Cardiac birth defects in a twin infant born to a woman with chronic myeloid leukemia on dasatinib

Preclinical animal studies have demonstrated an association between maternal use of tyrosine kinase inhibitors and embryofetal toxicity; yet, multiple clinical case series have reported normal pregnancy outcomes and healthy infants in women on these medications during the course of their pregnancy. We describe a case of a woman with chronic myeloid leukemia who had taken the second-generation tyrosine kinase inhibitor dasatinib during the first 12 weeks of her dichorionic diamniotic twin pregnancy and subsequently delivered two low-birth weight infants, one with severe cardiac malformations and the other without apparent birth abnormalities. To our knowledge, this is the first reported case of fetal cardiovascular defects in an infant born to a woman on dasatinib during a twin pregnancy and supports current recommendations to avoid this medication during pregnancy. We also review relevant preclinical and clinical studies of tyrosine kinase inhibitor use during pregnancy and explore alternative therapeutic options for patients with chronic myeloid leukemia during pregnancy to aid clinicians in the appropriate management of these patients so as to minimize both maternal and fetal risks.

Development of Churg-Strauss syndrome with severe multiple mononeuropathy after leukotriene receptor antagonist treatment in one of the monozygotic twins with asthma: case report

Several cases of Churg-Strauss syndrome (CSS) have been reported in asthmatic patients treated with leukotriene receptor antagonists (LTRAs). It is not clear whether LTRA is a causative factor in the development of vasculitis. We present the case of a 26-year-old patient, who developed severe central and peripheral neuropathy after a short-term treatment with LTRA, followed by gastrointestinal perforation and bleeding. The patient was successfully treated with high-dose glucocorticoids, immunoglobulins, and cyclophosphamide. His monozygotic twin brother treated for asthma does not meet classification criteria for Churg-Strauss syndrome at the moment, but his condition is being monitored. Both asthma and rheumatology specialists should consider the possibility of CSS development in patients treated with LTRAs.

Foetal kidney maldevelopment in maternal use of angiotensin II type I receptor antagonists

We report renal lesions observed in a foetus exposed throughout pregnancy to angiotensin II type I (AT 1) receptor antagonists. The mother suffered from essential hypertension and was treated with Cozaar (losartan 50 mg). Autopsy examination of the foetus revealed severe renal lesions, including tubular dysgenesis, hypertrophy of the endothelial and medial cells lining the arterial and arteriolar walls, hyperplasia of the juxtaglomerular apparatus and poorly developed vasa recta. Similar lesions have already been observed in foetuses of women treated with angiotensin-converting enzyme antagonists and also in foetuses and neonates of animals undergoing experimental blockade of the renin-angiotensin system. The purpose of this report is to describe structural lesions observed in the kidneys, and, particularly, vascular lesions. Our results suggest that the use of AT 1 receptor antagonists during pregnancy may have a severe deleterious effect on kidney development in the foetus.

[Fetal warfarin syndrome in twin pregnancy]

We describe a pair of twins, whose mother was being treated by oral anticoagulant drugs, as a result of having received mitral heart valve implantation in the past. The male twins monochorionic, monoamniotic--but one infant showed the features of fetal warfarin syndrome. In the study we discussed the pharmacogentetics and individual variation in the human metabolism during treatment with warfarin-perinatal growth and prevalence of congenital malformations. We analysed the threats to the fetus and mother, connected with administration of anticoagulant drugs.

The relationship between stimulant medication and tics

Clinical evidence supports the observation that stimulant drugs increase the severity of tics in 25% to 50% of patients with TS, and occasionally can precipitate TS in a patient who did not previously manifest symptoms of this disorder. As ADD is frequently associated with TS, the clinician is often faced with a dilemma. A conservative approach to the use of stimulant medication, stringent criteria for its use, adequate counseling of the child and parents, and a thorough cost-benefit analysis before initiating treatment are required. Behavior management and environmental manipulation can be useful techniques with the child with ADD, and should be tried before medication is considered.

[Congenital atrial flutter with hydrops fetalis caused by tocolytic therapy (author's transl)]

A 31-year-old healthy woman received Ritodrine (Pre-Par) from the 26th week of gestation because of twin pregnancy. Three weeks before birth continous intravenous medication with the same drug was commenced because of premature uterine contractions. Five days later a heart rate of over 200/minute was noted in one of the twins. This tachycardia persisted until birth while the heart rate of the other twin remained normal. At 33 weeks monozygotic female twins were delivered after artifical rupture of membranes. One twin was normal, birth weight 1.6 kg. The other baby showed persistent atrial flutter, was hydropic (weight 2.75 kg) and suffered from gross cardiac failure. Atrial flutter was converted to sinus rhythm one hour after birth by DC-countershock. Digoxin was commenced, the child rapidly improved and now still remains in sinus rhythm six month later.