Birth outcome following maternal use of fluoroquinolones

Which Antibiotic for Urinary Tract Infections in Pregnancy? A Literature Review of International Guidelines

Urinary tract infection (UTI) is considered to be a major problem in pregnant women. It is also one of the most prevalent infections during pregnancy, being diagnosed in as many as 50-60% of all gestations. Therefore, UTI treatment during pregnancy is extremely important and management guidelines have been published worldwide to assist physicians in selecting the right antibiotic for each patient, taking into account the maternal and fetal safety profile. A review of the literature was carried out and all international guidelines giving recommendations about antibiotic treatments for pregnancy-related UTI were selected. The search came back with 13 guidelines from 4 different continents (8 from Europe, 3 from South America, 1 from North America and 1 from Oceania). Our review demonstrated concordance between guidelines with regard to several aspects in the antibiotic treatment of UTI during pregnancy and in the follow-up after treatment. Nonetheless, there are some areas of discordance, as in the case of antenatal screening for bacteriuria and the use of fluoroquinolones in lower or upper UTI. Given the current evidence that we have from international guidelines, they all agree on several key points about antibiotic use.

Use of medications during pregnancy and breastfeeding for Crohn's disease and ulcerative colitis

Introduction: The peak age of diagnosis of inflammatory bowel disease (IBD) occurs during childbearing years, therefore management of IBD during pregnancy is a frequent occurrence. Maintenance of disease remission is crucial to optimize pregnancy outcomes, and potential maternal or fetal toxicity from medications must be balanced against the risks of untreated IBD.Areas covered: This review summarizes the literature on safety and use of medications for IBD during pregnancy and lactation.Expert opinion: 5-aminosalicylates, corticosteroids and thiopurines are safe for use during pregnancy, while methotrexate and tofacitinib should only be used with extreme caution. Anti-TNF agents (except certolizumab), vedolizumab, ustekinumab and tofacitinib readily traverse the placenta via active transport, therefore theoretically may affect fetal development. Certolizumab only undergoes passive transfer across the placenta, thus has markedly lower cord blood levels making it likely the safest biologic agent for infants. There is reasonable evidence to support the safety of anti-TNF monotherapy and combination therapy during pregnancy and lactation. Vedolizumab and ustekinumab are also thought to be safe in pregnancy and lactation, while tofacitinib is generally avoided due to teratogenic effects in animal studies.

Biogenic Silver Nanoparticles Can Control Toxoplasma gondii Infection in Both Human Trophoblast Cells and Villous Explants

The combination of sulfadiazine and pyrimethamine plus folinic acid is the conventional treatment for congenital toxoplasmosis. However, this classical treatment presents teratogenic effects and bone marrow suppression. In this sense, new therapeutic strategies are necessary to reduce these effects and improve the control of infection. In this context, biogenic silver nanoparticles (AgNp-Bio) appear as a promising alternative since they have antimicrobial, antiviral, and antiparasitic activity. The purpose of this study to investigate the action of AgNp-Bio in BeWo cells, HTR-8/SVneo cells and villous explants and its effects against Toxoplasma gondii infection. Both cells and villous explants were treated with different concentrations of AgNp-Bio or combination of sulfadiazine + pyrimethamine (SDZ + PYZ) in order to verify the viability. After, cells and villi were infected and treated with AgNp-Bio or SDZ + PYZ in different concentrations to ascertain the parasite proliferation and cytokine production profile. AgNp-Bio treatment did not reduce the cell viability and villous explants. Significant reduction was observed in parasite replication in both cells and villous explants treated with silver nanoparticles and classical treatment. The AgNp-Bio treatment increased of IL-4 and IL-10 by BeWo cells, while HTR8/SVneo cells produced macrophage migration inhibitory factor (MIF) and IL-4. In the presence of T. gondii, the treatment induced high levels of MIF production by BeWo cells and IL-6 by HTR8SV/neo. In villous explants, the AgNp-Bio treatment downregulated production of IL-4, IL-6, and IL-8 after infection. In conclusion, AgNp-Bio can decrease T. gondii infection in trophoblast cells and villous explants. Therefore, this treatment demonstrated the ability to reduce the T. gondii proliferation with induction of inflammatory mediators in the cells and independent of mediators in chorionic villus which we consider the use of AgNp-Bio promising in the treatment of toxoplasmosis in BeWo and HTR8/SVneo cell models and in chorionic villi.

