fit in with their clinical customs and in the end it is difficult to assess the validity of the data.
Alternatively a limited geographical basis may be used, with the trial going on for many years. During this time other things in the environment change, so again the results would not command our confidence. If it were to be suggested that there was something slightly teratogenic in milk, the hypothesis would be virtually untestable.
In practice we have to make up our minds which drugs may reasonably be given to pregnant women. Do we start from a position of presumed guilt or from one of presumed innocence? If the former course is chosen then we cannot give any drugs to pregnant women because we can never prove that they are completely free of teratogenic influence. It therefore seems that we must start from a position of presumed innocence and then take all possible steps to find out if the presumption is correct.
Finally, we must put the matter in perspective by considering the benefit/risk ratio. The problem of prescription in pregnancy cannot be considered from the point of view of only one side of the equation. Drugs are primarily designed to do good, and if a pregnant woman is ill it is in the best interests of her baby and herself that she gets better as quickly as possible. This often means giving her drugs. We can argue about the necessity of giving drugs to prevent vomiting, but there is no argument about the need for treatment of women with meningitis, septicaemia or venereal disease.
What we must try to avoid is medication by the media or prescription by politicians. A public scare about a well-tried drug will lead to wider use of less-tried alternatives. We do not want to be forced to practise the kind of defensive medicine that is primarily designed to avoid litigation.14
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