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Wlodarczyk BJ, Palacios AM, George TM, Finnell RH. Antiepileptic drugs and pregnancy outcomes. Am J Med Genet A 2012; 158A:2071-90. [PMID: 22711424 PMCID: PMC3402584 DOI: 10.1002/ajmg.a.35438] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 03/16/2012] [Indexed: 11/09/2022]
Abstract
The treatment of epilepsy in women of reproductive age remains a clinical challenge. While most women with epilepsy (WWE) require anticonvulsant drugs for adequate control of their seizures, the teratogenicity associated with some antiepileptic drugs (AEDs) is a risk that needs to be carefully addressed. Antiepileptic medications are also used to treat an ever broadening range of medical conditions such as bipolar disorder, migraine prophylaxis, cancer, and neuropathic pain. Despite the fact that the majority of pregnancies of WWE who are receiving pharmacological treatment are normal, studies have demonstrated that the risk of having a pregnancy complicated by a major congenital malformation is doubled when comparing the risk of untreated pregnancies. Furthermore, when AEDs are used in polytherapy regimens, the risk is tripled, especially when valproic acid (VPA) is included. However, it should be noted that the risks are specific for each anticonvulsant drug. Some investigations have suggested that the risk of teratogenicity is increased in a dose-dependent manner. More recent studies have reported that in utero exposure to AEDs can have detrimental effects on the cognitive functions and language skills in later stages of life. In fact, the FDA just issued a safety announcement on the impact of VPA on cognition (Safety Announcement 6-30-2011). The purpose of this document is to review the most commonly used compounds in the treatment of WWE, and to provide information on the latest experimental and human epidemiological studies of the effects of AEDs in the exposed embryos.
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Affiliation(s)
- Bogdan J Wlodarczyk
- Department of Nutritional Sciences, Dell Pediatric Research Institute, The University of Texas at Austin, Austin, Texas 78723, USA.
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Hill DS, Wlodarczyk BJ, Palacios AM, Finnell RH. Teratogenic effects of antiepileptic drugs. Expert Rev Neurother 2010; 10:943-59. [PMID: 20518610 DOI: 10.1586/ern.10.57] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Many antiepileptic drugs (AEDs) have therapeutic applications that extend beyond epilepsy to include neuropathic pain, migraine headaches and psychiatric disorders. The risk of some AEDs has been clearly established, but for newer drugs, small sample sizes and polytherapy exposures preclude a conclusive determination of their teratogenic potential. Most women with epilepsy will require AED therapy throughout their entire pregnancy to control seizures; the vast majority of pregnancies in women with epilepsy have positive outcomes. A conservative estimate suggests that AED monotherapy doubles, and polytherapy triples, the risk for major congenital malformations. Furthermore, while evidence is still accruing, recent investigations suggest that exposure to select AEDs results in altered cognitive function later in development. There is no evidence to suggest that additional folic acid supplementation ameliorates the increased risk of congenital malformations conferred by in utero AED exposure.
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Affiliation(s)
- Denise S Hill
- Texas A&M Health Science Center, Houston, TX 77030, USA
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Malaeb SN, Hovanesian V, Sarasin MD, Hartmann SM, Sadowska GB, Stonestreet BS. Effects of maternal antenatal glucocorticoid treatment on apoptosis in the ovine fetal cerebral cortex. J Neurosci Res 2009; 87:179-89. [PMID: 18711727 DOI: 10.1002/jnr.21825] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We examined the effects of single and multiple maternal glucocorticoid courses on apoptosis in the cerebral cortices of ovine fetuses (CC). Ewes received single dexamethasone or placebo courses at 104-106 or 133-135 days or multiple courses between 76-78 and 104-106 days gestation. In the single-course groups, ewes received four 6 mg dexamethasone or placebo injections every 12 hr for 48 hr. Multiple-course groups received the same treatment once per week for 5 weeks. Neuronal and nonneuronal apoptotic cell numbers per square millimeter were determined with TUNEL and NeuN staining and with caspase-3 enzyme activity on CC tissues harvested at 106-108 (70%) or 135-137 (90%) days of gestation. Apoptotic cell numbers and caspase-3 activity were 50% lower (P < 0.02) after single placebo courses at 90% than 70% gestation; 90% of apoptotic cells were (P < 0.01) nonneuronal at both ages. Nonneuronal apoptotic cells and caspase-3 activity were 40% and 20% lower (P < 0.02) after single dexamethasone than placebo courses at 70%, but not 90%, gestation. Caspase-3 activity was 20% lower (P < 0.01) after multiple dexamethasone than placebo courses, but apoptotic cell number did not differ. We conclude that nonneuronal apoptosis represents the major form of apoptosis in the CC at both 70% and 90% of gestation. Apoptosis in nonneuronal cells decreases with maturity and after a single course of dexamethasone at 70%, but not at 90%, gestation and not after multiple courses at 70% gestation. We speculate that a single course of glucocorticoids exerts maturational changes on the rate of apoptosis in the cerebral cortex of preterm ovine fetuses.
