Issue
Date Log
Copyright (c) 2024 Zahiyah Muqbil Al-Hanini Al-Khaibari, Turki Hamood Alotaibi, Abdullah Aloush Alotaibi, Ahmed Nuwaifea Q Aljohani, Zurayfah Muhanna Arnun, Mohammed Abdulghani Almaliki, Yasser Hassan Salhabi, Maha Aziz Alenzi, Hajah Mohamad Azybi, Sarah Falah Alenezi, Marwah Saad Jamaan Alharbi
This work is licensed under a Creative Commons Attribution 4.0 International License.
Medication Use during Pregnancy and Lactation: Integrating Pharmacovigilance, Maternal Nursing, Laboratory Monitoring, Imaging, and Dental Care
Corresponding Author(s) : Zahiyah Muqbil Al-Hanini Al-Khaibari
Saudi Journal of Medicine and Public Health, Vol. 1 No. 2 (2024)
Abstract
Medication use during pregnancy and lactation represents a complex clinical challenge requiring integration across multiple disciplines. Despite more than 200 million annual pregnancies globally, the majority of women receive medications with limited safety data, as pregnant and breastfeeding populations have historically been excluded from clinical trials. This narrative review synthesizes contemporary evidence (2016–2024) on medication safety during pregnancy and lactation, integrating perspectives from pharmacovigilance, maternal nursing, laboratory monitoring, diagnostic imaging, and dental care. Pharmacovigilance systems, including pregnancy exposure registries and the FDA Adverse Event Reporting System, provide essential post-marketing surveillance despite persistent regulatory fragmentation. Maternal nurses and midwives serve as frontline counselors, yet knowledge gaps and communication barriers limit optimal medication counseling. Therapeutic drug monitoring has demonstrated particular value for antiepileptic drugs and other agents with narrow therapeutic indices, where pregnancy-induced pharmacokinetic changes necessitate dose adjustment. Diagnostic imaging and dental care, often unnecessarily avoided during pregnancy, are safe when evidence-based guidelines are followed, with ultrasonography and MRI preferred, and lidocaine and amoxicillin representing low-risk dental medications. This review proposes an integrated, multidisciplinary framework emphasizing preconception counseling, risk-benefit assessment, interprofessional collaboration, and robust post-marketing surveillance to optimize maternal and fetal outcomes.
Keywords
Download Citation
Endnote/Zotero/Mendeley (RIS)BibTeX
- 1. AbuShweimeh, R., Knudson, S., Chaabane, S., Pal, S. N., Skidmore, B., Stergachis, A., & Bhat, N. (2023). Pregnancy exposure registries for drugs and vaccines in low-income and middle-income countries: scoping review protocol. BMJ open, 13(5), e070543.
- 2. Adrover, R., Siri, C., Cocozzella, D., Quarin, C., Romé, J., & Azi, H. (2016). Hepatotoxicity from Alpha-Methyldopa During Pregnancy: Two Case Reports. Journal of Clinical Gastroenterology and Treatment, 2(3), 1-3.
- 3. Alexe A, Eisele O, Fernandes MF, Garg A, Kovacs B, Wurst K, Balramsingh‐Harry L, Abramova N, Zheteyeva Y, Lewis D. Call to action: harmonization of pharmacovigilance regulations for post‐marketing pregnancy and breastfeeding safety studies. British Journal of Clinical Pharmacology. 2024 Mar;90(3):715-21.
- 4. American College of Obstetricians and Gynecologists. (2017). Committee Opinion No. 723: guidelines for diagnostic imaging during pregnancy and lactation. Obstetrics & Gynecology, 130(4), e210-e216.
- 5. Anderson, R., & Silk, H. (2022). Oral Health Intervention Before Pregnancy: A Preconception Approach. Journal of the California Dental Association, 50(4), 217-222.
- 6. Arfman, I. J., Wammes-van der Heijden, E. A., Ter Horst, P. G., Lambrechts, D. A., Wegner, I., & Touw, D. J. (2020). Therapeutic Drug Monitoring of Antiepileptic Drugs in Women with Epilepsy Before, During, and After Pregnancy: IJ Arfman et al. Clinical pharmacokinetics, 59(4), 427-445.
- 7. Balkam, J. J. (2022). Galactagogues and lactation: Considerations for counseling breastfeeding mothers. MCN: The American Journal of Maternal/Child Nursing, 47(3), 130-137.
