Eleanor Rhee

Antidepressants in pregnancy: a review of commonly prescribed medications.

Perinatal depression is an increasingly common comorbidity of pregnancy and is associated with adverse birth outcomes. Newer classes of antidepressants have been developed with a variety of mechanisms and improved side effect profiles. There is increasing use of these medications in reproductive-aged women. Medical providers have to balance the need to prevent relapse of maternal depressive symptoms with the need to minimize fetal exposure to medications. We review the literature on 10 of the most commonly used antidepressant medications: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine, duloxetine, bupropion, and mirtazapine. The pharmacokinetic properties of the medications are detailed, as well as practical considerations for their use in pregnant and lactating women. Guidance on counseling and management of pregnancies complicated by perinatal depression is discussed. Target Audience: Obstetricians & Gynecologists and Family Physicians. Learning Objectives: After completing this CME activity, physicians should be better able to differentiate the current classes of medications utilized commonly for perinatal depression, evaluate the reported adverse effects of antidepressant medications on the patient and developing fetus and choose the appropriate antidepressant medications for a depressed patient who is breast-feeding.

Superior mesenteric artery flow velocity waveforms in small for gestational age fetuses.

The objective of this study was to analyze the superior mesenteric artery flow velocity waveforms in small-for-gestational-age fetuses and to compare its contribution in their management with that already provided by the middle cerebral artery and umbilical artery flow velocity waveforms. Middle cerebral artery, umbilical artery, and superior mesenteric artery flow velocity waveforms were prospectively obtained in 41 small-for-gestational-age fetuses with color Doppler ultrasonography. The pulsatility index was used to quantify the waveforms. Poor perinatal outcome was defined by cesarean section for fetal distress, perinatal death, need for assisted ventilation, and necrotizing enterocolitis. In the small-for-gestational age fetuses, the middle cerebral artery pulsatility index was abnormal in 22/41, the umbilical artery in 26/41, and the superior mesenteric artery in 17/41. Coincident with abnormal umbilical and middle cerebral artery flow velocity waveforms were greater occurrences of poor perinatal outcome. The abnormality of an increased pulsatility index in the superior mesenteric artery velocity waveforms of small-for-gestational-age fetuses suggests greater vascular resistance and an overall reduction in visceral perfusion. However, the study of the superior mesenteric artery only seemed to support the information already provided for by the middle cerebral and umbilical arteries.

Antenatal surveillance of fetal growth restriction.

Fetal growth restriction is a complex problem in modern obstetrics. It is a condition of suboptimal fetal growth based on a genetically predetermined potential and affects approximately 5% to 10% of pregnancies. It is traditionally defined as an estimated fetal weight less than the 10th percentile. Those pregnancies that are affected by growth restriction are associated with increased risk of perinatal morbidity and mortality. Because of this increased risk, these pregnancies are monitored more closely to try to identify those fetuses at the greatest risk of fetal demise and initiate delivery before this critical event. Although the ideal management strategy is still being determined, there are several modalities available to assist in assessment of the growth-restricted fetus. These include the nonstress test test, biophysical profile, and Doppler velocimetry, most commonly of the fetal umbilical artery, in addition to sonographic growth assessment. The use of multiple fetal assessment tools may help improve the prediction of adverse outcomes and initiate delivery before cardiovascular collapse. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completing this CME activity, physicians should be better able to evaluate the modalities available to assess fetal well-being in the growth-restricted fetus, identify the sequence of changes that occurs in fetal well-being assessment as the growth-restricted fetus deteriorates, and determine the changes signifying worsening fetal status that should prompt delivery.

Characterization of antithrombin levels in pregnancy

OBJECTIVE To characterize antithrombin (AT) levels in normal pregnancy. METHODS We performed secondary analyses with data from 3 studies. Using a single measurement from each subject in the first analysis (cross-sectional), we correlated AT levels with gestational age from the middle of the second trimester throughout the third trimester of pregnancy. Using serial measurements in a second analysis (cohort), we compared AT levels between the late first and second trimesters of pregnancy and baseline (the level at 6 weeks postpartum). Using serial measurements in a third analysis (cohort), we analyzed the pattern of change in AT levels in the immediate postpartum period. Assays of AT activity were performed using the Dade Behring (Siemens) Berichrom Antithrombin III Chromogenic Assay. AT levels were correlated with gestational age using the Pearson correlation coefficient and compared between the different time points using one-way ANOVA. RESULTS Overall, AT levels were 20% lower than baseline during pregnancy (p<0.01). There was no significant difference between AT levels obtained between late first trimester and late second trimester. From midtrimester to term, however, AT levels were negatively correlated with gestational age with a 13% drop during this period of time (r=-0.26 [-0.39, -0.11]; p<0.01). Immediately after childbirth, AT levels fell precipitously to 30% below baseline (p<0.05) and reached a nadir 12 hours postpartum before rising and returning to baseline by 72 hours postpartum. CONCLUSION It appears that antithrombin (AT) is consumed at the time of delivery. Our findings have implications for AT replacement or even anticoagulation at the time of delivery.