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Affiliation(s)
- Shadi N Malaeb
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island 02905, USA
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Mehter NS, Sadowska GB, Malaeb SN, Stonestreet BS. Na+, K+-ATPase activity and subunit isoform protein abundance: effects of antenatal glucocorticoids in the frontal cerebral cortex and renal cortex of ovine fetuses. Reprod Sci 2008; 16:294-307. [PMID: 19001554 DOI: 10.1177/1933719108325507] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We examined the effects of single and multiple maternal glucocorticoid courses on cerebral cortical (CC) and renal cortical (RC) Na(+),K(+)-ATPase activity and protein isoform abundance in fetal sheep. Ewes received four dexamethasone or placebo injections in the single course (SC) groups, and the same treatment once a week for five-weeks in the multiple course (MC) groups. CC Na(+),K(+)-ATPase a(2)-abundance was higher (P<0.05) and beta(2)-abundance lower in the SC dexamethasone than placebo group, but Na(+),K(+)-ATPase activity did not change. CC Na(+),K(+)-ATPase activity, a(1)-, beta(1) -, and beta(2)-abundance were lower in the MC dexamethasone than placebo group, but a(2)- and a(3)-abundance did not change. Both dexamethasone courses did not affect CC cell number. RC Na(+),K(+)-ATPase activity, a(1)- and beta(1) -abundance were higher in the MC dexamethasone than placebo group, but did not change in the SC dexamethasone group. We conclude MC, but not a SC of dexamethasone, affect fetal cerebral and renal Na(+),K(+)-ATPase, and MC result in differential effects on Na(+),K(+)-ATPase in these organs.
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Affiliation(s)
- Najma S Mehter
- Warren Alpert Medical School of Brown University, Department of Pediatrics, Women & Infants' Hospital of Rhode Island, Providence, Rhode Island 02905, USA
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Young IR, Rice GE, Palliser HK, Ayhan M, Dellios NL, Hirst JJ. Identification of bactenecin-1 in cervicovaginal fluid by two-dimensional electrophoresis in an ovine model of preterm labour. Proteomics 2007; 7:281-8. [PMID: 17205609 DOI: 10.1002/pmic.200500705] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Preterm labour is a major problem in obstetrics. Timely intervention with available treatments is hampered by the lack of a reliable test of imminent preterm delivery. Current methods of diagnosis are based on the detection of breakdown products of foetal membranes or structural changes to the cervix when preterm labour is well established. The aim of this study was to screen the cervicovaginal fluid (CVF) proteome to identify labour-associated proteins that could be used as markers of imminent preterm delivery. Labour was induced in sheep at 135 days of gestation (term 147 days) by foetal infusion of dexamethasone (1 mg/24 h). CVF samples were collected before and 28 h after the start of infusion as well as at delivery (58.7 +/- 1.9 after the start of infusion, n = 5). One protein that was upregulated eight-fold, was bactenecin-1, a member of the cathelicidin family of antimicrobial proteins. This antimicrobial protein warrants further investigation as a marker of preterm labour, particularly during the period after the initiation of labour but before there is marked cervical connective tissue breakdown.
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Affiliation(s)
- I Ross Young
- Department of Physiology, Monash University, Victoria, Australia.