- 8. Barbosa, M. C. F., da Rocha, N. B., de Souza Gomes Rodrigues, H., de Oliveira, D. S. B., Fernandes, L. A., & de Lima, D. C. (2023). Maternal knowledge of oral health during pregnancy and childbirth. Maternal and Child Health Journal, 27(9), 1607-1615.
- 9. Bensaod, L. (2024). Evaluation of Practice and Awareness of the Safety Profile of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) among Dental Practitioners: A Cross-Sectional Study.
- 10. Berrueta, M., Ciapponi, A., Bardach, A., Cairoli, F. R., Castellano, F. J., Xiong, X., ... & Buekens, P. (2021). Maternal and neonatal data collection systems in low-and middle-income countries for maternal vaccines active safety surveillance systems: A scoping review. BMC pregnancy and childbirth, 21(1), 217.
- 11. Besimoglu, B., Öcal, F. D., Sinaci, S., Atalay, A., Tanaçan, A., & Şahin, D. (2022). Effect of antiepileptic drugs on serum biochemical marker levels of first and second trimester screening tests. Journal of Obstetrics and Gynaecology Research, 48(7), 1607-1612.
- 12. Blattner, C. M., Danesh, M., Safaee, M., & Murase, J. E. (2016). Understanding the new FDA pregnancy and lactation labeling rules. International Journal of Women's Dermatology, 2(1), 5.
- 13. Brucker, M. C., & King, T. L. (2017). The 2015 US Food and Drug Administration pregnancy and lactation labeling rule. Journal of midwifery & women's health, 62(3), 308-316.
- 14. Cha, E., Smart, M. J., Braxter, B. J., & Faulkner, M. S. (2021). Preconception care to reduce the risks of overweight and obesity in women of reproductive age: an integrative review. International journal of environmental research and public health, 18(9), 4582.
- 15. Charron, E., Mayo, R. M., Heavner-Sullivan, S. F., Eichelberger, K. Y., Dickes, L., Truong, K. D., & Rennert, L. (2020). “It’sa very nuanced discussion with every woman”: Health care providers’ communication practices during contraceptive counseling for patients with substance use disorders. Contraception, 102(5), 349-355.
- 16. Dathe, K., & Schaefer, C. (2018). Drug safety in pregnancy: the German Embryotox institute. European journal of clinical pharmacology, 74(2), 171-179.
- 17. Daw, J. R., Underhill, K., Liu, C., & Allen, H. L. (2023). The health and social needs of medicaid beneficiaries in the postpartum year: Evidence from a multistate survey: Study examines extension of Medicaid benefits one year postpartum. Health Affairs, 42(11), 1575-1585.
- 18. De Souza, J., Viswanath, V. K., Echterhoff, J. M., Chamberlain, K., & Wang, E. J. (2024). Augmenting telepostpartum care with vision-based detection of breastfeeding-related conditions: algorithm development and validation. JMIR AI, 3(1), e54798.
- 19. Ding, A., Joshi, J., & Tiwana, E. (2023). Patient safety in radiology and medical imaging. In Patient Safety: A Case-based Innovative Playbook for Safer Care (pp. 261-277). Cham: Springer International Publishing.
- 20. dos Santos, F. M., Senra, C., & Maciel, C. (2020, January). Contrast Agents Administration in Pregnancy and Lactation: Safety Issues and Practical Points in Everyday Practice. European Congress of Radiology-ECR 2020.
- 21. Favero, V., Bacci, C., Volpato, A., Bandiera, M., Favero, L., & Zanette, G. (2021). Pregnancy and dentistry: A literature review on risk management during dental surgical procedures. Dentistry journal, 9(4), 46.
- 22. Giles, A., Prusinski, R., & Wallace, L. (2024). Maternal-newborn nursing. OpenStax.
- 23. Gupta, R., Bajaj, S. K., Kumar, N., Chandra, R., Misra, R. N., Malik, A., & Thukral, B. B. (2016). Magnetic resonance imaging-a troubleshooter in obstetric emergencies: a pictorial review. Indian Journal of Radiology and Imaging, 26(01), 44-51.
- 24. Hwang, S. Y., Choi, E. S., Kim, Y. S., Gim, B. E., Ha, M., & Kim, H. Y. (2018). Health effects from exposure to dental diagnostic X-ray. Environmental health and toxicology, 33(4), e2018017.
