Danny Wu

False-positive amphetamine toxicology screen results in three pregnant women using labetalol.

BACKGROUND: Labetalol is commonly used for control of hypertension in pregnancy. A component of the workup for new-onset hypertension in pregnancy often includes a urine drug screen. A labetalol metabolite is structurally similar to amphetamine and methamphetamine, thus causing potential cross-reactivity in drug immunoassays. CASES: We present one case of cocaine-induced hypertensive crisis superimposed on chronic hypertension and two cases of severe preeclampsia for which patients required escalating doses of labetalol for hypertension, with subsequent false-positive amphetamine urine drug screen results. CONCLUSION: In pregnant women requiring labetalol for treatment of hypertensive disease, a urine drug screen may be falsely positive for amphetamines and methamphetamines. Providers should be cognizant of this possibility when interpreting the results of urine drug screens.

The Maternal Side of Maternal–Fetal Surgery

The term fetal surgery is used widely for fetal intervention during pregnancy; maternal-fetal surgery may be more appropriate, because all these invasive procedures also affect the mother. Although there is no direct benefit to the mother from these procedures, the risk to her is for a purely altruistic purpose. It is therefore important to understand the potential complications of maternal-fetal surgery, so the physician can provide accurate counseling to the patient.

Anomalous Mitral Arcade in Twin-Twin Transfusion Syndrome

Background— Echocardiography has documented acquired pulmonary stenosis and cardiomyopathy in recipient fetuses in twin-twin transfusion syndrome. At autopsy, we also have identified anomalous mitral arcade, a rare valve deformity associated with mitral regurgitation. Methods and Results— To identify a profile for anomalous mitral arcade, we compared clinicopathological data from 11 sets of autopsied twin-twin transfusion syndrome fetuses, including 4 twin pairs in whom the recipient had anomalous mitral arcade (affected) and 7 pairs in whom both had structurally normal mitral valves (unaffected). Anomalous mitral arcade was characterized by a thick fibrous band at the free margin of the leaflets tethering papillary muscles and absent/short tendinous cords. One affected recipient also had pulmonary stenosis and tricuspid valve dysplasia. In all 11 sets, recipient hearts were larger than paired donor hearts. All 11 recipients had moderate to severe cardiac dysfunction by echocardiography. Echocardiography disclosed left atrial enlargement in all affected recipients but none of the unaffected recipients. Mitral regurgitation was present before demise in all affected recipients evaluated with color Doppler. Progressive decrease in mitral leaflet mobility was noted in those affected recipients with serial echocardiography. Conclusions— Previously unreported in twin-twin transfusion syndrome, anomalous mitral arcade was identified in 4 of 11 recipient fetuses (36%) in this autopsy series. Ultrasound or echocardiographic evidence of left atrial dilation, mitral regurgitation, and decreased leaflet mobility in recipients should raise suspicion for anomalous mitral arcade. Development of anomalous mitral arcade in twin-twin transfusion syndrome recipients suggests that the lesion is an acquired valve deformity in this setting, not a malformation.

Does Antidepressant Exposure in Pregnancy Affect Maternal Serum Markers for Aneuploidy

INTRODUCTION: The objective of this study was to examine the effect of maternal antidepressant exposure on first- and second-trimester maternal serum markers for aneuploidy. METHODS: We conducted a 10-year retrospective cohort study within a large health care organization. Pregnant women diagnosed with depression who underwent serum screening for aneuploidy were identified. Antidepressant exposure was defined by a filled prescription. Levels of pregnancy-associated plasma protein-A, alpha-fetoprotein, estriol, inhibin, and second-trimester human chorionic gonadotropin (hCG) were obtained, expressed as multiples of the mean. We compared levels of serum analytes between women who were and were not exposed to antidepressants. Using recorded Patient Health Questionnaire scores, we assessed depression severity as a confounder. RESULTS: Antidepressant exposure occurred in 52% of 19,186 pregnancies. Mean inhibin levels were significantly higher in the unexposed group (1.124 multiples of the median compared with 1.084 multiples of the median, P=.003) as were mean hCG levels (1.188 multiples of the median compared with 1.165 multiples of the median, P=.007). Mean estriol levels were lower in the unexposed group (1.005 multiples of the median compared with 1.015 multiples of the median, P=.030). There were no statistically significant differences in the mean values of pregnancy-associated plasma protein-A or alpha-fetoprotein. In bivariate analyses, there were no interactions between analyte values and depression severity. There were no significant differences in the proportion of patients with one or more abnormal level of serum analytes between exposed and unexposed groups. CONCLUSION: Antidepressant exposure affects mean levels of inhibin, hCG, and estriol. As a result of our large number of participants, small differences could be detected. Further research is necessary to determine if such differences are of clinical significance.