Birth outcome and risk of neonatal hypoglycaemia following in utero exposure to pivmecillinam: a population-based cohort study with 414 exposed pregnancies

Concerns have been raised as to the safety of using pivaloyl-conjugated beta-lactam antibiotics during pregnancy as they cause carnitine depletion. Restrictions have been recommended in some Scandinavian countries as drug-induced carnitine depletion could constitute a risk to the developing foetus. One of these drugs, pivmecillinam, is widely used against urinary tract infections but few data exist concerning its safety in pregnancy. In a cohort study, we compared the prevalences of congenital abnormalities, pre-term delivery, low birth weight, low Apgar score and neonatal hypoglycaemia in the offspring of 414 women who had at least 1 prescription for pivmecillinam redeemed during pregnancy with those of the offspring of 7472 pregnant women for whom no drugs were prescribed during pregnancy. The prevalence of congenital abnormalities was 1.7% among 119 infants exposed in the first trimester and 3.7% among the reference group [odds ratio (OR) 0.46; 95% confidence interval (CI) 0.11-1.86]. We found no significantly increased risks in either pre-term delivery (OR 0.91, 95% CI 0.11-1.86), low birth weight (OR 0.57, 95%, CI 0.23-1.41), low Apgar score (OR 2.32, 95% CI 0.30-18.16) or hypoglycaemia (OR 0.73, 95% CI 0.18-3.00) that were induced by carnitine depletion. No significantly increased risk in adverse birth outcome was therefore found in women treated with pivmecillinam.

Induced abortion and placenta complications in the subsequent pregnancy

BACKGROUND

To study the risk of placenta complications following an induced abortion as a function of the interpregnancy interval.

METHODS

This study is based on three Danish national registries; the Medical Birth Registry, the Hospital Discharge Registry, and the Induced Abortion Registry. All primigravida women from 1980 to 1982 were identified in these three registries. A total of 15,727 women who terminated the pregnancy with a first trimester induced abortion were selected to the abortion cohort, and 46,026 women who did not terminate the pregnancy with an induced abortion constituted the control cohort. By register linkage all subsequent pregnancies were identified from 1980 to 1994. Only women who had a non-terminated pregnancy following the index pregnancy were selected to the study. Placenta complications were identified using either the Hospital Discharge Registry ICD-8 codes or the Medical Birth Registry records.

RESULTS

A slightly higher risk of placenta complications following an abortion was found. Retained placenta occurred more frequently in women with one, two or more previous abortions, compared with women without any previous abortion of similar gravidity. Adjusting for maternal age and residence at time of pregnancy, the interpregnancy interval, and the number of previous miscarriages (control cohort only), the odds ratios of retained placenta in deliveries of singleton live births in women with one previous abortion was 1.17 (95%CI=1.02-1.35), and for women with two or more previous abortions it was 1.68 (95%CI=1.23-2.30), respectively, compared with the control cohort of similar gravidity. Only for women who had one abortion did the results follow the predicted pattern of a higher risk of retained placenta after a short pregnancy interval. No association with placenta previa was seen.

CONCLUSIONS

The findings suggest a positive association between abortions and retained placenta in subsequent singleton live births, but the association was weak and confounding cannot be ruled out.

[Congenital malformations and fetal growth of children with intrauterine exposure to anticonvulsants]

OBJECTIVES

To examine the risk of malformations and fetal growth in the children of women treated with anticonvulsant drugs in North Jutland County, Denmark.

MATERIAL AND METHODS

All women treated with anticonvulsant drugs in the county were identified in a Pharmaco-Epidemiological Prescription Database and linked to the Danish Medical Birth Registry and the Regional Hospital Information system.

RESULTS

We identified 235 pregnancies where the mothers had used prescriptions for anticonvulsants around conception and/or during pregnancy, and 17,259 unexposed pregnancies where the mothers had not used prescriptions. One case of neural tube defect was found among 15 malformations in the exposed cohort. The overall odds ratio for malformations was 2.2 (95% confidence intervals 1.3-3.8). The odds ratios for low birth weight and preterm delivery were respectively 1.5 (95% confidence intervals 0.6-3.7) and 1.6 (95% confidence intervals 1.0-2.5).

