Pregnancy outcome following gestational exposure to fluoroquinolones: a multicenter prospective controlled study

Concerns regarding the teratogenicity of fluoroquinolones have resulted in their restricted use during gestation. This is despite an increasing need for their use due to emerging bacterial resistance. The objectives of the present investigation were to evaluate pregnancy and fetal outcomes following maternal exposure to fluoroquinolones and to examine whether in utero exposure to quinolones is associated with clinically significant musculoskeletal dysfunctions. We prospectively enrolled and followed up 200 women exposed to fluoroquinolones (norfloxacin, ciprofloxacin, ofloxacin) during gestation. Pregnancy outcome was compared with that for 200 controls matched for age and for smoking and alcohol consumption habits. Controls were exposed to nonteratogenic, nonembryotoxic antimicrobial agents matched by indication, duration of therapy (+/- 3 days), and trimester of exposure. Rates of major congenital malformations did not differ between the group exposed to quinolones in the first trimester (2.2%) and the control group (2.6%) (relative risk, 0.85; 95% confidence interval, 0.21 to 3.49). Women treated with quinolones had a tendency for an increased rate of therapeutic abortions compared with the rate among women exposed to nonteratogens (relative risk, 4.50; 95% confidence interval, 0.98 to 20.57), resulting in lower live-birth rates (86 versus 94%; P = 0.02). The rates of spontaneous abortions, fetal distress, and prematurity and the birth weight did not differ between the groups. Gross motor developmental milestone achievements did not differ between the children of the mothers in the two groups. We concluded that the use of fluoroquinolones during embryogenesis is not associated with an increased risk of major malformations. There were no clinically significant musculoskeletal dysfunctions in children exposed to fluoroquinolones in utero. The higher rate of therapeutic abortions observed in quinolone-exposed women compared to that for their controls may be secondary to the misperception of a major risk related to quinolone use during pregnancy.

[Therapeutic abortion. Critical study of 22 cases]

The abortion for medical reasons is the only abortion allowed in Morocco and it aims to preserve maternal health or to forewarn the birth of handicaped children. The author has ascribed 22 cases of medical abortion, their indications have maternal origin in 91% cases. In europeans series the indication have 80% of foetal origin. In order to change the profil of our indications, the author insists on the necessity to program the pregnancy in maternal pathology, to eliminate an early, pregnancy before any therapeutical act and to encourage antenatal diagnosis according to legal dispositions.

The prescription of isotretinoin to women: is every precaution taken?

A questionnaire survey of dermatologists practising in Scotland was carried out to assess strategies for the management of women prescribed isotretinoin for acne. The results of the study suggested that the prevention of pregnancy during treatment is of considerable concern to dermatologists: over 90% routinely asked women about sexual activity and 97% routinely gave both verbal and written advice on the need to avoid pregnancy during treatment. However, clinical practices which might place women at risk of pregnancy were identified: only 30% of trainees and 51% of consultants routinely carried out pregnancy tests before treatment, and when tests were carried out, there was a tendency to rely on potentially insensitive urine assays. Additionally, there was an apparent lack of recognition of the possibility of sexual activity in girls aged under 16 years. Suggestions for the management of women prescribed isotretinoin include taking a sexual history from all women; providing clear information on the need to avoid pregnancy during treatment; obtaining informed consent prior to treatment; recommending the use of effective contraceptive measures; and exclusion of pregnancy prior to treatment by means of a suitably timed blood or urine sample and sensitive assay technique.

[Epidemiology of prenatal diagnosis and selective pregnancy termination because of fetal neural tube defects in The Netherlands in comparison to other European countries]

OBJECTIVE

To describe the epidemiological impact of prenatal diagnosis and selective abortion on the frequency of neural tube defects (NTD) in the period 1980-1992 in the Northern Netherlands in comparison with data from other European regions.

DESIGN

Descriptive.

SETTING

17 'European registration of congenital anomalies' (EUROCAT) registrations, localized in 10 European countries.

METHOD

Data were collected actively and retrospectively from multiple sources fed by voluntary registration of congenital anomalies in live births, stillbirths and pregnancies terminated because of congenital anomalies.

