Pregnancy outcome following use of levodopa, pramipexole, ropinirole, and rotigotine for restless legs syndrome during pregnancy: a case series

BACKGROUND

Restless legs syndrome (RLS) is related to parity, and its symptoms may worsen during pregnancy. Treatment with levodopa or dopamine agonists is the first-line therapy for RLS; however, there are limited data on treatment in pregnancy. We therefore assessed the safety of levodopa, pramipexole, rotigotine, and ropinirole in pregnancy.

METHODS

Prospective documentation of pregnancies exposed to levodopa, pramipexole, rotigotine, and ropinirole between 1998 and 2011 was evaluated as to their outcome (teratogenicity or fetotoxicity) by the Berlin Institute for Clinical Teratology and Drug Risk Assessment in Pregnancy.

RESULTS

We were able to complete 59 pregnancy outcomes exposed to RLS pharmacotherapy. For specific treatments, the numbers of exposed pregnancies/live born children/spontaneous abortions/induced abortions/malformations were as follows: levodopa only: 38/29 (one pair of twins)/3/7/3; pramipexole only: 12/9/3/0/0; rotigotine only: 2/2/0/0/0; ropinirole only: 3/2/0/1/0; levodopa combined with pramipexole: 3/3/0/0/0; levodopa combined with ropinirole: 1/1/0/0/0. No major birth defects were found with any RLS treatment, and three infants exposed to levodopa had minor anomalies.

CONCLUSIONS

In our small prospective case series, there was no increased risk above baseline for major malformations or other adverse outcomes for levodopa and pramipexole. If necessary, levodopa treatment may be considered as an alternative to cabergoline, for which safety has been well documented in pregnancy.

Genetic variability of HVRII mtDNA in cord blood and respiratory morbidity in children

Genetic polymorphisms were examined using direct sequencing of the hypervariable region II (HVRII) in the D-loop of mtDNA in the cord blood of 355 children living in two areas of the Czech Republic - the industrial district of Teplice and the agricultural district of Prachatice. The incidence of the most frequent nucleotide variants of HVRII, C150T (10.1%), T152C (19.7%), T195C (19.7%) and 309.nC (41.4% for 309.2C and 13.8% for 309.3C), and the respiratory morbidity at the ages of 0-2 years and 2-6 years were investigated, considering many other factors such as locality, gender, ethnicity, heating by coal in household, maternal age, asthma bronchiale, allergic rhinitis, pollinosis, conjunctivitis and maternal tobacco exposure during and after pregnancy. We found that the T195C transversion in HVRII is connected with an increased risk of early childhood (0-2 years) bronchitis (RR 1.38, p=0.034, 95% CI 1.04-1.85) and with increased risk of otitis media in children aged 2-6 years (RR 1.62, p=0.032, 95% CI 1.04-2.53). Another polymorphism, 309.nC, is associated with an increased risk of bronchitis in children aged 2-6 years (RR 1.46, p=0.030, 95% CI 1.04-2.06). The results indicate that genetic polymorphisms in mtDNA may be an important factor not only for various types of cancers and neurodegenerative diseases, but also for respiratory morbidity in children.

A descriptive study of nursing judgment in the assessment and management of cardiac pain

Unrelieved cardiac pain in patients admitted to a coronary care unit (CCU) with a diagnosis of coronary artery disease was examined from the perspective of nursing judgment. The purpose of this study was to reveal expert clinical knowledge and judgment in this specific area of critical care practice. Using a naturalistic approach, nurses were observed and interviewed as they made judgments about cardiac pain. Qualitative data analysis identified patterns of nursing actions and thought processes. Findings indicated that clinical knowledge of the titration of drugs was used in the treatment of cardiac pain, and qualitative distinctions and sense of saliency were also important in pain assessment. Intuitive thought processes were identified in the clinical judgment of expert nurses.

Diminished release of atrial natriuretic factor in calves with a total artificial heart

Venous hypertension after total artificial heart (TAH) replacement, a common problem in humans as well as experimental animals, is thought to be related to reduced release of atrial natriuretic factor (ANF) due to atrial damage. To verify this hypothesis, we stimulated the release of ANF in 6 calves before (-7 days) and after TAH replacement (+25, +50, +80, and +100 days) by the rapid (+ = 10 min) infusion of 2 L of Ringer's solution. In normal calves (-7 days) this procedure induced a rise in plasma concentration of ANF from 18.5 +/- 12 to 31.6 +/- 12 pmol/L (p < 0.05). After TAH the ANF release continuously decreased (analysis of variance, p < 0.02). Thus, ANF increased by 9.8 +/- 9.3, 6.8 +/- 17.5, 0.4 +/- 5.2, and 0.5 +/- 3.2 pmol/L at days 25, 50, 80, and 100, respectively. The central venous pressure increased by 3.4 +/- 1.5 mm Hg (before TAH) and by 6 +/- 2.9 mm Hg (after TAH) during this procedure. A decrease in plasma concentrations of aldosterone, most likely due to extracellular volume expansion and a decrease in total protein plasma concentrations and in hematocrit due to the dilution of blood, was seen in each experiment. Necropsy demonstrated massive atrial dilatation and myocardial dystrophy with atrial fibrosis. ANF granules were present to a small extent in every calf. We conclude that rapid intravenous infusion is an adequate stimulus to release ANF in normal calves. After TAH implantation the release of ANF by high venous pressure declines although ANF granules are still present in the damaged atrial stumps. Therefore, the loss of stimulated ANF could contribute to the observed increase in venous pressure in TAH calves although other pathophysiologic mechanisms cannot be excluded.

Further studies on protective effects of vitamins in cyclophosphamide-induced cleft palate

The effects of vitamins B1, B6, and E administered 1 day before and simultaneously with an embryotoxic dose of cyclophosphamide (CPM) were studied using random-bred mice ICR (VELAZ). A single dose of 20 mg/kg CPM administered i.p. or i.m. on day 12 of pregnancy induced in the foetuses cleft palate and malformations of the upper and lower limbs. Both vitamins B1 and B6 decreased nonsignificantly the overall proportion of malformed foetuses and changed the spectrum of malformations, the decrease in foetuses with malformed upper limbs being statistically significant. In the groups supplemented with vitamins the mean foetal weight was higher in litters without malformed upper limbs than in litters with malformed upper limbs and those of both types in the control group. Similar effects of vitamin E were statistically nonsignificant. It is most likely that vitamins influence the pharmacokinetics of cyclophosphamide or its metabolites. The data provided offer no explanation for the claimed beneficial effects of vitamins for preventing the occurrence of orofacial clefts in patients at risk.

[Comparison of the effectiveness of various methods of testing drugs for embryotoxicity]

A comparative investigation on efficiency of four modern methods for testing embryotoxicity (intraamniotic administration, cultivation of postimplanted rat embryos in medium when certain teratogens were administered by various methods, test techniques on pregnant animals, testing, by CHEST--chick embryo toxicity screening test--method on chick embryos) was performed with a well known teratogen -- cyclophosphamide. A satisfactory correlation between the results was obtained, but a greater efficiency, less time for obtaining final results and greater sensitivity was noted for the new test methods in comparison to routine testing on pregnant animals. Advantages and disadvantages of every method applied were discussed.