CONCLUSION

We found an increased risk of congenital malformations and a tendency to growth retardation in the children of women taking anticonvulsants.

Smoking, sex of the offspring, and risk of placental abruption, placenta previa, and preeclampsia: a population-based cohort study

BACKGROUND

: Placental abruption, placenta previa, and preeclampsia are serious pregnancy complications with an increased risk of perinatal death. Smoking during pregnancy is associated with increased risk of abruption and placenta previa, and it reduces the risk of preeclampsia. We examined the association between mothers' smoking habits during pregnancy, taking the sex of the offspring into consideration, and the risk and prognosis of placental abruption, placenta previa, and preeclampsia

METHODS

: We conducted the study in the County of North Jutland, Denmark. Using the 10-digit personal identification number given to every Danish citizen at birth, we linked data from the Danish Medical Birth Registry, including information on mother and child, to data from the Pharmaco-Epidemiological Prescription Database with data on all reimbursed prescriptions to use selected drugs as a proxy measure for some maternal diseases, and data from the Regional Hospital Discharge Registry, including the discharge diagnoses. Among 47,932 singleton births we included only births for which we had information about the mothers' smoking habits, leaving 46,313 births for analysis.

RESULTS

: Smoking was associated with the risk of placental abruption (OR=1.99 (95% CI 1.72-2.30)) and placenta previa (OR=1.88 (95% CI 1.15-3.07)). Smoking was inversely associated with the risk of preeclampsia (OR=0.55 (95% CI 0.48-0.62)). After stratification for the sex of the offspring the risk estimate of smoking as risk factor for placenta previa decreased for male fetuses (OR=1.63 (95% CI 0.75-3.51)) and increased for female fetuses (OR=4.82 (95% CI 1.69-13.75)).

CONCLUSION

: Female fetuses are more vulnerable than male to the negative effect of maternal smoking on placenta previa.

Birth outcome following maternal use of fluoroquinolones

The aim of the study was to examine fetal risk associated with intrauterine exposure to fluoroquinolones. By using on record linkage between a Prescription Database and the Birth Registry in Denmark, the offspring of 57 users of fluoroquinolones and of 17259 patients who had no prescriptive medication during pregnancy, were compared in a cohort study. Among the users, the prevalence rate ratios of congenital abnormalities, preterm birth and low birth weight were 1.30 (95% CI: 0.30-5.30),1.53 (95% CI: 0.62-3.80) and 1.17 (95% CI: 0.15-8.90), respectively. The risk of congenital abnormalities among users of fluoroquinolones during pregnancy was close to unity. Despite these limitations of statistical analysis the study suggested that the use of fluoroquinolones during pregnancy may not be a major risk factor to the foetus.

Risk of adverse birth outcome and miscarriage in pregnant users of non-steroidal anti-inflammatory drugs: population based observational study and case-control study

OBJECTIVE

To estimate the risk of adverse birth outcome in women who take non-steroidal anti-inflammatory drugs during pregnancy.

DESIGN AND SETTING

Population based cohort study and a case-control study, both based on data from a prescription registry, the Danish birth registry, and one county's hospital discharge registry.

PARTICIPANTS

COHORT STUDY: 1462 pregnant women who had taken up prescriptions for non-steroidal anti-inflammatory drugs in the period from 30 days before conception to birth and 17 259 pregnant women who were not prescribed any drugs during pregnancy. CASE-CONTROL STUDY: 4268 women who had miscarriages, of whom 63 had taken non-steroidal anti-inflammatory drugs, and 29 750 primiparous controls who had live births.

MAIN OUTCOME MEASURES

Incidences of congenital abnormality, low birth weight, preterm birth, and miscarriage.