RESULTS

In Europe the total birth prevalence of NTD in the period 1980-1992 ranged from 5.3 per 10,000 in Switzerland to 29.0 per 10,000 in Glasgow, a difference of a factor 5.5. In live births the difference was ninefold: ranging from 2.0 per 10,000 in Paris to 18.8 per 10,000 in Dublin. The Netherlands had a conspicuously high prevalence among live births, higher than in other regions in continental Europe. For spina bifida the live birth prevalence both in other continental regions and in Glasgow was also lower than in the Netherlands. In Glasgow serum alpha-foetoprotein screening apparently led to frequent early prenatal diagnosis of NTD and to frequent termination of pregnancy. In Paris the use of ultrasound screening appears to lead to frequent later prenatal diagnosis, as well as frequent termination of pregnancy.

CONCLUSION

In the Netherlands the impact of prenatal diagnosis and selective abortion is limited, so that primary prevention (periconceptional use of folic acid) is more important than in some other European countries.

The influence of prenatal ultrasound on the prevalence of congenital anomalies at birth

The objectives of the study were (1) to assess whether prenatal ultrasound examinations affected the prevalence of congenital anomalies at birth and the incidence of terminations of pregnancy for fetal anomalies and (2) to examine the detection rate of the main fetal anomalies. We studied all births and stillbirths with congenital defects, and all terminations of pregnancy for fetal anomalies in the Rambam Medical Center during a 5-year period (1989-1993) and correlated them to ultrasound findings. There were 23439 births during the study period. The incidence of newborns with anomalies decreased from 1.95 to 1.34 per cent (P < 0.01). The incidence of termination of pregnancy because of fetal anomalies increased from 0.35 to 0.83 per cent (P < 0.003) and the detection rate of malformations increased from 53.94 to 79.60 per cent (P < 0.001). It is concluded that terminations of pregnancy after ultrasound detection of fetal anomalies had an impact on the prevalence of anomalies in newborns. There was also continuing significant improvement in the detection rate of ultrasound examinations.

Prospective controlled study of hydroxyzine and cetirizine in pregnancy

BACKGROUND

Hydroxyzine has been used for many years for the treatment of allergic symptoms. Cetirizine, an active metabolite of hydroxyzine, has become very popular for the treatment of allergy symptoms because of its efficacy without the sedating effects of the parent compound. Little is known about the safety of hydroxyzine use during pregnancy, and there are no published reports on the effects of cetirizine on pregnancy outcome.

OBJECTIVE

To determine whether hydroxyzine and cetirizine are associated with any increased risk of malformations in humans.

METHODS

All pregnant women counseled by the Motherisk Program in Toronto on the use of hydroxyzine or cetirizine during their pregnancies were enrolled in a prospective, controlled, observational study. The control group consisted of pregnant women matched for age, smoking, and alcohol consumption who were counseled for non-teratogenic drug.

RESULTS

One hundred twenty women were followed after exposure to either hydroxyzine or cetirizine during pregnancy. Of these, 53 were exposed to hydroxyzine during organogenesis and 39 to cetirizine. There were no significant differences found between the hydroxyzine or cetirizine groups and the control groups in the pregnancy outcome: rate of livebirths, spontaneous or therapeutic abortion, or stillbirth. There was also no difference in the rates of major or minor anomalies, mean birth weight, mode of delivery, gestational age, or presence of neonatal distress.

CONCLUSIONS

The use of hydroxyzine and cetirizine does not appear to be associated with increased teratogenic risk.

[Perinatal mortality in Denmark. An analysis of development assessed in connection with medically induced abortion during the period 1980-1993]

Based upon data from the Danish National Register of Causes of Deaths, the Birth Register and registers on induced abortions and congenital malformations the article analyses the trend in the Danish perinatal mortality and the impact of abortions induced on medical grounds during the period 1980-1993. Estimating that half of the induced abortions might have led to a perinatal death it is concluded that the perinatal mortality would still have been significantly reduced from the late 1980s to 1990-1993. It is stressed that the impact of induced abortions be included in analyses of trends in perinatal mortality. The perinatal deaths are classified in nine categories by which a grouping into non-avoidable (unexplained intrauterine deaths and deaths due to congenital birth defects) and avoidable deaths (all other categories) was possible. The classification mixed pathoanatomical, obstetrical and paediatric criteria and facilitated an evaluation of the trend in mortality in relation to health care. The recent decrease in the overall perinatal mortality to 7.5 per 1.000 born was both due to a fall in deaths caused by prematurity and in deaths due to congenital birth defects. The deaths due to prematurity were not significantly linked to maternal smoking during pregnancy and no differences could be found in the overall prenatal screening between mothers who lost a baby due to malformations and all mothers.