- 25. Jabehdar Maralani, P., Kapadia, A., Liu, G., Moretti, F., Ghandehari, H., Clarke, S. E., ... & Schieda, N. (2022). Canadian Association of Radiologists recommendations for the safe use of MRI during pregnancy. Canadian Association of Radiologists Journal, 73(1), 56-67.
- 26. Jain, C. (2019). ACOG Committee Opinion No. 723: guidelines for diagnostic imaging during pregnancy and lactation. Obstetrics & Gynecology, 133(1), 186.
- 27. Kamalabadi, Y. M., Campbell, M. K., Zitoun, N. M., & Jessani, A. (2023). Unfavourable beliefs about oral health and safety of dental care during pregnancy: a systematic review. BMC oral health, 23(1), 762.
- 28. Kim, E., & Boyd, B. (2022). Diagnostic imaging of pregnant women and fetuses: literature review. Bioengineering, 9(6), 236.
- 29. Lie, G., Eleti, S., Chan, D., Roshen, M., Cross, S., & Qureshi, M. (2022). Imaging the acute abdomen in pregnancy: a radiological decision-making tool and the role of MRI. Clinical Radiology, 77(9), 639-649.
- 30. Mansour, O., Russo, R. G., Straub, L., Bateman, B. T., Gray, K. J., Huybrechts, K. F., & Hernández-Díaz, S. (2024). Prescription medication use during pregnancy in the United States from 2011 to 2020: trends and safety evidence. American journal of obstetrics and gynecology, 231(2), 250-e1.
- 31. Nadanovsky, P., Pires dos Santos, A. P., & Nunan, D. (2024). Too Much Dental Radiography—Reply. JAMA internal medicine, 184(12), 1481-1481.
- 32. Naseem, M., Khurshid, Z., Khan, H. A., Niazi, F., Zohaib, S., & Zafar, M. S. (2016). Oral health challenges in pregnant women: Recommendations for dental care professionals. The Saudi Journal for Dental Research, 7(2), 138-146.
- 33. Opinc, M., & Kalinka, J. (2021). Drug-induced liver injury in early pregnancy associated with methyldopa administration during antihypertensive therapy. Journal of Obstetrics and Gynecological Investigations, 4(1), 1-4.
- 34. Ricci, S. (2020). Essentials of maternity, newborn, and women’s health. Lippincott Williams & Wilkins.
- 35. Roque Pereira, L., Durán, C. E., Layton, D., Poulentzas, G., Lalagkas, P. N., Kontogiorgis, C., & Sturkenboom, M. (2022). A Landscape Analysis of Post-Marketing Studies Registered in the EU PAS Register and ClinicalTrials. gov Focusing on Pregnancy Outcomes or Breastfeeding Effects: A Contribution from the ConcePTION Project: LR Pereira et al. Drug safety, 45(4), 333-344.
- 36. Rozylo-Kalinowska, I. (2020). Safety Precautions for Dental Patient and Dental Staff Using X-Rays. In Imaging Techniques in Dental Radiology: Acquisition, Anatomic Analysis and Interpretation of Radiographic Images (pp. 177-188). Cham: Springer International Publishing.
- 37. Siegel, C. H., & Sammaritano, L. R. (2024). Safety of medications used to treat autoimmune rheumatic diseases during pregnancy and lactation. JCR: Journal of Clinical Rheumatology, 30(7S), S25-S33.
- 38. Stojanova, J., Arancibia, M., Ghimire, S., & Sandaradura, I. (2022). Understanding the pharmacokinetics of antibiotics in pregnancy: is there a role for therapeutic drug monitoring? A narrative review. Therapeutic Drug Monitoring, 44(1), 50-64.
- 39. Surtimanah, T., Noviyanti, E., & Meliyanti, M. (2019). Differences of family support and iron tablets consumed post pregnant women classes and midwives counseling. IJPHRD, 10(3), 999-1006.
- 40. Tezel Yalçın, H., Yalçın, N., Ceulemans, M., & Allegaert, K. (2024). Drug safety during breastfeeding: A comparative analysis of FDA adverse event reports and LactMed®. Pharmaceuticals, 17(12), 1654.
- 41. Thorpe, P. G., Gilboa, S. M., Hernandez‐Diaz, S., Lind, J., Cragan, J. D., Briggs, G., ... & National Birth Defects Prevention Study. (2013). Medications in the first trimester of pregnancy: most common exposures and critical gaps in understanding fetal risk. Pharmacoepidemiology and drug safety, 22(9), 1013-1018.