Stenotrophomonas maltophilia as an Emerging Ubiquitous Pathogen: Looking Beyond Contemporary Antibiotic Therapy

Stenotrophomonas maltophilia is a commensal and an emerging pathogen earlier noted in broad-spectrum life threatening infections among the vulnerable, but more recently as a pathogen in immunocompetent individuals. The bacteria are consistently being implicated in necrotizing otitis, cutaneous infections including soft tissue infection and keratitis, endocarditis, meningitis, acute respiratory tract infection (RTI), bacteraemia (with/without hematological malignancies), tropical pyomyositis, cystic fibrosis, septic arthritis, among others. S. maltophilia is also an environmental bacteria occurring in water, rhizospheres, as part of the animals' microflora, in foods, and several other microbiota. This review highlights clinical reports on S. maltophilia both as an opportunistic and as true pathogen. Also, biofilm formation as well as quorum sensing, extracellular enzymes, flagella, pili/fimbriae, small colony variant, other virulence or virulence-associated factors, the antibiotic resistance factors, and their implications are considered. Low outer membrane permeability, natural MDR efflux systems, and/or resistance genes, resistance mechanisms like the production of two inducible chromosomally encoded β-lactamases, and lack of carefully compiled patient history are factors that pose great challenges to the S. maltophilia control arsenals. The fluoroquinolone, some tetracycline derivatives and trimethoprim-sulphamethaxole (TMP-SMX) were reported as effective antibiotics with good therapeutic outcome. However, TMP-SMX resistance and allergies to sulfa together with high toxicity of fluoroquinolone are notable setbacks. S. maltophilia's production and sustenance of biofilm by quorum sensing enhance their virulence, resistance to antibiotics and gene transfer, making quorum quenching an imperative step in Stenotrophomonas control. Incorporating several other proven approaches like bioengineered bacteriophage therapy, Epigallocatechin-3-gallate (EGCG), essential oil, nanoemulsions, and use of cationic compounds are promising alternatives which can be incorporated in Stenotrophomonas control arsenal.

Use of antibiotics during pregnancy and the risk of major congenital malformations: a population based cohort study

AIMS

Few studies have investigated the link between individual antibiotics and major congenital malformations (MCMs) including specific malformations owing to small sample size. We aimed to quantify the association between exposure to gestational antibiotic and the risk of MCMs.

METHODS

Using the Quebec pregnancy cohort (1998-2008), we included a total of 139 938 liveborn singleton alive whose mothers were covered by the "Régie de l'assurance maladie du Québec" drug plan for at least 12 months before and during pregnancy. Antibiotic exposure was assessed in the first trimester and MCMs were identified within the first year of life.

RESULTS

After adjusting for potential confounders, clindamycin exposure was associated with an increased risk of MCMs (aOR 1.34, 95% CI 1.02-1.77, 60 exposed cases), musculoskeletal system malformations (aOR 1.67, 95% CI 1.12-2.48, 29 exposed cases) and ventricular/atrial septal defect (aOR 1.81, 95% CI 1.04-3.16, 13 exposed cases). Doxycycline exposure increased the risk of circulatory system malformation, cardiac malformations and ventricular/atrial septal defect (aOR 2.38, 95% CI 1.21-4.67, 9 exposed cases; aOR 2.46, 95% CI 1.21-4.99, 8 exposed cases; aOR 3.19, 95% CI 1.57-6.48, 8 exposed cases, respectively). Additional associations were seen with quinolone (1 defect), moxifloxacin (1 defect), ofloxacin (1 defect), macrolide (1 defect), erythromycin (1 defect) and phenoxymethylpenicillin (1 defect). No link was observed with amoxicillin, cephalosporins and nitrofurantoin. Similar results were found when penicillins were used as the comparator group.