Health of children born to medical radiographers

OBJECTIVES

To develop a reliable method for collecting information on reproductive outcome in an occupational setting; and to investigate the health of children born to medical radiographers.

METHODS

The study population comprised 6730 members of the College of Radiographers who were, at the time of survey; aged between 30 and 64 years, on the current membership file of the College, and were resident in Britain.

RESULTS

The postal method developed proved to be reliable, with around 87% of questionnaires being returned. The observed frequencies of reproductive events were broadly in line with findings from other studies: of the 9208 pregnancies reported, 83% were livebirths, 12% were miscarriages (gestational age < 20 weeks), 1% were stillbirths (gestational age > or = 20 weeks), and 1% were other rarer spontaneous adverse events (ectopic pregnancy, blighted ovum, and hydatidiform mole). There was little difference between men and women in the frequency of adverse reproductive events reported, with the exception that male radiographers reported fewer medical terminations, the proportions being 3.1% and 1.4% for women and men respectively. Among children, the overall risks of major congenital malformation (RR 1.0, 95%CI 0.9-1.2), chromosomal anomaly (RR 1.4, 95%CI 0.8-2.3), and cancer (RR 1.2 95%CI 0.7-2.0) were as expected based on general population rates. Borderline excesses of chromosomal anomalies other than Down's syndrome in the children of female radiographers (RR 3.9, 95%CI 1.3-9.0, based on five observations), and cancer in the children of male radiographers (RR 2.7, 95%CI 0.9-6.5, based on five observations) were noted. The numbers on which these risks are based are small and the findings should be interpreted cautiously.

CONCLUSIONS

The postal methods developed for obtaining information about reproductive events and child health proved to be reliable in men, as well as in women. Overall, the findings for medical radiographers are reassuring. Dose-response relations could not, however, be examined as long term dose records of radiographers are not routinely kept in an accessible form.

[Epidemiological study of intestinal atresias: central-eastern France Registry 1976-1992]

OBJECTIVE

Our purpose was to describe the epidemiology of small intestinal atresia.

STUDY DESIGN

We used data collected by the Central-East France Congenital Malformations Registry from 1976 through 1992 to evaluate the prevalence of different types of intestinal atresia in liveborn and stillborn infants and to study some demographic and clinical features such as sex ratio, multiple births, gestational age, birth weight, maternal age, maternal disease, associated malformations.

RESULTS

Through surveillance of more than 1.5 million births, we identified 344 liveborn and 14 stillborn infants with intestinal atresia (1A). The prevalence of 1A was 2.25 per 10,000 livebirths. Fifty percent of the liveborn infants had duodenal atresia, 36% had jejunoileal atresia, 7% had colic atresia, 3% had intestinal duplication and 5% had multiple atresia. The twinning rate was 4.4% which is significantly higher than in the non malformed population. Gestational age was less than 37 weeks in 35.4% of the cases. Birth weight was less than 2,500 g in 52% of the cases. For those two variables we observed significant differences among the different types of malformations. Study of 1A rates by maternal age showed an increased risk below the age of 20 (p < 10(-5)). We didn't find significant differences compared to the population for ovulation induction and maternal diabetes. Study of associated malformations demonstrated significant differences in rates and types of associated malformations in the different groups of 1A which suggests heterogenous embryological mechanisms.

CONCLUSION

These findings confirm the literature data for most of the epidemiological characteristics. Only the association of an increased risk in the teenage mothers group was not previously described. This finding has to be confirmed by others studies.

Small-area variations in utilization of abortion services in Ontario from 1985 to 1992

OBJECTIVE

To assess interregional differences in the utilization of abortion services in Ontario from 1985 to 1992.

DESIGN

Retrospective analysis of provincial therapeutic abortion database.

SETTING

All hospitals conducting abortions between 1985 and 1992 and all free-standing abortion clinics conducting abortions between 1990 and 1992.

POPULATION

All women in Ontario aged 15 to 44 years who underwent a therapeutic abortion in Ontario during the study period.

OUTCOME MEASURES

Utilization of abortion services by county and age-specific abortion rates by county of residence.

