Atropine Pregnancy and Breastfeeding Warnings
Atropine Pregnancy Warnings
Atropine has been assigned to pregnancy category C by the FDA. Animal studies have not been reported. There are no controlled data in human pregnancy. Atropine is only recommended for use during pregnancy when benefit outweighs risk.
Some experts recommend that the use of atropine during pregnancy be limited to its use as a preoperative, preanesthetic agent to reduce salivation and bronchial secretions. One case, in which atropine was successfully used to treat organophosphate poisoning in a woman at gestation week 35 has been reported. Atropine rapidly crosses the human placenta. In one study of 44 healthy pregnant women, a maximum umbilical to maternal vein ratio of 1.27 was observed 6 minutes after administration of 0.01 mg/kg intravenously. The corresponding umbilical and maternal vein atropine levels were 22 and 17 nmol/L, respectively. The concentrations after intramuscular injection were lower. In another study of 25 pregnant women, labeled atropine was given intravenously prior to delivery to quantify placental transfer and fetal distribution of the drug. The concentrations in the umbilical vein 1 and 5 minutes after injection were 12% and 93%, respectively, of the corresponding maternal value. Concentrations in the umbilical artery were approximately 50% of those in the umbilical vein during the same period. Studies have shown that administration of atropine to a pregnant woman during the last trimester can mask the effects of vagal stimulation on the fetal heart, producing tachycardia within 5 to 30 minutes after injection. Limited data have shown that atropine can suppress fetal breathing, although fetal hypoxia has not been observed. There has also been concern that atropine could reduce lower esophageal sphincter pressure enough to predispose the newborn to aspiration. Uterine contractility does not appear to be significantly affected by atropine. This is thought to be due to a decrease in the sensitivity of muscarinic receptors on myometrial tissue during pregnancy. The Collaborative Perinatal Project monitored 50,282 mother-child pairs, of which 401 pairs were exposed to atropine during lunar months 1 through 4. Of the 401 pairs, 25 malformed children were observed. The calculated crude relative risk for malformation associated with atropine was 0.96. These data do not support an association between the use of atropine and congenital defects. Of the 50,282 mother-child pairs, 2,323 pairs had been exposed to parasympatholytic drugs, in general. Of these 2,323 pairs, 168 malformed children were observed, yielding a crude relative risk of 1.13. These data support an possible association between the use of some parasympatholytic agents and congenital defects. The Michigan Medicaid surveillance study showed an association between the use of atropine and congenital defects (written communication, Franz Rosa, MD, Food and Drug Administration, 1994). This report is a retrospective study of 229,101 pregnant women, of whom 381 received atropine during the first trimester between 1985 to 1992. Eighteen total defects and 4 cardiovascular defects were observed (16 and 4 were expected, respectively). The incidences of total and cardiovascular defects were not statistically greater than expected. A statistically significant incidence of limb reduction defects was observed (2 observed; 0.4 expected). Cleft palate was not observed. Of the 229,101 deliveries, 3,996 had exposure to atropine at any time during pregnancy. There were no statistically significant differences between the observed and expected incidences of brain or eye abnormalities among these 3,996. These data support an association between the use of atropine and some congenital defects, although other factors, such as underlying disease(s) of the mother and concomitant medications were not controlled. The use of diphenoxylate-atropine has been associated with congenital anomalies (one case report). The mother had taken diphenoxylate-atropine for diarrhea (probably of a viral etiology) during gestational week 10. A term infant was born at 36 weeks' gestation with multiple defects, including Ebstein's anomaly, hypertelorism, epicanthal folds, low-set ears, a cleft uvula, deafness, and blindness. Since exposure to atropine or diphenoxylate was at a later time during her gestation than when these stages of development occur, the authors of this case report did not consider the drugs causative of the anomalies.
Atropine Breastfeeding Warnings
Atropine is excreted into human milk in trace amounts. Caution should be exercised when atropine is administered to a nursing woman because of neonates' sensitivity to anticholinergic agents (probably because of immaturity of motor endplates). The gastrointestinal bioavailability of atropine in neonates has not been reported. The American Academy of Pediatrics considers atropine to be compatible with breast-feeding.
References for pregnancy information
- Weis OF, Muller FO, Lyell H, Badenhorst CH, van Niekerk P "Materno-fetal cholinesterase inhibitor poisoning." Anesth Analg 62 (1983): 233-5
- Hon EH, Bradfield AH, Hess OW "The electronic evaluation of the fetal heart rate." Am J Obstet Gynecol 82 (1961): 291-300
- John AH "Placental transfer of atropine and the effect on foetal heart rate." Br J Anaesth 37 (1965): 57-60
- Briggs GG, Freeman RK, Yaffe SJ.. "Drugs in Pregnancy and Lactation. 5th ed." Baltimore, MD: Williams & Wilkins (1998):
- Kretowicz J "Investigations on the effect of atropine sulfate on the fetal heart rate and rhythm. II. Term pregnancy complicated by symptoms of toxemia." Pol Med J 6 (1967): 760-4
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- Heinonen O, Slone D, Shapiro S; Kaufman DW ed. "Birth Defects and Drugs in Pregnancy." Littleton, MA: Publishing Sciences Group, Inc. (1977): 297
- "Product Information. Atropine Sulfate Injection, USP (atropine)." ESI Lederle Generics, Philadelphia, PA.