CONCLUSIONS

Clindamycin, doxycycline, quinolones, macrolides and phenoxymethylpenicillin in utero exposure were linked to organ-specific malformations. Amoxicillin, cephalosporins and nitrofurantoin were not associated with MCMs.

Enrofloxacin and Toltrazuril Are Able to Reduce Toxoplasma gondii Growth in Human BeWo Trophoblastic Cells and Villous Explants from Human Third Trimester Pregnancy

Classical treatment for congenital toxoplasmosis is based on combination of sulfadiazine and pyrimethamine plus folinic acid. Due to teratogenic effects and bone marrow suppression caused by pyrimethamine, the establishment of new therapeutic strategies is indispensable to minimize the side effects and improve the control of infection. Previous studies demonstrated that enrofloxacin and toltrazuril reduced the incidence of Neospora caninum and Toxoplasma gondii infection. The aim of the present study was to evaluate the efficacy of enrofloxacin and toltrazuril in the control of T. gondii infection in human trophoblast cells (BeWo line) and in human villous explants from the third trimester. BeWo cells and villous were treated with several concentrations of enrofloxacin, toltrazuril, sulfadiazine, pyrimethamine, or combination of sulfadiazine+pyrimethamine, and the cellular or tissue viability was verified. Next, BeWo cells were infected by T. gondii (2F1 clone or the ME49 strain), whereas villous samples were only infected by the 2F1 clone. Then, infected cells and villous were treated with all antibiotics and the T. gondii intracellular proliferation as well as the cytokine production were analyzed. Finally, we evaluated the direct effect of enrofloxacin and toltrazuril in tachyzoites to verify possible changes in parasite structure. Enrofloxacin and toltrazuril did not decrease the viability of cells and villous in lower concentrations. Both drugs were able to significantly reduce the parasite intracellular proliferation in BeWo cells and villous explants when compared to untreated conditions. Regardless of the T. gondii strain, BeWo cells infected and treated with enrofloxacin or toltrazuril induced high levels of IL-6 and MIF. In villous explants, enrofloxacin induced high MIF production. Finally, the drugs increased the number of unviable parasites and triggered damage to tachyzoite structure. Taken together, it can be concluded that enrofloxacin and toltrazuril are able to control T. gondii infection in BeWo cells and villous explants, probably by a direct action on the host cells and parasites, which leads to modifications of cytokine release and tachyzoite structure.

Managing IBD Therapies in Pregnancy

OPINION STATEMENT

Inflammatory bowel disease is frequently diagnosed before or during key childbearing years. One of the most important factors for a healthy pregnancy is having quiescent disease prior to conception and maintaining disease remission for the duration of the pregnancy. In order to achieve that, most women will need to continue their inflammatory bowel disease (IBD) treatment during pregnancy. One of the main concerns these women have is whether these medications will have adverse effects on their growing fetus. Aminosalicylates, antibiotics, and steroids are all relatively low risk for use during pregnancy and breastfeeding. Recent studies also support the safety of continuing immunomodulators and anti-tumor necrosis factor agents during pregnancy and with breastfeeding. There seems to be an increased risk for infection, however, with use of combination therapy including both a biologic agent and an immunomodulator. Less evidence is available on the use of anti-integrins in pregnancy; however, the current data suggest they may be safe as well. Conversations about a patient's desire for pregnancy should occur between the patient and provider on a regular basis prior to conception and particularly with any change in disease activity or change in the treatment regimen. This chapter will review the current evidence on the safety of IBD medications during pregnancy and lactation so that providers can more easily discuss the importance of medication adherence for disease remission with their patients who are contemplating conception.