RESULTS

From 1985 to 1989, when only hospital data were gathered, the mean therapeutic abortion rate increased by 11.2%. From 1990 to 1992, when data from hospitals and free-standing clinics were collected, the mean rate increased by 26.5%. Logistic regression analysis showed significant variation in the age-standardized abortion rates between counties in each study year (p < 0.0001). The counties with age-standardized rates below the 25th percentile had the highest proportions of women who sought abortion services outside their county of residence; in some of these counties no abortions were performed in local facilities.

CONCLUSION

There are interregional variations in the utilization of abortion services in Ontario. These disparities raise questions about the accessibility of abortion services and need to be further investigated.

[Monitoring of pregnancy in HIV seropositive women]

The management of pregnancy in a seropositive woman implies awareness of the effects of the disease on pregnancy and, inversely, of the pregnancy on HIV infection. It is important to be aware of the risk of materno-fetal transmission, as well as of the recent positive results of therapeutic trials of AZT during pregnancy regarding the prevention of such transmission. This quite stereotyped management approach is relatively simple, both clinically and regarding laboratory investigations, and in particular when the patient is at an asymptomatic stage of the disease. Obstetric management is, for the present, the same as in normal women. It is important to stress the need for specialised management of the newborn infant and of taking advantage of the postpartum period to ensure future effective contraception.

Multifetal pregnancy reduction in Sweden. Utilization rate and pregnancy outcome (1986-1992)

All departments of Obstetrics and Gynecology, as well as all private clinics in Sweden offering assisted conception, were surveyed by means of a questionnaire to determine the utilization rate and outcome of multifetal pregnancy reduction (MFR) for the period 1 January 1986 to 30 June 1992. The response rae was 100%. Multifetal reduction was performed in 26 women, giving an average utilization rate of 1/7 multiple births of three or more for the entire period. Of the various techniques used, intracardiac or intrathoracic injection of a potassium chloride solution was predominant. The experience of each center with multifetal reductions varied between one and six procedures. In this series, the overall complete pregnancy loss was 27% (n = 7). In 73% (n = 19) of women the pregnancy continued to delivery. One fetus died in utero in the second trimester, one child died from a subtentorial hemorrhage perinatally, and one child had a malformation of the right foot and hand. It seems necessary to limit MFR to a few centers in Sweden in order to maintain and increase the experience of the operators involved, and to decrease the fetal loss rate associated with the procedure. However, the ultimate goal is to make these procedures unnecessary when methods of avoiding excessive ovulation are refined and by limiting the number of replaced embryos in IVF-treatment.

Ultrasound detection of fetal structural abnormalities in Auckland 1988-9

AIMS

To conduct an audit of ultrasound screening for fetal abnormalities in central Auckland 1988-89.

METHOD

All babies born at National Women's Hospital in the time period were examined and fetal abnormalities coded on to a computer database. All terminations of pregnancy for fetal abnormality in the area were similarly audited.

RESULTS

There were 12,909 births. 218 babies had a congenital abnormality of whom 88% were scanned antenatally. 48% of abnormalities were detected (27% before 24 weeks). In fetuses that were scanned the detection rate was 52% (44% before 24 weeks). The range of detection of specific abnormalities included neural tube defects 95% and congenital heart defects 16%.

CONCLUSIONS

1. Major abnormalities of the central nervous system, renal tract and abdominal wall have a high detection rate. 2. Cardiovascular, facial and gastrointestinal abnormalities are either not detectable or difficult to detect. 3. Detection rates could be improved by routine scanning, better ultrasound equipment and training, and by the introduction of maternal biochemical screening tests. 4. The detection rate is similar to other overseas surveys.

[Chorionic villus needle sampling by the transabdominal route or by placental centesis. A series of 930 cases]

The authors report on a series of 930 chorion villus sampling diagnoses made with a needle by the transabdominal route, from January 1991 to October 1992 at the Prenatal Diagnosis Center in Marseille. Indications for prenatal diagnosis were: raised maternal age in 75% of cases (N:698); ultrasound findings in 11% (N:106), chromosome abnormalities in the family in 6% cases (N:53), raised human chorionic gonadotrophin in 4% cases (N:38), parental rearrangement in 2% cases (N:20), and sex linked disease in 1% (N:15). The success rate was 97% with 29 failures; the number of needle insertions was one in 97% cases and two in 3% cases. The average gestational age at sampling was related to the indications; 16 weeks of amenorrhoea for raised maternal age, and 22 weeks of amenorrhoea for ultrasound findings. Thirty one abnormalities were observed, four balanced translocations, and seven placental mosaicisms. Forty eight pregnancies terminated in abortion. The rate of fetal loss was 3.5% (7 cases) for the 200 first cases and 1% (8 cases) for the 730 following cases. Choriocentesis through the transabdominal route provides a diagnosis within a few days and the rate of fetal loss is close to that of amniocentesis. These arguments are in favour of an extension of this method of sampling.

