No association found between use of very large doses of diazepam by 112 pregnant women for a suicide attempt and congenital abnormalities in their offspring

Status epilepticus in pregnancy: a literature review and a protocol proposal

INTRODUCTION

Status epilepticus (SE) in pregnancy represents a life-threatening medical emergency for both mother and fetus. Pregnancy-related pharmacokinetic modifications and the risks for fetus associated with the use of antiseizure medications (ASMs) and anesthetic drugs complicate SE management. No standardized treatment protocol for SE in pregnancy is available to date.

AREAS COVERED

In this review, we provide an overview of the current literature on the management of SE in pregnancy and we propose a multidisciplinary-based protocol approach.

EXPERT OPINION

Literature data are scarce (mainly anecdotal case reports or small case series). Prompt treatment of SE during pregnancy is paramount and a multidisciplinary team is needed. Benzodiazepines are the drugs of choice for SE in pregnancy. Levetiracetam and phenytoin represent the most suitable second-line agents. Valproic acid should be administered only if other ASMs failed and preferably avoided in the first trimester of pregnancy. For refractory SE, anesthetic drugs are needed, with propofol and midazolam as preferred drugs. Magnesium sulfate is the first-line treatment for SE in eclampsia. Termination of pregnancy, via delivery or abortion, is recommended in case of failure of general anesthetics. Further studies are needed to identify the safest and most effective treatment protocol.

Pharmacotherapy during Pregnancy: An Endodontic Perspective

Odontogenic pain affects up to 54.9% of pregnant women^1-3. This pain is often associated with pulpal and/or periapical infections that pose risks to women and their fetus. The American Dental Association in collaboration with the American College of Obstetricians and Gynecologists developed a consensus statement to affirm the importance of timely and appropriate oral health care as a critical component of a healthy pregnancy⁴. However, limited knowledge of endodontic procedure safety and related medication use often result in the avoidance of treatment during pregnancy. This article, a collaborative effort by specialists from endodontics, pediatric dentistry, and obstetrics, reviews the current evidence on the safety of medications commonly used in endodontics including local anesthetics, analgesics, anxiolytics, and antibiotics.

Suicidal ideation in pregnancy: an epidemiologic review

Suicidal behaviors are the leading causes of injury and death worldwide, and are leading causes of maternal deaths in some countries. One of the strongest risk factors, suicidal ideation, is considered a harbinger and distal predictor of later suicide attempt and completion, and also presents an opportunity for interventions prior to physical self-harm. The purpose of this systematic epidemiologic review is to synthesize available research on antepartum suicidal ideation. Original publications were identified through searches of the electronic databases using the search terms pregnancy, pregnant women, suicidal ideation, and pregnan* and suicid* as root searches. We also reviewed references of published articles. We identified a total of 2626 articles through the electronic database search. After irrelevant and redundant articles were excluded, 57 articles were selected. The selected articles were original articles that focused on pregnancy and suicidal ideation. Of the 57 included articles, 20 reported prevalence, 26 reported risk factors, 21 reported consequences of antepartum suicidal ideation, and 5 reported on screening measures. Available evidence indicates that pregnant women are more likely than the general population to endorse suicidal ideation. Additionally, a number of risk factors for antepartum suicidal ideation were identified including intimate partner violence, <12-year education, and major depressive disorder. There is a need for enhanced screening for antepartum suicidal ideation. The few screening instruments that exist are limited as they were primarily developed to measure antepartum and postpartum depression. Given a substantial proportion of women with suicidal ideation that does not meet clinical thresholds of depression and given the stress-diathesis model that shows susceptibility to suicidal behavior independent of depressive disorders, innovative approaches to improve screening and detection of antepartum suicidal ideation are urgently needed.

Psychopharmacological treatment of mood and anxiety disorders during pregnancy

Many women with psychiatric disorders want to become mothers and only a minority seek advise prior to becoming pregnant. In those women, in whom pregnancy can be planned, the decision, if a medication is required for stabilisation and which one to choose if this is the case, is easier to make than in women in whom pregnancy occurs unplanned. The physician has to weigh the risk that a relapse of the psychiatric disorder during pregnancy poses to the foetus against the reproductive risk of psychotropic drugs. This presentation is intended to assist in understanding the general principles of pharmacotherapy during pregnancy as well as the morphological, perinatal and neurobehavioural toxicity of antidepressants, antipsychotics, benzodiazepines and mood stabilisers.

Benzodiazepine exposure in pregnancy and risk of major malformations: a critical overview

OBJECTIVE

Benzodiazepines (BDZs) safety profiles in pregnancy suggest that the risk of major malformations (MMs) cannot be considered simply as a "class effect". The aim of this paper was to review and update the available literature on the risks of MMs in women exposed to BDZs in the first trimester of pregnancy.

METHODS

PubMed was searched for English-language articles, from January 2001 to November 2011, introducing as keywords "teratogens", " major malformation", "foetus", "infant", "newborn", "pregnancy", in conjunction with "benzodiazepines" as a keyword or BDZ generic name as text words.

RESULTS

Twelve studies were selected for the review. BDZ exposure during the first trimester of pregnancy seems not to be associated with an increasing risk of congenital MMs. Diazepam and chlordiazepoxide should be considered drugs of first choice.

CONCLUSIONS

Data published in the last 10 years did not indicate an absolute contraindication in prescribing BDZs during the first gestational trimester. In any case, studies analyzed suffer from a number of methodological limitations such as lack of careful report of BDZ patterns of use in pregnancy, possible influences of recall bias, lack of controlling for confounding factors and lack of data concerning possible MMs in aborted fetuses.