Treating Inflammatory Bowel Disease in Pregnancy: The Issues We Face Today

Many women of childbearing age are living with inflammatory bowel disease [IBD], yet there are limited studies on the use of IBD medications in pregnancy. In this review, we provide a comprehensive update on the safety of these medications during pregnancy, particularly thiopurines and biologicals. Antibiotics, steroids, and aminosalicylates are relatively low risk for use in pregnancy, and growing evidence supports the safety of immunomodulators and anti-tumour necrosis factor agents as well. Available studies on infliximab, adalimumab, and certolizumab pegol show no increase in adverse events during pregnancy or perinatally. Similarly, studies on lactation demonstrate that concentrations of subcutaneous anti-tumour necrosis factor biologicals are undetectable, and levels of thiopurines and infliximab are negligible in breast milk. Less is known about anti-integrins in pregnancy [eg natalizumab and vedolizumab] but currently available data suggest they may be safe as well. Although more studies are needed to examine the long-term effects of these medications on offspring, the available data provide reassuring information for providers caring for women of childbearing age.

Urinary tract infections in pregnancy: old and new unresolved diagnostic and therapeutic problems

Urinary tract infections (UTIs) are common in pregnant women and pose a great therapeutic challenge, since the risk of serious complications in both the mother and her child is high. Pregnancy is a state associated with physiological, structural and functional urinary tract changes which promote ascending infections from the urethra. Unlike the general population, all pregnant women should be screened for bacteriuria with urine culture, and asymptomatic bacteriuria must be treated in every case that is diagnosed, as it is an important risk factor for pyelonephritis in this population. The antibiotic chosen should have a good maternal and fetal safety profile. In this paper, current principles of diagnosis and management of UTI in pregnancy are reviewed, and the main problems and controversies are identified and discussed.

IBD medications during pregnancy and lactation

IBD often affects patients during their peak reproductive years. Several drugs are available for the treatment of IBD and new drugs are continuously in the pipeline. As long-term administration of medications is often necessary, the safety of drug therapy during pregnancy and breast-feeding needs to be considered in daily clinical practice. The aim of this Review is to summarize the latest information concerning the safety of medications used to treat IBD during pregnancy and lactation, as well as their effect on fertility. Although only thalidomide and methotrexate are absolutely contraindicated during pregnancy and breast-feeding, alternatives to ciprofloxacin, natalizumab and sodium phosphate should also be considered for pregnant women. Breast-feeding is also discouraged while on treatment with ciclosporin, metronidazole and ciprofloxacin. However, therapy with 5-aminosalicylic acid preparations, glucocorticoids, thiopurines and TNF inhibitors are acceptable during pregnancy and lactation. Pregnant women who have symptomatic IBD or who require therapy should have the opportunity to discuss any associated risks to their pregnancy and infant with the appropriate consultants. By ensuring that the patient and her family are informed, the clinical outcome might be optimized.

Prophylaxis and treatment of anthrax in pregnant women

OBJECTIVE

To review the safety and pharmacokinetics of antimicrobials recommended for anthrax postexposure prophylaxis and treatment in pregnant women.

DATA SOURCES

Articles were identified in the PubMed database from inception through December 2012 by searching the keywords (["pregnancy]" and [generic antibiotic drug name]). Additionally, we searched clinicaltrials.gov and conducted hand searches of references from REPROTOX, TERIS, review articles, and Briggs' Drugs in Pregnancy and Lactation.

METHODS OF STUDY SELECTION

Articles included in the review contain primary data related to the safety and pharmacokinetics among pregnant women of 14 antimicrobials recommended for anthrax postexposure prophylaxis and treatment (amoxicillin, ampicillin, chloramphenicol, clindamycin, ciprofloxacin, doripenem, doxycycline, levofloxacin, linezolid, meropenem, moxifloxacin, penicillin, rifampin, and vancomycin).

TABULATION, INTEGRATION, AND RESULTS

The PubMed search identified 3,850 articles for review. Reference hand searching yielded nine additional articles. In total, 112 articles met the inclusion criteria.

CONCLUSIONS

Overall, safety and pharmacokinetic information is limited for these antimicrobials. Although small increases in risks for certain anomalies have been observed with some antimicrobials recommended for prophylaxis and treatment of anthrax, the absolute risk of these antimicrobials appears low. Given the high morbidity and mortality associated with anthrax, antimicrobials should be dosed appropriately to ensure that antibiotic levels can be achieved and sustained. Dosing adjustments may be necessary for the β-lactam antimicrobials and the fluoroquinolones to achieve therapeutic levels in pregnant women. Data indicate that the β-lactam antimicrobials, the fluoroquinolones, and, to a lesser extent, clindamycin enter the fetal compartment, an important consideration in the treatment of anthrax, because these antimicrobials may provide additional fetal benefit in the second and third trimesters of pregnancy.