- Kanto J, Lindberg R, Pihlajamaki K, Scheinin M "Placental and blood-CSF transfer of intramuscularly administered atropine in the same person." Pharmacol Toxicol 60 (1987): 108-9
- Roper RE, Salem MG "Effects of glycopyrrolate and atropine combined with antacid on gastric acidity." Br J Anaesth 53 (1981): 1277-80
- Schwarcz RL Jr, Sala NL, Althabe O Jr, Fisch L "Effect of atropine upon uterine contractility induced by artificial cervical dilatation." Am J Obstet Gynecol 98 (1967): 577-80
- Hicks JA, Jenkins JG "Atropine and obstetric anesthesia." Anaesth Intensive Care 13 (1985): 104-5
- Hellman LM, Johnson HL, Tolles WE, Jones EH "Some factors affecting the fetal heart rate." Am J Obstet Gynecol 82 (1961): 1055
- Siebert JR, Barr M, Jackson JC, Benjamin DR "Ebstein's Anomaly and extracardiac defects." Am J Dis Child 143 (1989): 570-2
- Kivalo I, Saarikoski S "Placental transmission of atropine at full-term pregnancy." Br J Anaesth 49 (1977): 1017-21
- Berkowitz R, Coustan D, Mochizuki T. "Handbook for Prescribing Medications During Pregnancy. 2nd ed." Boston, MA: Little, Brown, and Company (1986): 242
- Jenssen H "Fetal systolic time intervals in late pregnancy. Effect of atropine." Acta Obstet Gynecol Scand 58 (1979): 519-26
- Kanto J "New aspects in the use of atropine." Int J Clin Pharmacol Ther Toxicol 21 (1983): 92-4
- Shutt LE, Bowes JB "Atropine and hyoscine." Anaesthesia 34 (1979): 476-90
- Kretowicz J "Investigations on the effect of atropine sulfate on the fetal heart rate and rhythm. 3. Uncomplicated pregnancy before term." Pol Med J 6 (1967): 765-70
- Abboud T, Raya J, Sadri S, Grobler N, Stine L, Miller F "Fetal and maternal cardiovascular effects of atropine and glycopyrrolate." Anesth Analg 62 (1983): 426-30
- Kanto J, Virtanen R, Iisalo E, Maenpaa K, Liukko P "Placental transfer and pharmacokinetics of atropine after a single maternal intravenous and intramuscular administration." Acta Anaesthesiol Scand 25 (1981): 85-8
- Nakanishi H, Wood C "Cholinergic mechanisms in the human uterus." J Obstet Gynaecol Br Commonw 78 (1971): 716-23
- Viby-Mogensen J "Routine use of atropine in obstetric anaesthesia." Br J Anaesth 61 (1988): 119-20
- Downing JW "Atropine and caesarean section." Anaesth Intensive Care 13 (1985): 210
- May AE, Theophilus SW, James RH "Routine use of atropine in obstetric anaesthesia." Br J Anaesth 60 (1988): 243-4
- Soiva K, Salmi A "Phonocardiographic studies of the foetal heart rate." Ann Chir Gynaecol Fenn 48 (1959): 287-98
- Kivalo I, Saarikoski S "Quantitative measurements of placental transfer and distribution of radioactive atropine in fetus." Ann Chir Gynaecol Fenn 59 (1970): 80-4
- Kretowicz J "Studies on the influence of atropine sulfate on the rate and rhythm of the fetal heart. 1. Normal pregnancy at term." Pol Med J 5 (1966): 1447-57
- Onnen I, Barrier G, d'Athis P, Sureau C, Olive G "Placental transfer of atropine at the end of pregnancy." Eur J Clin Pharmacol 15 (1979): 443-6
- Kretowicz J "Investigations on the effect of atropine sulfate on the frequency and rhythm of fetal heart activity." Pol Med J 7 (1968): 1009-14
References for breastfeeding information
- Committee on Drugs, 1992 to 1993 "The transfer of drugs and other chemicals into human milk." Pediatrics 93 (1994): 137-50
- Gin T "Anaesthesia and breast feeding." Anaesth Intensive Care 21 (1993): 256-7
- "Drugs in breast milk." Med Lett Drugs Ther 16 (1974): 25-7
- "Product Information. Atropine Sulfate Injection, USP (atropine)." ESI Lederle Generics, Philadelphia, PA.
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