NSAIDs in Pregnancy: Is There an Association with Miscarriage?
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Discuss the biologic plausibility underlying the potential relationship between NSAIDs and early miscarriage 2. Describe the findings in this study by Li et al., (AJOG, 2018) on the impact of NSAIDs on miscarriage risk
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from July 6 2018 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Pharmacy Education
Postgraduate Institute for Medicine designates this continuing education activity for 0.25 contact hour(s) (0.25 CEUs) of the Accreditation Council for Pharmacy Education. (Universal Activity Number – JA4008162-9999-18-289-H01-P)
Type of Activity: Knowledge
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.
NSAIDs block the biosynthesis of prostaglandins, lipid compounds that are necessary for implantation
Previous studies have been inconsistent as to whether NSAIDs may cause early miscarriage and may not have adequately controlled for confounders
Li et al. (AJOG 2018) sought to determine whether there is an association between use of NSAIDs early in pregnancy and risk of miscarriage, using women taking acetaminophen as a control for indication
Prospective Cohort study
≥18 years with an early positive pregnancy test
Subjects were recruited early in pregnancy as to insure early losses would not be missed
Women exposed to NSAIDs
Women exposed to acetaminophen only (indication control)
Women who used neither NSAIDs or acetaminophen (unexposed controls)
Aspirin was excluded because it may “possess a somewhat similar pharmacologic effect and pathway to NSAIDs”
Adjustment was made for confounders including
Age | Race/Ethnicity | Education | Smoking | Previous miscarriages | Caffeine | Vitamin use | Number of previous pregnancies | History of fever, DM and fertility issues
Primary outcome: Miscarriage
Based on medical records and interview
1,097 women recruited for the study
63% of eligible women contacted agreed to participate
Adjusting for confounding variables, NSAID use during pregnancy was associated with significantly higher risk of miscarriage, when compared to
Unexposed controls: Adjusted hazard ratio (aHR) 1.59; 95% CI, 1.13–2.24
Acetaminophen users (indication control subjects; aHR 1.45; 95% CI, 1.01–2.08
Most of the risk attributed to NSAID use occurred around conception (first 2 weeks of gestation)
aHR 1.89; 95% CI, 1.31–2.71
Dose-response effect related to duration of use
Drug use of ≤14 days: aHR 1.37 (95% CI, 0.70–2.71)
Drug use of ≥15 days: aHR 1.85 (95% CI, 1.24–2.78)
Association stronger for <8 weeks gestational age
aHR 4.08 (95% CI, 2.25–7.41)
Risk was noted in women who were not overweight (BMI ≤25)
These results are consistent with studies that also had more complete ascertainment of miscarriage
NSAID use around the time of conception appears to increase risk of miscarriage
The authors state that “it would be prudent for women planning pregnancy to avoid the use of NSAIDs around the time of conception because pregnancy is usually not recognized until weeks into pregnancy”
OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.
Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
Jointly provided by
NOT ENOUGH CME HOURS
It appears you don't have enough CME Hours to take this Post-Test. Feel free to buy additional CME hours or upgrade your current CME subscription plan