Update on pregnancy and breastfeeding in the era of biologics

Inflammatory bowel diseases are chronic conditions that frequently affect patients during their childbearing years. Considering the characteristics of disease and the medications used to treat it, several issues arise in the care of these patients when they attempt or achieve conception. We review the most current evidence concerning fertility and pregnancy outcomes in patients with inflammatory bowel diseases. With the exception of those women who undergo pelvic surgery, patients with inflammatory bowel diseases have no decreased fertility. Sulfasalazine decreases fertility in men. When looking at obstetrical outcomes, active disease at conception is associated with an increased risk of preterm delivery and low birth weight. While most medications used to treat inflammatory bowel diseases are low risk, some precautions need to be taken and the risk-to-benefit ratio needs to be considered on an individualized basis. In general, aminosalicylates and thiopurines should be continued, but methotrexate is contraindicated. Anti-tumour necrosis factor agents are considered safe to continue but full monoclonal antibodies do cross the placenta. As a general rule, the it is important to counsel women that conception is optimal when disease is in remission, as adverse obstetrical outcomes are directly associated with disease activity. Clinicians need to educate patients before, during and after conception, emphasizing treatment compliance.

Pregnancy related issues in inflammatory bowel disease: evidence base and patients' perspective

Inflammatory bowel disease (IBD) affects women of childbearing age and can influence fertility, pregnancy and decisions regarding breastfeeding. Women with IBD need to consider the possible course of disease during pregnancy, the benefits and risks associated with medications required for disease management during pregnancy and breastfeeding and the effects of mode of delivery on their disease. When indicated, aminosalicylates and thiopurines can be safely used during pregnancy. Infliximab and Adalimumab are considered probably safe during the first two trimesters. During the third trimester the placenta can be crossed and caution should be applied. Methotrexate is associated with severe teratogenicity due to its folate antagonism and is strictly contraindicated. Women with IBD tend to deliver earlier than healthy women, but can have a vaginal delivery in most cases. Caesarean sections are generally recommended for women with active perianal disease or after ileo-anal pouch surgery.While the impact of disease activity and medication has been addressed in several studies, there are minimal studies evaluating patients' perspective on these issues. Women's attitudes may influence their decision to have children and can positively or negatively influence the chance of conceiving, and their beliefs regarding therapies may impact on the course of their disease during pregnancy and/or breastfeeding. This review article outlines the impact of IBD and its treatment on pregnancy, and examines the available data on patients' views on this subject.

Inflammatory bowel disease in pregnancy

Crohn disease and ulcerative colitis commonly affect women in their childbearing years. Fortunately, advances in the field of inflammatory bowel disease have made successful pregnancy outcomes a reality for many women. These advances have led to family planning as a common discussion between gastroenterologists and inflammatory bowel disease patients. Common discussion topics are fertility, conception, medication safety, pregnancy, delivery, and breastfeeding although there are limited available data. Education and patient awareness have become vital factors in successful pregnancy outcomes.

Inflammatory bowel disease and pregnancy: an update

Women with inflammatory bowel disease have similar rates of conception to the general population unless they have had pelvic surgery. Once pregnant, regardless of disease activity, they have an increased risk of adverse pregnancy outcome and should be followed as high-risk obstetric patients. Most medications are compatible with pregnancy and lactation, as described in this article. Ideally, women should discuss their plans for pregnancy with their physician prior to conception so that risks and benefits can be reviewed, medications adjusted and healthcare maintenance updated. Once pregnant, a multidisciplinary team of gastroenterologists, obstetricians and pediatricians should help to ensure the best care for the mother and child.

