based study

First published: 11 April 2023. OnlinePublObjective: To describe the pharmacoepidemiology and costs associated with medications dispensed during pregnancy. Design: Pharmacoepidemiological study and cost analysis. Setting: Queensland, Australia. Population: All women who gave birth in Queensland between January 2013 and June 2018. Methods: We used a whole-of- population linked administrative dataset, Maternity 1000, to describe medications approved for public subsidy that were dispensed to 255 408 pregnant women. We describe the volume of medications dispensed and their associated costs from a Government and patient perspective. Main outcome measures: Prevalence of medication use; proportion of total dispensings; total medication costs in AUD 2020/21 ($1AUD =$0.67USD/£0.55GBP in December 2022). Results: During pregnancy, 61% (95% CI 60.96–61.29%) of women were dispensed at least one medication approved for public subsidy. The mean number of items dispensed per pregnancy increased from 2.14 (95% CI 2.11–2.17) in 2013 to 2.47 (95% CI 2.44–2.51) in 2017; an increase of 15%. Furthermore, mean Government cost per dispensing increased by 41% from $21.60 (95$20.99–$22.20) in 2013 to$30.44 (95% CI $29.38–$ 31.49) in 2017. These factors influenced the 53% increase in total Government expenditure observed for medication use during pregnancy between 2013 and 2017 ($2,834,227 versus$4,324,377); a disproportionate rise compared with the 17% rise in women's total out-of- pocket expenses observed over the same timeframe ($1,880,961 versus$2,204,415). Conclusions: Prevalence of medication use in pregnancy is rising and is associated with disproportionate and rapidly escalating cost implications for the Government.H. Jackson, L. E. Grzeskowiak, J. Enticott, E. Callande

Safety and protective effects of maternal influenza vaccination on pregnancy and birth outcomes: A prospective cohort study

Background Our study aimed to assess the safety and protective effect of maternal influenza vaccination on pregnancy and birth outcomes. Methods The study population comprised 1253 healthy nulliparous pregnant women in South Australia between 2015 and 2018. Participants were followed prospectively, with vaccination status (confirmed by medical records), pregnancy, and birth outcome data collected by midwives. Adjusted relative risks (aRRs) and adjusted hazard ratios (aHRs) were estimated accounting for time-varying vaccine exposure and temporal nature of each outcome. Findings Maternal influenza vaccination (48%, 603 of 1253) reduced the risk for pre-delivery hospitalisation with influenza like illness (aHR 0•61; 95% CI 0•39, 0•97). Maternal influenza vaccination was not associated with spontaneous abortion (aHR 0•42, 95% CI 0•12, 1•45), chorioamnionitis (aRR 0•78, 95% CI, 0•32, 1•88), gestational hypertension (aHR 0•78, 95% CI 0•47, 1•29), pre-eclampsia (aHR 0.84, 95% CI 0•54, 1•27), gestational diabetes (aHR 1•16, 95% CI 0•82, 1•66) nor preterm birth (aHR 0•94, 95% CI 0•59, 1•49). No associations between antenatal influenza vaccination and congenital anomalies, admission to the neonatal care unit, low Apgar scores, and mechanical ventilation were observed. Results were not materially changed after adjustment for pertussis vaccination. We observed a protective effect of maternal influenza vaccination on low birth weight (aHR 0•46, 95% CI 0•23, 0•94) and a marginal protective effect on small for gestational age births (aHR 0•65, 95% CI 0•40, 1•04) during periods of high influenza activity. Interpretation These results support the safety of maternal influenza vaccination and suggest a protective effect in reducing the rates of low birthweight and small for gestational age births. Funding There was no funding for this study.Hassen Mohammed, Claire T.Roberts, Luke E. Grzeskowiak, Lynne C. Giles, Gustaaf A. Dekker ... et al

Use and experiences of galactagogues while breastfeeding among Australian women

Background: Galactagogues are substances thought to increase breast milk production, however evidence to support their efficacy and safety remain limited. We undertook a survey among Australian women to examine patterns of use of galactagogues and perceptions regarding their safety and effectiveness. Methods: An online, cross-sectional survey was distributed between September and December 2019 via national breastfeeding and preterm birth support organisations, and networks of several research institutions in Australia. Women were eligible to participate if they lived in Australia and were currently/previously breastfeeding. The survey included questions about galactagogue use (including duration and timing), side effects and perceived effectiveness (on a scale of 1 [Not at all effective] to 5 [Extremely effective]). Results: Among 1876 respondents, 1120 (60%) reported using one or more galactagogues. Women were 31.5 ± 4.8 years (mean ± standard deviation) at their most recent birth. Sixty-five percent of women were currently breastfeeding at the time of the survey. The most commonly reported galactagogues included lactation cookies (47%), brewer's yeast (32%), fenugreek (22%) and domperidone (19%). The mean duration of use for each galactagogue ranged from 2 to 20 weeks. Approximately 1 in 6 women reported commencing galactagogues within the first week postpartum. Most women reported receiving recommendations to use herbal/dietary galactagogues from the internet (38%) or friends (25%), whereas pharmaceutical galactagogues were most commonly prescribed by General Practitioners (72%). The perceived effectiveness varied greatly across galactagogues. Perceived effectiveness was highest for domperidone (mean rating of 3.3 compared with 2.0 to 3.0 among other galactagogues). Over 23% of domperidone users reported experiencing multiple side effects, compared to an average of 3% of women taking herbal galactagogues. Conclusions: This survey demonstrates that galactagogues use is common in Australia. Further research is needed to generate robust evidence about galactagogues' efficacy and safety to support evidence-based strategies and improve breastfeeding outcomes.Grace M. McBride, Robyn Stevenson, Gabriella Zizzo, Alice R. Rumbold, Lisa H. Ami, Amy K. Keir, Luke E. Grzeskowia

