Disinfectants should have a strong bactericidal or bacteriostatic action, and skin, mucosa, and wounds should tolerate them well. In addition, they should not cause systemic toxic effects when they are absorbed.
No toxic effects have been observed, as yet, from the local topical use of alcohols during pregnancy. Ethanol and isopropyl alcohol (isopropanol) are the primary alcohols used.
Recommendation. Alcohols may be used topically as disinfectants during pregnancy.
Benzoyl peroxide is used, in particular, for external treatment of acne. Approximately 5% is absorbed. It is converted to benzoic acid in the skin. Concurrent topical therapy with retinoids increases the absorption of these agents. Benzoyl peroxide is also used in the food and plastics industries. There are insufficient experimental or epidemiological data for a risk assessment; however, there are also no case reports indicating teratogenic effects.
Recommendation. Benzoyl peroxide in therapeutic concentrations may be used topically on a limited area (i.e. the face) to treat acne.
When povidone iodine is used as a local disinfectant on intact skin, on wounds and on the mucosa as well as in body cavities, iodine transfer to the fetus must be assumed. This can lead to functional disturbances in the fetal thyroid gland. The intake of iodine from a vaginal douche during labor can lead to a temporary TSH-increase in the newborn's blood - a sign of transient hypothyroidism (Weber 1998). This should be considered in the interest of the undisturbed thyroid status necessary for central nervous system differentiation. Retrospective evaluation of children born to mothers who applied iodine vaginal douching did not show indications of teratogenic effects (Czeizel 2004). However, this study did not identify the time of exposure or usage during pregnancy.
Recommendation. Iodine-containing disinfectants may only be used during pregnancy on small areas for a few days. Body cavities should not be cleaned with iodine-containing solutions. However, its use is not connected to any irreversible damage.
Phenol derivatives are used primarily in over-the-counter preparations for rinsing the mouth, disinfecting the skin, and treating perianal infections. Solutions of phenol derivatives, such as cresol and thymol, as well as the chlorinated phenol derivatives (i.e. 4-chlorocresol and triclosan) are viewed as relatively safe during pregnancy (sec, for example, Bhargava 1996). They should not be used in a concentration stronger than 2%, and should only be used on intact skin. With higher concentrations, incremental absorption must be assumed.
Chlorhexidine is appropriate for pregnant women to disinfect the skin and mucosa. It is effective as a disinfectant of the vagina and vulva before birth, and for the abdomen before cesarean section (Briggs 2005).
In contrast, caution should be exercised during pregnancy with the neurotoxic phenol derivative hexachlorophene, because when larger areas are treated with concentrations of more than 3%, poisoning, with central nervous system symptoms, has been observed in treated patients (Lockhart 1972). In some animal studies, hexachlorophene has been shown to be teratogenic (Kimmel 1972). In many publications over the last decades, workplace contact with hexachloro-phene has been controversially discussed with respect to fetotoxic effects. A Swedish study of medical staff, involving about 3000 pregnant women who were occupationally exposed and 1653 control pregnancies, did not report an increase in perinatal death or congenital malformations (Baltzar 1979), A further retrospective study associated mental retardation in 306 children from women with, among others, hexachlorophene exposure in the last trimester (Roeleveld 1993).
Recommendation. Hexachlorophene should be avoided during pregnancy. However, accidental use requires no action. Pregnant women should use the other phenol derivatives mentioned, such as Chlorhexidine, for disinfecting the skin and mucosa.
Pharmacology and toxicology
Mercury can be substantially absorbed from external use, and is a potential developmental toxicant (Lauwerys 1987; see also Chapters 2.23 and 4.18),
Recommendation. Mercury-containing disinfectants are contraindicated. However, their accidental limited application does not justify either a pregnancy interruption or additional diagnostic procedures.
Quinoline sulfate has been discussed with respect to mutagenic properties (Andersen 2006). Clioquinol is one of the iodine-containing antiseptics. Gentian violet or crystal violet has been in widespread use for many years. In animal studies, there are indications of a carcinogenic activity, and contradictory data on teratogenicity (Aidoo 1990, Au 1978). Neither of these has been confirmed as yet in humans. There have also been no adverse effects described for pyoktanin as a result of use in pregnancy. However, there are no systematic studies on prenatal toxicity for these substances. The same can be said about ethacridine, used for purulent skin infections.
Recommendation. Short-term topical use of the substances mentioned, over limited areas, is acceptable for relevant indications.
Glucocorticoids and nonsteroid anti-inflammatory drugs
When glucocorticoids (see also Chapter 2.15) or nonsteroid antiinflammatory drugs such as bufexamac are applied regularly over larger areas of skin, absorption through the skin and transfer to the fetus must be assumed.
Mygind (2002) found no greater risk for developmental disorders, or difference in birth data, in 363 children born to mothers who had used topical glucocorticoids (170 during the first trimester) (see also Chapter 2.15).
There are no systematic studies for bufexamac, which is used widely in dermatology. Furthermore, there are no studies on other topically applied nonsteroid anti-inflammatory substances such as levomenol and benzydamine. NSAIDs for systemic treatment have not, as yet, shown any teratogenic effects (see Chapter 2.1).
Recommendation. There is no objection to topical therapy with glucocorticoids or bufexamac, as long as treatment time is brief and the area covered is moderately sized. Because of their prostaglandin antagonism, nonsteroid anti-inflammatory drugs should be limited to small areas after the thirtieth week of gestation.
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