Fluoroquinolone resistance in campylobacter

Campylobacter is a commensal in poultry, and therefore, poultry and poultry products are major sources of Campylobacter infections in humans. Fluoroquinolones inhibit the growth of Campylobacter and other microorganisms by binding to bacterial DNA gyrase and DNA topoisomerase IV. These enzymes are associated with bacterial transcription, replication, and chromosome condensation and segregation. Selection pressure in the presence of fluoroquinolones rapidly leads to resistance in Campylobacter, due to the selection for mutations in DNA gyrase. Fluoroquinolone-resistant campylobacters have been found in poultry feces and carcasses, and in retail poultry meat products in most areas of the world. In addition, other food animals and the meat products from those animals have been shown contaminated with fluoroquinolone-resistant campylobacters. Even the removal of fluoroquinolones from use in treating animal diseases has not entirely eliminated the presence of resistant Campylobacter jejuni and Campylobacter coli from animals and animal products. Human exposure to Campylobacter infection could be reduced by using strategies that decrease colonization of chickens by the pathogen.

Pregnancy and inflammatory bowel disease

This review covers important questions that arise for physicians caring for women with inflammatory bowel disease. Fertility, pregnancy outcomes and the safety of medications in pregnancy and lactation are discussed.

Pregnancy and inflammatory bowel disease

This review covers important questions that arise for physicians caring for women with inflammatory bowel disease. Fertility, pregnancy outcomes and the safety of medications in pregnancy and lactation are discussed.

The safety of quinolones--a meta-analysis of pregnancy outcomes

OBJECTIVE

We conducted a meta-analysis of all published data in order to evaluate the risk for birth defects, stillbirths, preterm births and low birth weight following exposure to quinolones in the first trimester of pregnancy.

STUDY DESIGN

Medline, Embase, Scopus, Biological Abstracts and Proquest Thesis Dissertation databases were searched. Other papers and abstracts were located from the retrieved articles' references, meeting booklets, internet web sites and books on teratology.

RESULTS

Five studies met the inclusion criteria. The summary odds ratio for all the included studies was 1.05 (95% CI 0.90-1.22) for major malformations, 2.6 (95% CI 0.36-18.67) for stillbirths, 1.15 (95% CI 0.69-1.91) for preterm births and 0.73 (95% CI 0.30-1.79) for low birth weight. In an additional analysis including only fluoroquinolones (nalidixic acid was removed), the summary odds ratio for major malformations remained non-significant (1.11, 95% CI 0.57-2.15).

CONCLUSIONS

The use of quinolones during the first trimester of pregnancy does not appear to represent an increased risk for major malformations recognized after birth, stillbirths, preterm births or low birth weight.

Management of the pregnant IBD patient

Women with inflammatory bowel disease (IBD) and the physicians who care for them must make difficult decisions on issues of conception, pregnancy, and breastfeeding with very limited and often contradictory information. This review provides the most current information on the inheritance of IBD, fertility, pregnancy outcomes, the management of disease during pregnancy, and the safety of medications in pregnancy and breastfeeding. We would like to emphasize that the information presented here must be individualized to the specific situation of each patient, their acceptance of risk, and their degree of disease severity.

Pre-travel vaccination and medical prophylaxis in the pregnant traveler

BACKGROUND

Practitioners are often fearful of giving vaccinations and prophylactic medications to pregnant travelers. And yet pregnancy is often a time of heightened danger from travel-related infections and illnesses.

METHOD

Literature search and communication with researchers.

RESULTS

With a few exceptions, there is little systematic research regarding the use of prophylactic medications and vaccines during pregnancy. Case reports and small studies do, however, indicate an increased risk in pregnancy from many of the preventable illnesses, and there is some data to support the use of preventive measures.

CONCLUSIONS

The authors present some non-medical interventions that may be used to limit exposure to a number of disease processes. They then review the available information regarding the safety and efficacy of routine and travel-related vaccines as well as prophylactic medications for malaria, diarrhea, motion sickness and altitude sickness. When there are no obstetrical or medical contraindications, travel-related illness can usually be safely prevented during pregnancy in much the same ways as in the non-pregnant state.