Chorionic villus sampling in Auckland 1989-90

AIMS

to perform an audit of all 197 chorionic villus sampling procedures performed in Auckland in 1989-90.

METHOD

an attempt to trace the outcome in all 197 cases and this was possible in 188 cases.

RESULTS

89% of chorionic villus samples were performed transvaginally and 11% transabdominally. The total fetal loss rate was 9.6% (18) with six spontaneous miscarriages before 20 weeks gestation (3.2%), one intermediate fetal death and one neonatal death. There were 10 elective terminations of pregnancy following abnormal results so the spontaneous loss rate was 4.3%.

CONCLUSIONS

the loss rate was lower than that reported in the European and Canadian multicentre trials. The sampling success rate, however, was poor with 13.7% failed procedures. This improved in the second year of the service to 10%. There were no failure cultures or examples of mosaicism.

Medically indigent women seeking abortion prior to legalization: New York City, 1969-1970

If the efforts now underway to limit access to abortion services in the United States are successful, their greatest impact will be on women who lack the funds to obtain abortions elsewhere. There is little published information, however, about the experience of medically indigent women who sought abortions under the old, restrictive state laws. This article details the psychiatric evaluation of 199 women requesting a therapeutic abortion at a large municipal hospital in New York City under a restrictive abortion law. Thirty-nine percent had tried to abort the pregnancy. Fifty-seven percent had concrete evidence of serious psychiatric disorder. Forty-eight percent had been traumatized by severe family disruption, gross emotional deprivation or abuse during childhood. Seventy-nine percent lacked emotional support from the man responsible for the pregnancy, and the majority were experiencing overwhelming stress from the interplay of multiple problems exacerbated by their unwanted pregnancy.

Gynaecologists' abortion practice

OBJECTIVE

To ascertain the relation between gynaecologists' opinions on the provision of abortion and the service provided by the Health Service in their district and to investigate the methods used for second trimester abortion.

DESIGN AND SETTING

A postal questionnaire sent three times to a 50% random sample of gynaecologists practising in the National Health Service (NHS) in 1989 in Great Britain.

SUBJECTS

343 of 396 practising gynaecologists, 87% of those selected.

MAIN OUTCOME MEASURES

Proportion of gynaecologists holding views or reporting practice.

RESULTS

Although only 11% actually performed abortions beyond 20 weeks, 57% approved later operations in cases of rape and 85% for a threat to the woman's health; only 47% approved late abortion for schoolgirls under 16 years. Dilatation and evacuation was used by only 1% of NHS gynaecologists even though from 13 to 16 weeks it is a safe and efficient method. Although Government statistics report that vacuum aspiration is used in over one third of second trimester abortions, this is technically unlikely and was not confirmed by this study. Less than 50% of abortions in England and Wales are performed in the NHS yet fewer than 40% of gynaecologists reported problems in providing an abortion service. Overall 21% thought they were providing abortions for over 90% of the women resident in their districts, whereas only 2% of districts achieve this proportion in their home regional health authority. Overall 60% supported separating abortion work from general gynaecology, and 45% would like regional abortion units. Only 27% supported fertility control acquiring the status of a subspecialty.

CONCLUSIONS

Accepting these suggestions would improve the service, reduce regional variations in provision, provide opportunities for research and could have an important effect in helping slow the world population increase.

[Medical interruption of pregnancy. Indications and techniques. Critical study and reflections on 324 cases]

A retrospective study of 324 cases highlights the difficulties encountered in identifying indications for medical pregnancy terminations (MPTs) which are permitted by French law and medically justified. In addition, the ethical problems raised do not facilitate the decision to opt for a MPT, which must be made by a multi-disciplinary committee. The methods used to evaluate the pregnancy are largely surgical during the first three months, and these are succeeded during the next six months by medical methods involving the use of synthetic prostaglandins. The complications which may occur are far from minor. The various protocols used by the authors are described together with their results and complications.