RESULTS

Odds ratios for congenital abnormality, low birth weight, and preterm birth among women who took up prescriptions for non-steroidal anti-inflammatory drugs were 1.27 (95% confidence interval 0.93 to 1.75), 0.79 (0.45 to 1.38), and 1.05 (0.80 to 1.39) respectively. Odds ratios for the taking up of prescriptions in the weeks before miscarriage ranged from 6.99 (2.75 to 17.74) when prescriptions were taken up during the last week before the miscarriage to 2.69 (1.81 to 4.00) when taken up between 7 and 9 weeks before. The risk estimates were no different when the analysis was restricted to missed abortions.

CONCLUSIONS

Use of non-steroidal anti-inflammatory drugs during pregnancy does not seem to increase the risk of adverse birth outcome but is associated with increased risk of miscarriage.

Effect of diuretics on fetal growth: A drug effect or confounding by indication? Pooled Danish and Scottish cohort data

AIMS

The diabetogenic effect of diuretics, as well as the indication for prescribing them, may impact on fetal growth. We analysed whether the purchase of prescription drugs for diuretics during pregnancy was associated with measures of fetal growth.

METHODS

During 1991-98 all women who purchased prescription drugs for diuretics during pregnancy were identified in the Northern Jutland Prescription Database (NJDP), Denmark, and in the Medicines Monitoring Unit's Database (MEMO), Scotland. Information on birth weight and gestational age was obtained from the Danish Birth Registry, the Danish Hospital Discharge Registry and the Scottish Tayside Neonatal Database. Information on diabetes, hypertension and prepregnancy weight were obtained by hospital record review in a sample of women in the Danish cohort. Women who did not purchase prescription diuretics during pregnancy were used as a reference group in both cohorts.

RESULTS

Danish women who purchased prescription loop diuretics during pregnancy gave birth to infants with higher birth weights than women who did not use diuretics; mean difference 104.7 g (95% CI; 2.6, 206.9). However, the high prevalence of diabetes (10.3%) among Danish women who purchased prescription loop diuretics during pregnancy might explain this result. Both the Danish and the Scottish women who purchased prescription diuretics during their pregnancy were at increased risk of preterm delivery (< 37 completed weeks); ORs: 1.8 (CI; 1.2, 2.7)NJDP, 1.9 (CI; 0.9, 4.3)MEMO. The proportion of hypertension among women who purchased prescription thiazides was 15.8%, and the risk of having an infant with a birth weight (BW) < 2500 g was increased; ORs: 2.6 (CI; 1.4, 5.0)NJDP, 2.4 (CI; 0.8, 7.8)MEMO.

CONCLUSIONS

Prescribing diuretics during pregnancy was associated with differences in birth weight and incidence of preterm delivery. Confounding by indication may explain the findings.

Birth outcomes in pregnant women treated with low-molecular-weight heparin

BACKGROUND

Pregnancy and puerperium are associated with an increased risk of venous thromboembolism. Low-molecular-weight heparin is the anticoagulant of choice in pregnant women because, unlike warfarin, it does not cross the placenta. However, there are limited data on the risk of adverse birth outcomes following use of low-molecular-weight heparin in pregnancy.

PATIENTS AND METHODS

We performed a population-based cohort study to examine the safety of low-molecular-weight heparin use in pregnancy using data from the Pharmacoepidemiological Prescription Database, The Danish Medical Birth Registry and the Regional Hospital Discharge Registry in North Jutland County, Denmark. The birth outcomes in a cohort of 66 pregnant women treated with low-molecular-weight heparin between 1991-98 were compared with the birth outcomes of 17,259 pregnant women who did not receive any prescriptive drugs during pregnancy.

RESULTS

No increased risk of malformations, low birth weight or stillbirth was found. However, an increased risk of pre-term delivery was found (odds ratio: 2.11, 95%, confidence interval: 0.96-4.65), which could reflect inherited thrombophilia as an indication of low-molecular-weight heparin.

CONCLUSION

We have provided additional evidence of the safety of low-molecular-weight heparin use in pregnancy.