Gastrointestinal medications in pregnancy

Management of the pregnant patient presents unique challenges to the treating physician. Current Food and Drug Administration classifications do not necessarily reflect clinical experience or recent literature. Ideally, one should use the lowest-risk drug possible, with attention to the appropriate level of efficacy for the patient's condition, the stage of pregnancy and dose adjustment. Every treatment decision should be fully discussed with the patient and a multidisciplinary team that should include the obstetrician and, if appropriate, the paediatrician. This review will cover the medications commonly used to treat gastrointestinal disease. The majority of medications can be categorised as 'low risk' or 'should be avoided'. The following medications should never be used during pregnancy due to the clear risk of teratogenicity or adverse events: bismuth, castor oil, sodium bicarbonate, methotrexate, ribavirin, doxycycline, tetracycline, and thalidomide.

Review article: Reproduction in the patient with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) affects mainly the young population. The effect of IBD and its treatment on fertility and pregnancy is therefore an important clinical consideration.

AIM

To review the best management of IBD in the reproductive and pregnant population.

METHODS

A MEDLINE and an EMBASE search were performed using mainly the search phrases 'pregnancy AND IBD,''sulphasalazine AND male fertility,''abdominal surgery AND female fertility,''AZA AND placenta' and 'infliximab AND pregnancy.' No language or date restrictions were placed. References of review articles were examined.

RESULTS

Overall male and female fertility are not affected by IBD. Sulphasalzine reduces male fertility. No other drugs used in IBD affect significantly fertility in humans. The risk of pregnancy-related complications and the disease behaviour during pregnancy depends mainly on disease activity at time of conception. Proactive treatment for maintenance of disease remission during gestation is recommended. Except for methotrexate, drugs used in IBD appear safe in pregnancy. Breast feeding should be encouraged.

CONCLUSION

The management of IBD in the young and pregnant population remains controversial because the literature comes mostly from retrospective studies. Further studies particularly large prospective trials are needed to guide clinicians in decision making.

[Urinary tract infection in pregnancy]

Urinary tract infections, asymptomatic bacteriuria (AB), acute cystitis (AC) and acute pyelonephritis (AP), are favored by the morphological and functional changes involved in pregnancy. AB increases the risk of preterm labor, low birth weight and AP. AB should be detected by uroculture (other methods are not sufficiently effective) and treated early. Approximately 80% of cases are caused by Escherichia coli. The risks and effectiveness of the distinct antibiotic regimens should be evaluated: fosfomycin trometamol in monotherapy or as short course therapy is safe and effective for the treatment of AB and AC. AP is the most frequent cause of hospital admission for medical reasons in pregnant women and can lead to complications in 10% of cases, putting the lives of the mother and fetus at risk. Currently outpatient treatment of AP is recommended in selected cases. Adequate follow-up of pregnant women with urinary tract infections is required due to frequent recurrence.

American gastroenterological association institute technical review on the use of gastrointestinal medications in pregnancy

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on February 22, 2006 and by the AGA Institute Governing Board on April 20, 2006.

Further analysis of the risk of adverse birth outcome after maternal use of fluoroquinolones

In a database cohort study, the risk of adverse birth outcome in Danish women who redeemed a fluoroquinolone prescription during pregnancy was examined. Among 87 women who redeemed a fluoroquinolone prescription at any time during the pregnancy, the prevalence ratio of preterm birth was 1.4 (95% confidence interval (CI), 0.6-3.2), one woman had a stillbirth, and no children died during the perinatal period. Among 130 women who redeemed a prescription during the first trimester or 30 days before conception, the prevalence ratio of congenital malformation was 0.7 (95% CI, 0.3-2.0) and the prevalence ratio of bone malformations was 2.2 (95% CI, 0.7-6.7). Our study raises the concern that prenatal fluoroquinolone exposure may be associated with an increased risk of bone malformations.

Drugs that affect the fetus and newborn infant via the placenta or breast milk

In general, drugs that are taken by a mother during pregnancy or after birth may be transferred to the fetus or the infant (through breast milk). Many factors are involved that determine the amount of drugs that are transferred and their potential effects on the fetus or infant. A careful assessment of the risk versus benefit is necessary and should be individualized. In the breastfed infant, many measures can be undertaken further so that the amount of drug transferred to the infant is minimized.