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RESULTS: During the first trimester, 0.4% and 0.7% of control women
heart defects (CHD) and pyloric stenosis (PS) after prenatal exposure to
macrolide antibiotics. We sought to assess the association between
maternal use of erythromycin and nonerythromycin macrolides and the
risks of CHD and PS.
STUDY DESIGN: Among participants in the Slone Epidemiology
Center Birth Defects Study from 1994 through 2008, we identified
4132 infants with CHD and 735 with PS as cases, and 6952 infants
without any malformation as controls. We estimated odds ratios
(ORs) and 95% confidence intervals (CIs) associated with use of
erythromycin or nonerythromycin macrolides in each trimester using conditional logistic regression and adjusting for risk factors for
CHD and PS, fever, specific types of infections, and their associated
treatments.
Cite this article as: Lin KJ, Mitchell AA, Yau W-P, et al. Safety of macrolides during pregnancy. Am J Obstet Gynecol 2013;208:221.e1-8.
From the Department of Epidemiology, Harvard School of Public Health (Drs Lin, Yau, and
Hernndez-Daz), and Slone Epidemiology Center at Boston University (Drs Mitchell and Louik),
Boston, MA, and the Department of Pharmacy, National University of Singapore, Singapore (Dr
Yau).
Supported by grant number R01 HD046595-04 from the Eunice Kennedy Shriver National
Institute of Child Health and Human Development.
Participating hospitals and other acknowledgments are listed in the full-length article at AJOG.org.
The authors report no conflict of interest.
Presented as an abstract at the 26th International Conference on Pharmacoepidemiology and
Therapeutic Risk Management, Brighton, United Kingdom, Aug. 19-22, 2010.
0002-9378/free 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2012.12.023
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TABLE
Maternal exposure to macrolide antibiotics and risk of congenital heart defects or pyloric stenosis
Variable
Nonmalformed
controls (N 6952),
n (%)
Cases of PS (N 735)
OR (95% CI)a
n (%)
OR (95% CI)a
Any macrolides
.......................................................................................................................................................................................................................................................................................................................................................................
6655 (95.7)
3948 (95.5)
70 (1.0)
46 (1.1)
0.9 (0.61.3)
1.0 (Ref)
693 (94.3)
12 (1.6)
1.3 (0.62.8)
1.0 (Ref)
74 (1.1)
47 (1.1)
1.1 (0.71.7)
7 (1.0)
1.3 (0.53.0)
71 (1.0)
47 (1.1)
1.0 (0.61.6)
11 (1.5)
1.3 (0.62.9)
.......................................................................................................................................................................................................................................................................................................................................................................
b
.......................................................................................................................................................................................................................................................................................................................................................................
b
.......................................................................................................................................................................................................................................................................................................................................................................
b,c
................................................................................................................................................................................................................................................................................................................................................................................
Erythromycin
.......................................................................................................................................................................................................................................................................................................................................................................
6828 (98.2)
4064 (98.4)
1.0 (Ref)
717 (97.6)
1.0 (Ref)
28 (0.4)
18 (0.4)
1.3 (0.62.6)
4 (0.5)
0.9 (0.33.0)
27 (0.4)
15 (0.4)
0.9 (0.42.0)
4 (0.5)
1.5 (0.44.8)
20 (0.3)
15 (0.4)
1.1 (0.52.6)
5 (0.7)
1.5 (0.55.1)
.......................................................................................................................................................................................................................................................................................................................................................................
d
.......................................................................................................................................................................................................................................................................................................................................................................
d
.......................................................................................................................................................................................................................................................................................................................................................................
c,d
................................................................................................................................................................................................................................................................................................................................................................................
Nonerythromycin macrolides
.......................................................................................................................................................................................................................................................................................................................................................................
6773 (97.4)
4013 (97.1)
1.0 (Ref)
711 (96.7)
1.0 (Ref)
43 (0.6)
29 (0.7)
0.7 (0.41.3)
8 (1.1)
1.7 (0.64.6)
48 (0.7)
32 (0.8)
1.2 (0.72.0)
3 (0.4)
51 (0.7)
32 (0.8)
1.0 (0.61.7)
7 (1.0)
1.5 (0.63.8)
.......................................................................................................................................................................................................................................................................................................................................................................
e
.......................................................................................................................................................................................................................................................................................................................................................................
e
.......................................................................................................................................................................................................................................................................................................................................................................
c,e
................................................................................................................................................................................................................................................................................................................................................................................