- 42. van de Vusse, D., Mian, P., Schoenmakers, S., Flint, R. B., Visser, W., Allegaert, K., & Versmissen, J. (2022). Pharmacokinetics of the most commonly used antihypertensive drugs throughout pregnancy methyldopa, labetalol, and nifedipine: a systematic review. European journal of clinical pharmacology, 78(11), 1763-1776.
- 43. Vignato, J., Mehner, B., Negrete, A., & Segre, L. S. (2023). Over-the-counter pain medication use during pregnancy. MCN: The American Journal of Maternal/Child Nursing, 48(4), 209-214.
- 44. Vinogradov, R., Smith, V., Hiu, S., McParlin, C., Farnworth, A., & Araújo-Soares, V. (2023). Let's talk aspirin: A survey of barriers and facilitators faced by midwives when engaging in conversations about aspirin with women at risk of pre-eclampsia. Midwifery, 127, 103860.
- 45. World Health Organization. (2022). WHO Pharmaceuticals Newsletter: No. 2, 2022. World Health Organization.
- 46. World Health Organization. (2024). Landscape analysis of pregnancy exposure registries in low-and middle-income countries. World Health Organization.
References
1. AbuShweimeh, R., Knudson, S., Chaabane, S., Pal, S. N., Skidmore, B., Stergachis, A., & Bhat, N. (2023). Pregnancy exposure registries for drugs and vaccines in low-income and middle-income countries: scoping review protocol. BMJ open, 13(5), e070543.
2. Adrover, R., Siri, C., Cocozzella, D., Quarin, C., Romé, J., & Azi, H. (2016). Hepatotoxicity from Alpha-Methyldopa During Pregnancy: Two Case Reports. Journal of Clinical Gastroenterology and Treatment, 2(3), 1-3.
3. Alexe A, Eisele O, Fernandes MF, Garg A, Kovacs B, Wurst K, Balramsingh‐Harry L, Abramova N, Zheteyeva Y, Lewis D. Call to action: harmonization of pharmacovigilance regulations for post‐marketing pregnancy and breastfeeding safety studies. British Journal of Clinical Pharmacology. 2024 Mar;90(3):715-21.
4. American College of Obstetricians and Gynecologists. (2017). Committee Opinion No. 723: guidelines for diagnostic imaging during pregnancy and lactation. Obstetrics & Gynecology, 130(4), e210-e216.
5. Anderson, R., & Silk, H. (2022). Oral Health Intervention Before Pregnancy: A Preconception Approach. Journal of the California Dental Association, 50(4), 217-222.
6. Arfman, I. J., Wammes-van der Heijden, E. A., Ter Horst, P. G., Lambrechts, D. A., Wegner, I., & Touw, D. J. (2020). Therapeutic Drug Monitoring of Antiepileptic Drugs in Women with Epilepsy Before, During, and After Pregnancy: IJ Arfman et al. Clinical pharmacokinetics, 59(4), 427-445.
7. Balkam, J. J. (2022). Galactagogues and lactation: Considerations for counseling breastfeeding mothers. MCN: The American Journal of Maternal/Child Nursing, 47(3), 130-137.
8. Barbosa, M. C. F., da Rocha, N. B., de Souza Gomes Rodrigues, H., de Oliveira, D. S. B., Fernandes, L. A., & de Lima, D. C. (2023). Maternal knowledge of oral health during pregnancy and childbirth. Maternal and Child Health Journal, 27(9), 1607-1615.
9. Bensaod, L. (2024). Evaluation of Practice and Awareness of the Safety Profile of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) among Dental Practitioners: A Cross-Sectional Study.
10. Berrueta, M., Ciapponi, A., Bardach, A., Cairoli, F. R., Castellano, F. J., Xiong, X., ... & Buekens, P. (2021). Maternal and neonatal data collection systems in low-and middle-income countries for maternal vaccines active safety surveillance systems: A scoping review. BMC pregnancy and childbirth, 21(1), 217.
11. Besimoglu, B., Öcal, F. D., Sinaci, S., Atalay, A., Tanaçan, A., & Şahin, D. (2022). Effect of antiepileptic drugs on serum biochemical marker levels of first and second trimester screening tests. Journal of Obstetrics and Gynaecology Research, 48(7), 1607-1612.