Antiepileptic drugs and pregnancy outcomes

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.

Bladder exstrophy: an epidemiologic study from the International Clearinghouse for Birth Defects Surveillance and Research, and an overview of the literature

Bladder exstrophy (BE) is a complex congenital anomaly characterized by a defect in the closure of the lower abdominal wall and bladder. We aimed to provide an overview of the literature and conduct an epidemiologic study to describe the prevalence, and maternal and case characteristics of BE. We used data from 22 participating member programs of the International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR). All cases were reviewed and classified as isolated, syndrome, and multiple congenital anomalies. We estimated the total prevalence of BE and calculated the frequency and odds ratios for various maternal and case characteristics. A total of 546 cases with BE were identified among 26,355,094 births. The total prevalence of BE was 2.07 per 100,000 births (95% CI: 1.90-2.25) and varied between 0.52 and 4.63 among surveillance programs participating in the study. BE was nearly twice as common among male as among female cases. The proportion of isolated cases was 71%. Prevalence appeared to increase with increasing categories of maternal age, particularly among isolated cases. The total prevalence of BE showed some variations by geographical region, which is most likely attributable to differences in registration of cases. The higher total prevalence among male cases and older mothers, especially among isolated cases, warrants further attention.

Efficacy of medical care of epileptic pregnant women based on the rate of congenital abnormalities in their offspring

The objective of the present study was to check the efficacy of progress in the medical care of epileptic pregnant women on the basis of the reduction of different congenital abnormalities (CAs) in their offspring. First, the prevalence of medically recorded epilepsy was compared in 95 pregnant women who later had offspring with different CAs (case group) and 90 pregnant women who later delivered newborn infants without CA (control group) and matched to cases in the Hungarian Case-Control Surveillance System of Congenital Abnormalities, 1980-1996. Second, the rate of different CAs was compared in the offspring of epileptic pregnant women between 1980 and 1989 and 1990-1996. Cleft lip with or without cleft palate, cleft palate, cardiovascular CAs, oesophageal atresia/stenosis, hypospadias and multiple CAs showed a higher risk in the offspring of pregnant women with epilepsy treated with different antiepileptic drugs, explained mainly by polytherapy. There was no higher risk for total CAs after monotherapy. There was no significantly lower rate of total CAs in the offspring of epileptic pregnant women during the second period of the study. The efficacy of special medical care of epileptic pregnant women was not shown on the basis of decrease in the rate of CAs in the offspring of epileptic pregnant women.

Attempted suicide and pregnancy

BACKGROUND

The aim of the Budapest Monitoring System of Self-Poisoning Pregnant Women was to evaluate the potential congenital abnormality inducing effect of extremely large doses of drugs among pregnant women who attempted suicide. This system was appropriate to describe the characteristics of these pregnant women as a secondary finding from this model.

METHODS

All self-poisoned patients were cared for at a toxicological inpatient clinic in Budapest, between 1960 and 1993. Of a total of 1,044 pregnant women identified from the three different periods of the project, only 19 (1.8%) died. Women who survived were visited at home to reveal birth outcomes, and their exposed children were examined medically to identify congenital abnormalities and tested to estimate their cognitive-behavioral status. The previous or subsequent children of these pregnant women were used as controls with a similar examination protocol.

RESULTS

In general, self-poisoned pregnant women were young (peak age was between 18 and 20 years), 62% had their first pregnancy, 55% were unmarried, they had lower socioeconomic status, 46% were smokers and 22.5% drinkers, but depression/panic disorder occurred only among 17 pregnant women. Suicide attempts with drugs were most frequent in the fourth post-conceptional week and second month of pregnancy. In general they used smaller doses of drugs for suicide than non-pregnant age-matched women. Of 1,044 self-poisoned pregnant women, 926 had known pregnancy outcomes and 411 (44.4%) delivered live-born babies.

CONCLUSIONS

The self-poisoning model appears to have several benefits (e.g., dose-response estimation of drugs) in comparison with other methods when evaluating teratogenic/fetotoxic effect of drugs. It is suggested that an international monitoring system of self-poisoned pregnant women should be established to provide a larger data base. ‎

Teratogenic effects of antiepileptic drugs

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.

A study of the potential teratogenic effects of large doses of drugs rarely used for a suicide attempt during pregnancy

The available data set regarding pregnant women who attempted suicide during pregnancy was evaluated to estimate the teratogenic effect of very large doses of drugs based on the rate and distribution of congenital abnormalities of exposed children. These pregnant women were identified from patients of central toxicological inpatients clinic, Budapest, Hungary, 1960–1993. Of 1044 women with self-poisoning during pregnancy, 411 delivered live-born babies; 367 of these children were examined in this study. Data for 12 frequently used (10 or more times) drugs were published previously; this paper presents 77 medicines (58 drugs and 19 medicinal products including multiple components) that were rarely used for a suicide attempt by 197 pregnant women. Although 23 (11.7%) exposed children had congenital abnormalities (CAs), in general, a causal relationship of the CA and the drug taken by the pregnant woman cannot be assumed. This is because the suicide attempt often did not occur during a critical period for producing the CA. Of 67 pregnant women who attempted suicide between the 3rd and 12th postconceptional week, that is, the critical period of most major CAs, 7 (10.5%) children were affected with CAs. This high rate of CAs in exposed children can be explained by the intensive medical examinations, including diagnosis of mild CAs and minor anomalies, or the low socioeconomic status and hazardous lifestyle of mothers. None of the rarely used drugs was identified as a potential human teratogen. Experience of the authors shows the feasibility and benefits of using the self-poisoning model in estimating human teratogenic/fetotoxic risks of exposure to drugs.