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Sadowska GB, Patlak CS, Petersson KH, Stonestreet BS. Effects of multiple courses of antenatal corticosteroids on blood-brain barrier permeability in the ovine fetus. ACTA ACUST UNITED AC 2006; 13:248-55. [PMID: 16697940 DOI: 10.1016/j.jsgi.2006.02.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To test the hypothesis that multiple courses of antenatal corticosteroids accentuate the decreases in blood-brain barrier permeability observed after a single course of corticosteroids in preterm ovine fetuses. METHODS Chronically instrumented 106-day gestation ovine fetuses were studied after single and multiple courses of dexamethasone or placebo were given to ewes beginning at 104 to 106 or 76 to 78 days of gestation, respectively. In the single-course groups, the ewes received dexamethasone (6 mg, n = 6) or placebo (n = 6) as four intramuscular injections every 12 hours over 48 hours. In the multiple course groups, the ewes received the same treatment (dexamethasone, n = 9, or placebo, n = 8), once per week for 5 weeks starting at 76 to 78 days of gestation. Blood-brain barrier permeability was quantified with the blood-to-brain transfer constant (K(i)) for alpha-aminoisobutyric acid (AIB) in the brain regions of the fetuses 12 hours after the last injection of dexamethasone was given to the ewes at 106 to 107 days of gestation. RESULTS Both single (analysis of variance [ANOVA]; main effects for dexamethasone treatment, F = 5.92, P <.04) and multiple (ANOVA; main effects for dexamethasone treatment, F = 4.74, P <.04) courses of antenatal corticosteroids were associated with decreases in blood-brain barrier permeability in the brain regions of the ovine fetus. However, the multiple courses did not accentuate (ANOVA; main effects for single versus multiple courses, F = 1.06, P = .32) the decreases in permeability observed after a single course. CONCLUSION Contrary to our hypothesis, antenatal treatment with a 5-week course of corticosteroids did not accentuate the reductions in blood-brain barrier permeability that we observed after a single course of corticosteroids in the fetus.
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Affiliation(s)
- Grazyna B Sadowska
- Department of Pediatrics, Brown University Medical School, Women and Infants' Hospital of Rhode Island, Providence, RI 02905-2499 , USA
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Hagen EW, Palta M, Albanese A, Sadek-Badawi M. School achievement in a regional cohort of children born very low birthweight. J Dev Behav Pediatr 2006; 27:112-20. [PMID: 16682874 DOI: 10.1097/00004703-200604000-00005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Children born very low birthweight (VLBW, <=1500 g) have historically had lower average school achievement than their normal birthweight peers. However, perinatal care and survival have changed dramatically since prior cohorts accrued, prompting reassessment. Surfactant therapy became generally available 8/1/1990, and the use of ante- and postnatal steroids increased substantially around this time. Standardized test scores and teacher ratings in math, reading, science, and social studies were obtained at age 10 for a cohort of children admitted to six regional NICUs in Wisconsin and Iowa, 8/1/1988 - 6/30/1991. We compared achievement between the VLBW cohort and controls from the same school districts. Among VLBW children, we determined neonatal and early childhood factors associated with achievement on standardized tests (ordinal logistic regression) and teacher ratings (linear regression) and evaluated whether achievement differed by birth year. Compared to population controls, VLBW children's greatest deficits occurred in mathematics. Scores on the standardized math exam and teacher ratings of overall achievement were positively associated with birthweight, social function measured at age five, and socioeconomic status. VLBW children born in the post-surfactant era (after 8/1/1990) had lower achievement on the standardized math exam than children born during the pre-surfactant era of the prior two years. Lower achievement in the post-surfactant era may be due to greater survival among less healthy neonates or increased exposure to postnatal steroids. VLBW children more likely to struggle academically could be identified by early childhood measures, allowing for targeted interventions to mitigate their difficulties.
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Affiliation(s)
- Erika W Hagen
- Department of Population Health Sciences, University of Wisconsin-Madison, USA.
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Spinillo A, Chiara A, Bergante C, Biancheri D, Fabiana D, Fazzi E. Obstetric risk factors and persistent increases in brain parenchymal echogenicity in preterm infants. BJOG 2004; 111:913-8. [PMID: 15327604 DOI: 10.1111/j.1471-0528.2004.00229.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the risk of persistent (>7 days) increases in brain parenchymal echogenicity in preterm infants and their association with known obstetric risk factors. DESIGN Case-control study of prospectively collected data. SETTING A University hospital in Northern Italy. POPULATION Eighty-five singleton infants between 24 and 34 weeks of gestation with a cranial ultrasonographic diagnosis of persistently increased parenchymal echogenicity without development of cystic degeneration, and 170 control infants with negative cranial ultrasonographic findings. METHODS A comparison of the prevalence of selected obstetric risk factors between infants with persistent echo-dense lesions and negative controls. MAIN OUTCOME MEASURES Odds ratios of persistent echo-dense lesions including first-degree interactions between variables. RESULTS After adjusting for birthweight, logistic regression analysis showed that the only factor associated with an increased risk of persistent brain echo-dense lesions in infants was multiple courses of antenatal steroids (OR = 2.14, 95% CI = 1.11-4.15, P= 0.024). In this group, the risk of persistent echo-dense lesions was particularly high in: (i) mothers receiving dexamethasone rather than betamethasone (P value for interaction = 0.015) and (ii) after expectant management of pre-eclampsia or intrauterine growth retardation (P value for interaction = 0.03). CONCLUSIONS Multiple doses of antenatal steroids, especially dexamethasone, could influence the prevalence of persistent increases in brain parenchymal echogenicity in preterm infants.