12. Blattner, C. M., Danesh, M., Safaee, M., & Murase, J. E. (2016). Understanding the new FDA pregnancy and lactation labeling rules. International Journal of Women's Dermatology, 2(1), 5.
13. Brucker, M. C., & King, T. L. (2017). The 2015 US Food and Drug Administration pregnancy and lactation labeling rule. Journal of midwifery & women's health, 62(3), 308-316.
14. Cha, E., Smart, M. J., Braxter, B. J., & Faulkner, M. S. (2021). Preconception care to reduce the risks of overweight and obesity in women of reproductive age: an integrative review. International journal of environmental research and public health, 18(9), 4582.
15. Charron, E., Mayo, R. M., Heavner-Sullivan, S. F., Eichelberger, K. Y., Dickes, L., Truong, K. D., & Rennert, L. (2020). “It’sa very nuanced discussion with every woman”: Health care providers’ communication practices during contraceptive counseling for patients with substance use disorders. Contraception, 102(5), 349-355.
16. Dathe, K., & Schaefer, C. (2018). Drug safety in pregnancy: the German Embryotox institute. European journal of clinical pharmacology, 74(2), 171-179.
17. Daw, J. R., Underhill, K., Liu, C., & Allen, H. L. (2023). The health and social needs of medicaid beneficiaries in the postpartum year: Evidence from a multistate survey: Study examines extension of Medicaid benefits one year postpartum. Health Affairs, 42(11), 1575-1585.
18. De Souza, J., Viswanath, V. K., Echterhoff, J. M., Chamberlain, K., & Wang, E. J. (2024). Augmenting telepostpartum care with vision-based detection of breastfeeding-related conditions: algorithm development and validation. JMIR AI, 3(1), e54798.
19. Ding, A., Joshi, J., & Tiwana, E. (2023). Patient safety in radiology and medical imaging. In Patient Safety: A Case-based Innovative Playbook for Safer Care (pp. 261-277). Cham: Springer International Publishing.
20. dos Santos, F. M., Senra, C., & Maciel, C. (2020, January). Contrast Agents Administration in Pregnancy and Lactation: Safety Issues and Practical Points in Everyday Practice. European Congress of Radiology-ECR 2020.
21. Favero, V., Bacci, C., Volpato, A., Bandiera, M., Favero, L., & Zanette, G. (2021). Pregnancy and dentistry: A literature review on risk management during dental surgical procedures. Dentistry journal, 9(4), 46.
22. Giles, A., Prusinski, R., & Wallace, L. (2024). Maternal-newborn nursing. OpenStax.
23. Gupta, R., Bajaj, S. K., Kumar, N., Chandra, R., Misra, R. N., Malik, A., & Thukral, B. B. (2016). Magnetic resonance imaging-a troubleshooter in obstetric emergencies: a pictorial review. Indian Journal of Radiology and Imaging, 26(01), 44-51.
24. Hwang, S. Y., Choi, E. S., Kim, Y. S., Gim, B. E., Ha, M., & Kim, H. Y. (2018). Health effects from exposure to dental diagnostic X-ray. Environmental health and toxicology, 33(4), e2018017.
25. Jabehdar Maralani, P., Kapadia, A., Liu, G., Moretti, F., Ghandehari, H., Clarke, S. E., ... & Schieda, N. (2022). Canadian Association of Radiologists recommendations for the safe use of MRI during pregnancy. Canadian Association of Radiologists Journal, 73(1), 56-67.
26. Jain, C. (2019). ACOG Committee Opinion No. 723: guidelines for diagnostic imaging during pregnancy and lactation. Obstetrics & Gynecology, 133(1), 186.
27. Kamalabadi, Y. M., Campbell, M. K., Zitoun, N. M., & Jessani, A. (2023). Unfavourable beliefs about oral health and safety of dental care during pregnancy: a systematic review. BMC oral health, 23(1), 762.
28. Kim, E., & Boyd, B. (2022). Diagnostic imaging of pregnant women and fetuses: literature review. Bioengineering, 9(6), 236.
29. Lie, G., Eleti, S., Chan, D., Roshen, M., Cross, S., & Qureshi, M. (2022). Imaging the acute abdomen in pregnancy: a radiological decision-making tool and the role of MRI. Clinical Radiology, 77(9), 639-649.