CHD, congenital heart defects; CI, confidence interval; OR, odds ratio; PS, pyloric stenosis; Ref, reference group.
a
ORs adjusted for region of participants residences and calendar year when they were ascertained; maternal age, race, education level; prepregnancy body mass index; family history of congenital
malformations; diabetes mellitus; first-trimester cigarette smoking; periconceptional folic acid supplement; multiple pregnancy; urinary tract, respiratory, or vaginal/yeast infection, sexually transmitted
disease, and other kinds of infection; and/or febrile events that occurred in first trimester; b ORs comparing likely exposure to any macrolide antibiotic in the window of interest with no exposure to any
macrolide antibiotic during pregnancy based on previously published algorithm14; c Excluding preterm deliveries,stillbirths, and terminated abortions did not change estimates materially; d ORs
comparing likely exposure to erythromycin in the window of interest with no exposure to erythromycin during pregnancy based on previously published algorithm14; e ORs comparing likely exposure
to nonerythromycin macrolides in the window of interest with no exposure to nonerythromycin macrolides during pregnancy based on previously published algorithm.14
not as part of an identified chromosomal or mendelian inherited syndrome) were included in the general
analysis and studied separately in a
secondary analysis.
Other major defects examined included the following categories: 1348
oral clefts, 1138 central nervous system
defects, 308 respiratory system defects,
1825 gastrointestinal system defects,
1099 genital system defects, 1511 urinary
system defects, 1948 musculoskeletal
system defects, and 385 others. The same
exclusion criteria described above applied to these case groups. Our control
group consisted of 6952 infants without
any malformation.
Within 6 months of the subjects delivery, trained study nurses unaware of study
hypotheses interview mothers of study
subjects. The 45- to 60-minute interview is
detailed and structured and includes questions on maternal demographic characteristics, mothers medical histories, obstetric
222
R ESULTS
We found no association between firsttrimester maternal use of macrolides as a
class and the risk of CHD (odds ratio
[OR], 0.9; 95% confidence interval [CI],
0.6 1.3) or PS (OR, 1.3; 95% CI, 0.6
2.8). For erythromycin, the risk of CHD
was 1.3 (95% CI, 0.6 2.6) and for PS it
was 0.9 (95% CI, 0.33.0). The corresponding ORs for nonerythromycin
macrolides were 0.7 (95% CI, 0.4 1.3)
for CHD and 1.7 (95% CI, 0.6 4.6) for
PS. We also found no meaningful association between the risk of PS and expo-
C OMMENT
For the hypotheses we tested related to
CHD and PS, our results are consistent
with 3 recently published large studies.
For CHD, an American cohort study
found no association between the risk of
CHD overall and maternal use of erythromycin or nonerythromycin macrolides during pregnancy, nor did a Norwegian study find elevated risks of CHD
overall or atrial/ventricular septal defects
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in infants exposed to erythromycin in
the first trimester. The National Birth
Defects Prevention Study also reported
null findings for macrolide antibiotic use
overall in relation to subgroups of CHD.
For PS, our group had previously reported a lack of association with erythromycin use in either early (gestational
weeks 1-25) or late (32nd gestational
week) pregnancy. Findings from the
current study, which added data collected from 1998 through 2008, indicate that exposure to erythromycin or
nonerythromycin macrolides in either
early or late pregnancy is not associated with an increased risk of PS; the
Research
CLINICAL IMPLICATIONS
17P altered the expression of uterine contraction-associated proteins, progesterone-mediated regulators of uterine quiescence, microRNA involved in uterine contractility, or pathways involved in cervical remodeling. In addition, neither agent had an effect on immune
cell trafficking or collagen content in the cervix.
CONCLUSION: Neither VP nor 17P had any effect on the studied
pathways known to be involved in uterine contractility or quiescence. In the cervix, neither VP nor 17P altered pathways demonstrated to be involved in cervical remodeling. Administration of VP
was noted to increase the expression of the antimicrobial protein
defensin 1. Whether this molecular change from VP results in a
functional effect and is a key mechanism by which VP prevents PTB
requires further study.
Cite this article as: Nold C, Maubert M, Anton L, et al. Prevention of preterm birth by progestational agents: what are the molecular mechanisms? Am J Obstet
Gynecol 2013;208:223.e1-7.
From Maternal and Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA (Drs Nold, Anton, and Elovitz and Ms Maubert), and the Department of Physiology, Loma Linda University School of Medicine, Loma Linda,
CA (Dr Yellon).
The animal experiments and molecular analysis were supported by the Maternal and Child Heath Research Fund, University of Pennsylvania. Cervical cell
staining and immune cell analysis were performed by the Loma Linda University School of Medicine Advanced Imaging and Microscopy core facility and
supported in part by National Institutes of Health HD054931.
The authors report no conflict of interest.
Presented orally at the 33rd annual meeting of the Society for Maternal-Fetal Medicine, San Francisco, CA, Feb. 11-16, 2013.
The racing flag logo above indicates that this article was rushed to press for the benefit of the scientific community.
0002-9378/free 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2013.01.020
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