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Affiliation(s)
- Arsenio Spinillo
- Department of Obstetrics and Gynecology, IRCCS Policlinico S. Matteo, University of Pavia, Piazzale Golgi 2, 27100 Pavia, Italy
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Purdy IB, Wiley DJ. Perinatal corticosteroids: A review of research. Part I: Antenatal administration. Neonatal Netw 2004; 23:15-30. [PMID: 15077857 DOI: 10.1891/0730-0832.23.2.15] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The premature infant may receive therapeutic glucocorticoid drugs while in utero or in the postnatal period. This article (part I of a two-part series) discusses the benefits and risks of in utero, or antenatal, corticosteroids (ACS) for the premature infant. Part II addresses the benefits and risks of postnatal corticosteroid (PCS) use. There are numerous clinical studies on the therapeutic use of these steroids for the prevention of respiratory distress syndrome and chronic lung disease in the premature infant, although research results on the efficacy of repeated steroid exposure among premature infants vary. Premature infants who are exposed to repeated courses of ACS and/or high-cumulative-dose PCS may show no neurologic side effects until later in life. Research in newborn animal models focused on the timing, duration, and amounts of ACS and PCS. Current clinical research includes examination of the neurodevelopment of infants who are therapeutically exposed to perinatal corticosteroids, to identify safer minimal dose protocols. Over the past 30 years, corticosteroids have been increasingly prescribed before and after birth. Understanding the potential treatment benefits and risks to human fetuses and neonates is vital to clinical practice. This review presents historic and pharmacokinetic information about prenatal use of corticosteroids. It also offers scientific evidence of the benefits and risks identified in animal models and clinical trials, to stimulate thought that gtiides neonatal clinical practice.
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Affiliation(s)
- Isabell B Purdy
- UCLA School of Nursing, 700 Tiverton Avenue, Factor Building, Box 95619, Los Angeles, CA 90095-6919, USA.
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Abstract
Experience with certain perinatal interventions, such as supplemental oxygen and dexamethasone, leads to the conclusion that follow-up data are needed to be well informed about the safety of certain perinatal interventions. Experience with indomethacin suggests that follow-up data also are regarded by some clinicians as a necessary aspect of evidence about effectiveness. Ideally, clinical trials of perinatal interventions might involve collection of data about neonatal predictors of outcome (such as a neuroimaging study and a standardized neurologic assessment); several developmental and neurologic assessments before school entry; a comprehensive evaluation of the child's cognitive function, behavioral competencies, and academic performance at 7 to 8 years of age; serial detailed assessments of the family psychosocial functioning; and an inventory of resources available for the child. Many clinical trials have not included follow-up after the neonatal period, and in such cases information about the effect of the intervention on participants' HRQL is incomplete. The approach taken in several recent trials, in which the outcome of interest is neurodevelopmental outcome at 18 months, attempts to strike a balance between a theoretical ideal (a comprehensive, longitudinal follow-up through school age) and a follow-up regimen that is not prohibitively expensive. Such trials include follow-up during the first 1 to 3 years of life, when major disabilities can be identified reliably, thereby providing moderately informative data about participants' eventual quality of life, related to the presence or absence of major disability. If, however, there is reason to suspect that the intervention has effects on the developing brain, follow-up after school entry may provide additional evidence pertinent to the risks and benefits of the intervention.
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Affiliation(s)
- T Michael O'Shea
- Department of Pediatrics, Wake Forest University Health Sciences, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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Kent A, Kecskes Z. Magnesium sulfate for term infants following perinatal asphyxia. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2003. [DOI: 10.1002/14651858.cd004494] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alison Kent
- The Canberra Hospital; Department of Neonatology; Yamba Drive Garran Australian Capital Territory Australia 4506
| | - Zsuzsoka Kecskes
- The Canberra Hospital; Centre for Newborn Care; Woden Canberra ACT Australia 2506
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CURRENT CONTROVERSIES SURROUNDING THE USE OF REPEATED COURSES OF ANTENATAL STEROIDS. Adv Neonatal Care 2002. [DOI: 10.1097/00149525-200212000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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