30. Mansour, O., Russo, R. G., Straub, L., Bateman, B. T., Gray, K. J., Huybrechts, K. F., & Hernández-Díaz, S. (2024). Prescription medication use during pregnancy in the United States from 2011 to 2020: trends and safety evidence. American journal of obstetrics and gynecology, 231(2), 250-e1.
31. Nadanovsky, P., Pires dos Santos, A. P., & Nunan, D. (2024). Too Much Dental Radiography—Reply. JAMA internal medicine, 184(12), 1481-1481.
32. Naseem, M., Khurshid, Z., Khan, H. A., Niazi, F., Zohaib, S., & Zafar, M. S. (2016). Oral health challenges in pregnant women: Recommendations for dental care professionals. The Saudi Journal for Dental Research, 7(2), 138-146.
33. Opinc, M., & Kalinka, J. (2021). Drug-induced liver injury in early pregnancy associated with methyldopa administration during antihypertensive therapy. Journal of Obstetrics and Gynecological Investigations, 4(1), 1-4.
34. Ricci, S. (2020). Essentials of maternity, newborn, and women’s health. Lippincott Williams & Wilkins.
35. Roque Pereira, L., Durán, C. E., Layton, D., Poulentzas, G., Lalagkas, P. N., Kontogiorgis, C., & Sturkenboom, M. (2022). A Landscape Analysis of Post-Marketing Studies Registered in the EU PAS Register and ClinicalTrials. gov Focusing on Pregnancy Outcomes or Breastfeeding Effects: A Contribution from the ConcePTION Project: LR Pereira et al. Drug safety, 45(4), 333-344.
36. Rozylo-Kalinowska, I. (2020). Safety Precautions for Dental Patient and Dental Staff Using X-Rays. In Imaging Techniques in Dental Radiology: Acquisition, Anatomic Analysis and Interpretation of Radiographic Images (pp. 177-188). Cham: Springer International Publishing.
37. Siegel, C. H., & Sammaritano, L. R. (2024). Safety of medications used to treat autoimmune rheumatic diseases during pregnancy and lactation. JCR: Journal of Clinical Rheumatology, 30(7S), S25-S33.
38. Stojanova, J., Arancibia, M., Ghimire, S., & Sandaradura, I. (2022). Understanding the pharmacokinetics of antibiotics in pregnancy: is there a role for therapeutic drug monitoring? A narrative review. Therapeutic Drug Monitoring, 44(1), 50-64.
39. Surtimanah, T., Noviyanti, E., & Meliyanti, M. (2019). Differences of family support and iron tablets consumed post pregnant women classes and midwives counseling. IJPHRD, 10(3), 999-1006.
40. Tezel Yalçın, H., Yalçın, N., Ceulemans, M., & Allegaert, K. (2024). Drug safety during breastfeeding: A comparative analysis of FDA adverse event reports and LactMed®. Pharmaceuticals, 17(12), 1654.
41. Thorpe, P. G., Gilboa, S. M., Hernandez‐Diaz, S., Lind, J., Cragan, J. D., Briggs, G., ... & National Birth Defects Prevention Study. (2013). Medications in the first trimester of pregnancy: most common exposures and critical gaps in understanding fetal risk. Pharmacoepidemiology and drug safety, 22(9), 1013-1018.
42. van de Vusse, D., Mian, P., Schoenmakers, S., Flint, R. B., Visser, W., Allegaert, K., & Versmissen, J. (2022). Pharmacokinetics of the most commonly used antihypertensive drugs throughout pregnancy methyldopa, labetalol, and nifedipine: a systematic review. European journal of clinical pharmacology, 78(11), 1763-1776.
43. Vignato, J., Mehner, B., Negrete, A., & Segre, L. S. (2023). Over-the-counter pain medication use during pregnancy. MCN: The American Journal of Maternal/Child Nursing, 48(4), 209-214.
44. Vinogradov, R., Smith, V., Hiu, S., McParlin, C., Farnworth, A., & Araújo-Soares, V. (2023). Let's talk aspirin: A survey of barriers and facilitators faced by midwives when engaging in conversations about aspirin with women at risk of pre-eclampsia. Midwifery, 127, 103860.
45. World Health Organization. (2022). WHO Pharmaceuticals Newsletter: No. 2, 2022. World Health Organization.
46. World Health Organization. (2024). Landscape analysis of pregnancy exposure registries in low-and middle-income countries. World Health Organization.