A follow-up study of birth outcome in users of pivampicillin during pregnancy

BACKGROUND

Pivampicillin is a prodrug which is widely used in Scandinavian countries for oral antibiotic therapy. The pivaloyl moiety has a carnitine depleting effect, which has caused doubts about the safety of administering pivampicillin during pregnancy. The aim of the study was to evaluate the risk of congenital malformations in general, preterm delivery and low birth weight in users of pivampicillin.

METHODS

Seven hundred and ninety-one women who had redeemed a prescription of pivampicillin during their first pregnancy from 1 January 1991 to 31 December 1996 were identified in the North Jutland Pharmaco-Epidemiological Prescription Database. By linkage to the Danish Medical Birth Registry and Regional Hospital Discharge Registry we compared their birth outcomes (malformations, preterm delivery and low birth weight) with the outcomes in 7472 reference pregnancies on which the mother had not redeemed any prescription at all during pregnancy.

RESULTS

The prevalence of malformations was 5.5% (11 cases) in offspring of 199 women who had used pivampicillin during the first trimester, and 5.6% (420 cases) in offspring of controls (OR: 0.95, 95% CI: 0.51-1.76). Furthermore, we did not find any significant risk of preterm delivery (OR: 0.75, 95% CI: 0.54-1.05) or low birth weight (OR: 0.93, 95% CI: 0.55-1.57).

CONCLUSION

This study showed no increased risk of congenital malformations, preterm delivery or low birth weight in offspring of women who had redeemed a prescription for pivampicillin during pregnancy.

Birth outcomes in women exposed to anticonvulsant drugs

OBJECTIVES

To examine the risk of malformations and fetal growth in women treated with anticonvulsant drugs in North Jutland County, Denmark.

MATERIAL AND METHODS

All women treated with anticonvulsant drugs in the county were identified in a Pharmaco-Epidemiological Prescription Database and linked to the Danish Medical Birth Registry and the Regional Hospital Discharge Registry.

RESULTS

We identified 235 pregnancies exposed to anticonvulsants around conception and/or during pregnancy as well as 17,259 unexposed pregnancies where the mother had not received any prescription. There was 1 case of neural tube defect among 15 malformations in the exposed cohort. The overall risk of malformations was 2.2 (95% confidence intervals 1.3-3.8). The risk of low birth weight and preterm delivery was 1.5 (95% confidence intervals 0.6-3.7) and 1.6 (95% confidence intervals 1.0-2.5), respectively.

CONCLUSION

We found an increased risk of congenital malformations and a tendency to growth retardation in children of women exposed to anticonvulsants.

Metastatic pattern in non-resectable non-small cell lung cancer

This study describes the metastatic pattern at autopsy in patients with non-resectable non-small cell lung cancer (NSCLC) and evaluates the impact of various pretreatment variables and treatment outcomes on the metastatic spread. In eight phase II chemotherapy trials from 1985 through 1993, 337 patients were treated and 51 autopsies were performed (autopsy rate 15%). The male/female ratio was 31/20, median age 56 years (range 36-71), response rate to chemotherapy 8%, and median survival 88 days (range 3-899). Histologic types included adenocarcinoma, 31 cases (60%), squamous cell carcinoma, 9 cases (18%), large cell carcinoma, 9 cases (18%), and unclassified NSCLC, 2 cases (4%). Patients who were autopsied had a shorter median survival than patients without autopsy (p = 0.002, log-rank test). Most commonly involved metastatic sites found at autopsy were mediastinal lymph nodes (84%), pleura (51%), liver (47%), bone (34%), brain (32%), pericardium (29%), adrenals (29%). The median number of involved organs was 5 (range 1-16), with a median of 3 intrathoracic sites (range 1-8) and 2 extrathoracic sites (range 0-11). Patients who initially had metastatic NSCLC also had significantly more metastatic sites at autopsy both extrathoracic (p = 0.004) and totally (p = 0.03) compared to patients with locally advanced disease. No other relation to pretreatment variables was found.