Online platforms for prescription and supply of hormonal contraception in Australia: a mapping review

First online 4/4/23 OnlinePublOnline platforms have emerged as a convenient way for individuals to access contraception. However, the extent to which such services exist in Australia and how they operate is currently unknown. We aimed to identify Australian online contraception platforms and evaluate the services they provide to determine the degree to which they may facilitate equitable access to contraception. We conducted an internet search to identify online contraception platforms operating in Australia. Data were extracted from each of the platforms relating to operating policies, services provided and associated payment processes, as well as prescribing and screening processes for assessing user suitability. As of July 2022, eight online contraception platforms operating within Australia were identified. All platforms offered oral contraception, with two also offering the vaginal ring, and one emergency oral contraception. None of the platforms provided access to long-acting reversible contraception. Significant variability existed in product and membership costs across platforms, with only one platform providing access to subsidised medicines. Five platforms restricted services to those already using oral contraception. Overall, online questionnaires were deemed to be adequately screening for important contraindications to using oral contraception. While online contraception platforms may be a valuable option for some individuals who face access barriers and are willing to pay out-of-pocket for to have their contraception sent straight to their home, they do not necessarily ensure that individuals can access their contraceptive method of choice or address recognised financial and structural barriers to contraceptive care.Tahlee B. Stevenson, Alice Rumbold, Emily Callander, Pip Buckingham, Anisa Assifi, Danielle Mazza and Luke E. Grzeskowia

Maternal selenium, copper and zinc concentrations in early pregnancy, and the association with fertility

Trace elements such as zinc, copper, and selenium are essential for reproductive health, but there is limited work examining how circulating trace elements may associate with fertility in humans. The aim of this study was to determine the association between maternal plasma concentrations of zinc, copper, and selenium, and time to pregnancy and subfertility. Australian women (n = 1060) who participated in the multi-centre prospective Screening for Pregnancy Endpoints study were included. Maternal plasma concentrations of copper, zinc and selenium were assessed at 15 ± 1 weeks' gestation. Estimates of retrospectively reported time to pregnancy were documented as number of months to conceive; subfertility was defined as taking more than 12 months to conceive. A range of maternal and paternal adjustments were included. Women who had lower zinc (time ratio, 1.20 (0.99-1.44)) or who had lower selenium concentrations (1.19 (1.01-1.40)) had a longer time to pregnancy, equivalent to a median difference in time to pregnancy of around 0.6 months. Women with low selenium concentrations were also at a 1.46 (1.06-2.03) greater relative risk for subfertility compared to women with higher selenium concentrations. There were no associations between copper and time to pregnancy or subfertility. Lower selenium and zinc trace element concentrations, which likely reflect lower dietary intakes, associate with a longer time to pregnancy. Further research supporting our work is required, which may inform recommendations to increase maternal trace element intake in women planning a pregnancy.Jessica A. Grieger, Luke E. Grzeskowiak, Rebecca L. Wilson, Tina Bianco-Miotto, Shalem Y. Leemaqz, Tanja Jankovic-Karasoulos, Anthony V. Perkins, Robert J. Norman, Gus A. Dekker and Claire T. Robert

Maternal folate, one-carbon metabolism and pregnancy outcomes

Single nucleotide polymorphisms and pre- and peri-conception folic acid (FA) supplementation and dietary data were used to identify one-carbon metabolic factors associated with pregnancy outcomes in 3196 nulliparous women. In 325 participants, we also measured circulating folate, vitamin B12 and homocysteine. Pregnancy outcomes included preeclampsia (PE), gestational hypertension (GHT), small for gestational age (SGA), spontaneous preterm birth (sPTB) and gestational diabetes mellitus (GDM). Study findings show that maternal genotype MTHFR A1298C(CC) was associated with increased risk for PE, whereas TCN2 C766G(GG) had a reduced risk for sPTB. Paternal MTHFR A1298C(CC) and MTHFD1 G1958A(AA) genotypes were associated with reduced risk for sPTB, whereas MTHFR C677T(CT) genotype had an increased risk for GHT. FA supplementation was associated with higher serum folate and vitamin B12 concentrations, reduced uterine artery resistance index and increased birth weight. Women who supplemented with <800 μg daily FA at 15-week gestation had a higher incidence of PE (10.3%) compared with women who did not supplement (6.1%) or who supplemented with ≥800 μg (5.4%) (P < .0001). Higher serum folate levels were found in women who later developed GDM compared with women with uncomplicated pregnancies (Mean ± SD: 37.6 ± 8 nmol L-1 vs. 31.9 ± 11.2, P = .007). Fast food consumption was associated with increased risk for developing GDM, whereas low consumption of green leafy vegetables and fruit were independent risk factors for SGA and GDM and sPTB and SGA, respectively. In conclusion, maternal and paternal genotypes, together with maternal circulating folate and homocysteine concentrations, and pre- and early-pregnancy dietary factors, are independent risk factors for pregnancy complications.Tanja Jankovic-Karasoulos, Denise L. Furness, Shalem Y. Leemaqz, Gustaaf A. Dekker, Luke E. Grzeskowiak, Jessica A. Grieger, Prabha H. Andraweera, Dylan McCullough, Dale McAninch, Lesley M. McCowan, Tina Bianco-Miotto, Claire T. Robert

Pharmacological management of low milk supply with domperidone: separating fact from fiction

Luke E Grzeskowiak, Lisa H Ami