Risk Factors for Birth Defects

Importance Major congenital abnormalities, or birth defects, carry significant medical, surgical, cosmetic, or lifestyle consequences. Such abnormalities may be syndromic, involving multiple organ systems, or can be isolated. Overall, 2% to 4% of live births involve congenital abnormalities. Risk factors for birth defects are categorized as modifiable and nonmodifiable. Modifiable risk factors require thorough patient education/counseling. The strongest risk factors, such as age, family history, and a previously affected child, are usually nonmodifiable. Objective This review focuses on risk factors for birth defects including alcohol consumption, illicit drug use, smoking, obesity, pregestational diabetes, maternal phenylketonuria, multiple gestation, advanced maternal age, advanced paternal age, family history/consanguinity, folic acid deficiency, medication exposure, and radiation exposure. Evidence Acquisition Literature review via PubMed. Results There is a strong link between alcohol use, folic acid deficiency, obesity, uncontrolled maternal diabetes mellitus, uncontrolled maternal phenylketonuria, and monozygotic twins and an increased risk of congenital anomalies. Advanced maternal age confers an increased risk of aneuploidy, as well as nonchromosomal abnormalities. Some medications, including angiotensin converting enzyme inhibitors, retinoic acid, folic acid antagonists, and certain anticonvulsants, are associated with various birth defects. However, there are few proven links between illicit drug use, smoking, advanced paternal age, radiation exposure, and statins with specific birth defects. Conclusions and Relevance Birth defects are associated with multiple modifiable and nonmodifiable risk factors. Obstetrics providers should work with patients to minimize their risk of birth defects if modifiable risk factors are present and to appropriately counsel patients when nonmodifiable risk factors are present.

Ultrasound Examination of the Fetal Heart.

Congenital heart disease (CHD) occurs in 4-13 per 1000 births in the United States. While many risk factors for CHD have been identified, more than 90% of cases occur in low-risk patients. Guidelines for fetal cardiac screening during the second trimester anatomy ultrasound have been developed by the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) in order to improve antenatal detection rates and to standardize the fetal cardiac screening examination. Patients found to be at increased risk of CHD because of risk factors or an abnormal screening examination should be referred for second trimester fetal echocardiography. Recently, 3D and 4D ultrasound techniques are being utilized to enhance detection rates and to better characterize cardiac lesions, and several first trimester ultrasound screening markers have been proposed to identify patients at increased risk of CHD. However, detection rates have not improved significantly due to limitations such as cost, access, and training that are associated with new technologies and screening methods. The most cost effective way to improve detection rates of CHD may be to standardize screening protocols across practices according to established guidelines and to have a low threshold for referral for fetal echocardiography.

The effects of magnesium sulfate on maternal and fetal platelet aggregation

Objective: To evaluate platelet function in mothers and fetuses/neonates exposed to magnesium sulfate intrapartum. Methods: This was a prospective cohort study of mothers and fetuses/neonates exposed to magnesium sulfate intrapartum compared to mothers and fetuses/neonates not exposed. Platelet aggregometry was performed in duplicate on specimens from subjects using two different agonists, ADP and collagen, on a whole blood impedance aggregometer. Results: Specimens were processed from 11 mothers and 10 fetuses/neonates exposed to magnesium and 12 mothers and fetuses/neonates, not exposed. There was no difference in platelet aggregation between the specimens from the mothers who were exposed and mothers not exposed. In the specimens from the fetuses/neonates, there was no difference using collagen as an agonist, but using ADP as an agonist, there was a remarkable difference - 0.0 ohms in the exposed group vs. 3.0 ohms in the unexposed group (p < 0.01). Conclusions: In-utero magnesium sulfate exposure significantly suppresses fetal platelet function.