Risk of malformations and other outcomes in children exposed to fluconazole in utero

AIM

Fluconazole is an active drug systematically used in the oral treatment of vaginal candidiasis and other fungal diseases. We examined the risk of malformations and other birth outcomes following pregnancy related exposures.

METHOD

From 1 January 1991 to 31 December 1996 we identified 165 women who had taken fluconazole just before or during pregnancy in the Pregnancy Outcome Section of the North Jutland Pharmacoepidemiological Prescription Database, Denmark, which is linked to the Danish Medical Birth Registry. We compared their birth outcomes (malformation, low birth weight and preterm delivery) with the outcomes among 13 327 women who did not receive any prescriptions during their pregnancies.

RESULTS

The prevalence of malformation was 3.3% (four cases) among the 121 women, who had used fluconazole in the first trimester, and 5.2% (697 cases) in offspring to controls (odds ratio: 0.65, 95% confidence limits: 0.24-1.77). Furthermore, we did not find any significantly elevated risk of preterm delivery (odds ratio: 1.17, 95% confidence limits: 0.63-2.17) and low birth weight (odds ratio: 1.19, 95% confidence limits: 0.37-3.79).

CONCLUSION

The study showed no increased risk of congenital malformations, low birth weight or preterm birth in offspring to women who had used single dose fluconazole before conception or during pregnancy.

Double-stapled esophagogastric anastomosis for resection of esophagogastric or cardia cancer: new application for an old technique

In colorectal surgery, the double-stapled technique is used extensively, because it is a fairly safe and simple procedure and is useful in relatively inaccessible areas. For these reasons, we adapted the procedure to the upper gastrointestinal tract. The present study reports our first experiences of the surgical efficacy using an esophagogastric double-stapled end-to-end anastomosis for subtotal esophagectomy and cardia resection. We retrospectively studied 31 patients treated between January 1991 and January 1997 with respect to hospital mortality, anastomotic leakage, cancer recurrence, and benign stricture rate. No hospital mortality was seen. One nonfatal anastomotic leak occurred (3%). In three patients, esophageal resection was not radical (10%). Of the remaining 28 patients, one had an anastomotic cancer recurrence (4%). Eleven of the remaining 27 patients (41%) developed a benign anastomotic stricture. All achieved normal swallowing after a median of two endoscopic dilatation procedures using TTS balloons. In conclusion, the double-stapled end-to-end anastomosis technique after resection for esophagogastric or cardia cancer is a simple and expeditious procedure, carrying an acceptable perioperative morbidity and cancer recurrence rate. Larger staplers are recommended to lower the high stricture rate observed after the usage of a 21-mm stapler in this study.

NR1 and NR2 subunit contributions to N-methyl-D-aspartate receptor channel blocker pharmacology

The potencies of various N-methyl-D-aspartate(NMDA) receptor channel blockers were determined at recombinant NMDA receptors containing differing combinations of NR1 and NR2 subunits expressed in Xenopus laevis oocytes. When the NR1 subunit was varied (NR1e/NR2A or NR1b/NR2A), none of the 9 channel blockers tested displayed a statistically different affinity. In contrast, altering NR2 composition changed the affinities of several channel blockers. Three of 10 compounds displayed significantly higher affinities for NR1b/NR2C receptors than NR1b/NR2A receptors, and three of five compounds had higher affinity at NR1b/NR2C than NR1b/NR2B receptors. Both MK-801 and N-[1-(2-thienyl)cyclohyxyl]piperidine displayed identical affinities at all receptor subunit combinations tested. However, these two compounds displayed significantly slower rates of blockade and unblockade at NR1b/NR2C than at NR1b/NR2A receptors, perhaps reflecting the shorter mean open times of NR1/NR2C receptors. NR1b/NR2B and NR1b/NR2A were distinguished by one of five compounds tested. Taken together, these results indicate that NR2 subunits impart differing pharmacological profiles to NMDA receptors; thus, it may be possible to develop NMDA receptor channel blocker antagonists of greater subtype selectivity.

Cementless AGC revision of unicompartmental knee arthroplasty

Twenty-eight patients (29 knees) who had revision of a failed unicompartmental knee arthroplasty to total knee arthroplasty were evaluated. All revisions were made with cementless technique using the AGC prosthesis (Biomet, Warsaw, IN). Major osseous defects were found in 20 knees, and bone-grafting was used to fill the defects. Aseptic loosening and progression of osteoarthrosis were the main reasons for revision. The median follow-up period was 38 months. Twenty knees were excellent or good, four fair, and five poor. One tibial component had been revised because of loosening. Three knees with instability had been reoperated with a thicker polyethylene component, but one of these patients still suffered from instability, and revision with a constrained prosthesis was planned. One was revised after a deep infection. Two tibial components were suspected to be loose because radiographs exposed fluoroscopically revealed a complete radiolucent line under the component. The results with cementless revision and bone-grafting are comparable to the results achieved after cemented revision, and cementless revision is recommended in young patients and in patients with major bone loss.

Brain relapses in chemotherapy-treated small cell lung cancer: a retrospective review of two time-dose regimens of therapeutic brain irradiation

The incidence of brain metastases secondary to small cell lung cancer (SCLC) is about 35% and the treatment strategy of brain irradiation with respect to dose and fractionation is controversial. In order to evaluate treatment outcome of brain irradiation in SCLC patients with brain relapse, we retrospectively evaluated all patients treated with brain irradiation in the eastern part of Denmark from 1988 to 1992 (PCI patients excluded). During this 5-year period, 101 evaluable patients were included (44 females, 57 males) (median age 61 years; range, 39-75 years). Forty-four patients, of whom 43 were in extracerebral complete remission (CR), received extended course (EC) brain irradiation (> 45 Gy, treatment schedule > 4 weeks). Fifty-seven patients received short course (SC) brain irradiation (< 30 Gy, treatment schedule < 1 week). Among the SC treated patients, 14 were in CR, 20 had partial remission or stable disease and 23 had progressive extracerebral disease. The median survival (from diagnosis of brain metastases) in the group receiving irradiation with EC (44 patients) was 160 days (range, 74-2021 days), while the 57 patients treated with SC had a median survival of 88 days (range, 20-948 days) (P = 0.00001, Log-Rank analysis). In a subgroup of 14 patients in extracerebral CR, receiving SC irradiation, the median survival was 83 days (range, 15-948 days). When the latter patients were compared to the 43 patients in CR in the group treated with EC, a statistically significant difference was shown (P = 0.034, Log-Rank analysis). Using Cox-hazard regression analysis with backward elimination, liver metastases and poor performance status were adverse prognostic signs, although the only significant parameters of survival were gender (female vs. male, relative risk of dying 1 and 1.52, P = 0.05) and schedule of brain irradiation (extended course vs. short course, relative risk of dying, 0.36 and 1, P < 0.001). Extended course irradiation of brain relapse secondary to SCLC seems in general to be of limited value, although a significant prolonged survival at approximately 7 weeks, was obtained. The prolongation of survival does not seem worthwhile considering the length of treatment time (5-6 weeks) compared to SC treatment (1 week). However, the data do not permit evaluation of the quality of life of the patients. This retrospective evaluation suggests the need for randomized trials with carefully planned quality-of-life assessments.

Evidence for a further enterotoxin complex produced by Bacillus cereus

Out of 321 strains of Bacillus cereus from several sources and isolated in four different countries, 239 (74%) produced cytotoxins. Only 127 (53%) of the cytotoxic strains were positive for the B-component gene of the haemolysin BL (enterotoxin) by polymerase chain reaction (PCR). Western blots using antiserum produced against enterotoxin(s) gave positive results for 199 (83%) of the cytotoxic B. cereus strains. On closer examination of seven of the strains, involved in food poisoning, we found that two strains completely lacked the L2- and B-components (of the haemolysin BL), and two strains were negative for the B-component gene by PCR, but were positive for the L2-component. From our experiments we concluded that there is at least one enterotoxin complex in addition to the haemolysin BL enterotoxin and enterotoxin T.