Pregnancy Outcomes Following Cervical Conization or Loop Electrosurgical Excision Procedures

Background Conservative excisional measures used to manage cervical dysplasia are often cited as risk factors for preterm labor in subsequent pregnancies. Objective We performed an evidence-based review of the obstetric complications following excisional procedures for cervical dysplasia in women of reproductive age. Evidence Acquisition Between 1993 and 2016, there were 7 published meta-analyses of cohort studies that consistently demonstrated an association between excisional cervical procedures and preterm labor. However, controversy remains as to whether the increased risk is due to the cervical amputation or to the risk factors that underlie the dysplasia. Results Although data suggest an association between excisional procedures and preterm labor, the choice of the control group may either overestimate or underestimate the relative risk. In addition, recent data suggest that depth of excision greater than 10 to 12 mm is associated with increases in risk of preterm birth. Conclusions Women with cervical dysplasia are at an increased baseline risk of preterm birth, and surgical excision confers additional risk. Pregnant patients with advanced cervical dysplasia or a history of surgical excision should be considered high-risk pregnancies.

Pregnancy complicated by foetal abdominal mass: Fetiform teratoma versus foetus-in-fetu

A thirty-eight-year-old gravida 4 para 1021 at 38 weeks of gestation was referred to our foetal diagnostic clinic for evaluation of a complex foetal abdominal mass found on ultrasound. Our detailed ultrasound revealed a 3.3 2.8 2.8 cm mass in the right lower quadrant of the foetal abdomen which appeared sac-like and was surrounded by foetal bowel. Within the sac, there was a complex mass with the appearance of bone and soft tissue, surrounded by anechoic fluid (Figure 1). A feeding vessel was noted. Differential diagnosis included foetus-in-fetu versus fetiform teratoma. The patient subsequently delivered a live born male infant by vaginal delivery at 41 weeks. Physical examination was significant for a small palpable abdominal mass and an undescended right testicle. The neonate’s alpha-foetoprotein (AFP) level was within normal limits for his age. Ultrasound and CT revealed a 3.6 3.3 4.3 cm ovoid structure in the right subhepatic region containing fluid, soft tissue and calcifications. No invasion into the surrounding vasculature or organs was noted. The mass was resected on day 6 of life. A 3 5 cm mass filled with fluid and cartilaginous structures was noted. A single pedicle containing blood vessels and a vas deferens fed into the mass, suggesting that it arose from an intra-abdominal testicle that had been obliterated by the mass (Figure 2). When the pedicle was traced back to the inguinal region, no salvageable testicular tissue could be identified. Pathologic examination revealed a 4 3 2 cm soft tissue mass with a 1.5 cm limb bud covered by hair-bearing skin with three attached phalanges-like structures and an adherent segment of tortuous intestine (Figures 3 and 4). Radiograph of the sectioned specimen confirmed the presence of long bone and the absence of vertebrae (Figure 5). Neither foetal membranes nor chorionic villi were identified. Residual testicular parenchyma was identified within the cyst wall lining. Final pathologic diagnosis was a mature fetiform teratoma. At five months of age, a left abdominal mass was palpated on physical examination and was confirmed by ultrasound and CT. He was diagnosed with adrenal neuroblastoma by biopsy. Pathology report showed no teratomatous or germ cell elements in adrenal biopsy. Since, he had undergone one cycle of chemotherapy and surgical resection of the adrenal neuroblastoma, and was doing well off of therapy. No further genetic testing had been performed.

Pregnancy Management After Bariatric Surgery.

Obesity is a source of major morbidity and mortality and is a growing concern worldwide. Maternal obesity is associated with increased maternal and fetal risks during pregnancy. Bariatric surgery has emerged as one of the most sustainable treatments for severe obesity and its comorbidities. Patients who have undergone bariatric surgery often experience drastic improvements in hypertension and diabetes. It is not surprising, therefore, that the incidence of bariatric surgery is increasing, particularly in women of childbearing age. In fact, many women undergoing bariatric surgery plan to become pregnant in the future. Bariatric surgery may have a beneficial effect on rates of fetal macrosomia, gestational diabetes, hypertension, and preeclampsia. Conversely, studies have showed that bariatric surgery may increase the risk of small for gestational age infants and preterm birth. Given its rising incidence, it is important that physicians be able to thoroughly and accurately counsel and treat patients who plan to, or do, become pregnant after bariatric surgery. Target Audience Obstetricians and gynecologists, family physicians. Learning Objectives After completing this activity, the learner should be better able to identify medical risks associated with obesity; educate patients regarding the risks and benefits of pregnancy after bariatric surgery; and identify the key aspects of management of pregnant patients who have undergone bariatric surgery.