William J. Watson

Congenital Heart Disease Associated With Selective Serotonin Reuptake Inhibitor Use During Pregnancy

OBJECTIVE To determine the risk of congenital cardiac abnormalities associated with use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy. PATIENTS AND METHODS We conducted a retrospective review of the medical records of all pregnant women presenting at Mayo Clinics site in Rochester, MN, from January 1, 1993, to July 15, 2005, and identified 25,214 deliveries. A total of 808 mothers were treated with SSRIs at some point during their pregnancy. We reviewed the medical records of the newborns exposed to SSRIs during pregnancy to analyze their outcomes, specifically for congenital heart disease and persistent pulmonary hypertension of the newborn. RESULTS Of the study patients, 808 (3.2%) took an SSRI at some point during the antenatal period. Of the 25,214 deliveries, 208 newborns (0.8%) were diagnosed as having congenital heart disease. Of the 808 women exposed to SSRI during pregnancy, 3 (0.4%) had congenital heart disease compared with 205 (0.8%) of the 24,406 women not exposed to an SSRI (P=.23). Of the total number of deliveries, 16 newborns were diagnosed as having persistent pulmonary hypertension of the newborn, none of whom had exposure to SSRIs (P>.99). CONCLUSION Our data are reassuring regarding the safety of using SSRIs during pregnancy.

Herceptin (trastuzumab) therapy during pregnancy: association with reversible anhydramnios.

BACKGROUND: Herceptin (trastuzumab), a new a chemotherapeutic agent, is a monoclonal antibody that blocks the human epidermal growth factor receptor 2 protein. There is no reported experience with use of this agent during pregnancy and possible effects on the fetus. CASE: A patient with breast cancer was treated with Herceptin during pregnancy. This treatment was associated with anhydramnios, which resolved slowly after the drug was discontinued. CONCLUSION: Although listed as a category B drug, experience with Herceptin in human pregnancy is limited, and it should be used with caution. Investigation of the role of human epidermal growth factor receptor 2 protein in the embryonic kidney may further our understanding of amniotic fluid dynamics.

Current trends in narcotic use in pregnancy and neonatal outcomes

OBJECTIVE The purpose of this study was to evaluate trends and prevalence of chronic prescription narcotic use during pregnancy and the subsequent neonatal outcomes. STUDY DESIGN We conducted a retrospective cohort study of all deliveries at Mayo Clinic from 1998 through 2009; the data was obtained from prospectively maintained obstetrics and neonatal databases. RESULTS Over the study time period, there were 26,314 deliveries; 167 women used prescription narcotics chronically during pregnancy. The prevalence of women who used chronic narcotics during their pregnancy increased over the time period from 1998-2009 (P < .0001). Neonatal withdrawal syndrome occurred in 10 of neonates (5.6%), and all but 1 of these neonates required pharmacologic treatment for the disease. CONCLUSION Chronic narcotic use during pregnancy is increasing in prevalence. Neonatal withdrawal syndrome occurred in 5.6% of the exposed neonates. Although neonatal withdrawal syndrome is uncommon, it is clinically significant. Physicians need to consider the risks and benefits carefully when prescribing narcotic pain medications during pregnancy.

Obstetric vacuum extraction: state of the art in the new millennium.

This article summarizes the current state of knowledge of obstetric vacuum extraction. The discussed topics include the history of vacuum extraction, indications and contraindications, technique of the procedure, currently marketed instruments, special uses of the vacuum extractor, comparison of vacuum extraction with forceps delivery, and maternal and fetal outcomes. Areas of controversy are identified and discussed. Vacuum extraction is replacing forceps as the preferred method of instrumental delivery. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to summarize the current state of knowledge of obstetric vacuum extraction, to list the indications and contraindications of obstetric vacuum extraction, and to compare vacuum extraction and forcep delivery of the fetus.

Monozygotic twins discordant for partial trisomy 1

A 25-year-old primigravida delivered monozygotic twins discordant for multiple anomalies and partial trisomy 1 mosaicism. The phenotype of partial trisomy 1 includes craniofacial, central nervous system, and ocular anomalies. The most likely explanation for these findings is that the translocation occurred after twinning occurred. This observation emphasizes that monozygotic twins are not necessarily genetically identical. They are identical at conception, but subsequent mutation and rearrangement of the genome may cause substantial phenotypic differences.

Maternal and Fetal Outcome After Colectomy for Fulminant Ulcerative Colitis During Pregnancy: Case Series and Literature Review

PurposePrevious studies have reported high morbidity and mortality in mothers and their offspring after colectomy for ulcerative colitis during pregnancy. This study was designed to assess the maternal and fetal outcomes of pregnant females undergoing colectomy for ulcerative colitis in the current era.MethodsA retrospective analysis was performed at our institution of all pregnant females undergoing operation for ulcerative colitis between 1980 and 2004. To compare this data to that of past literature, a MEDLINE search from 1951 to 2004 reviewed all cases reported on this topic.ResultsBetween 1980 and 2004, five females underwent an operation at our institution for fulminant ulcerative colitis while pregnant. All five patients underwent subtotal colectomy with Brooke ileostomy. Postoperative maternal morbidity included a superficial wound infection and a small asymptomatic intra-abdominal abscess. All females had successful pregnancies, and no maternal or fetal deaths occurred. Two patients went on to have an ileal pouch-anal anastomosis, one had a completion proctectomy and end ileostomy, oneis scheduled for an ileal pouch-anal anastomosis, andone patient is lost to follow-up. The literature review revealed 37 cases. The overall fetal and maternal mortality was 49 and 22 percent respectively. Postoperative maternal morbidity was reported in 24 percent.ConclusionsIn contrast to historic data, the maternal and fetal mortality from our series was zero and maternal morbidity was low. Subtotal colectomy and Brooke ileostomy for ulcerative colitis during pregnancy is safe. A multidisciplinary team that includes a gastroenterologist, high-risk obstetrician, and experienced surgeon is necessary for an optimal outcome.

Prenatal Sonographic Diagnosis of Hemivertebrae Associations and Outcomes

Objective. The purpose of this study was to evaluate associated anomalies and outcomes of fetuses with prenatally diagnosed hemivertebrae. Methods. Fetuses with prenatally diagnosed hemivertebrae, excluding those associated with spina bifida, were identified by searching the prospectively maintained ultrasound databases of 4 institutions from 1997 to August 2007. Associated birth defects were tabulated by organ system and hemivertebra location. Outcomes included karyotypes, gestational ages, and routes and outcomes of deliveries. Results. Nineteen fetuses had a diagnosis of hemivertebrae at a mean gestational age ± SD of 20.5 ± 5.4 weeks. Fourteen (73.7%) fetuses had additional anomalies, of which 5 (35.7%) were syndromic (4 with cloacal exstrophy and omphaloceles and 1 with Jarcho‐Levin syndrome). Karyotypes were normal in all 11 available cases, each of which had additional anomalies. Fourteen (73.7%) neonates were live born at a mean gestational age of 34.9 ± 4.3 weeks, of which 7 (50%) were born by cesarean delivery. Ten neonates (71.4%) were delivered before term, and 4 (28.6%) were growth restricted (<10th percentile). Two (14.3%) of these neonates died; both had cloacal exstrophy and large omphaloceles. The remaining pregnancies were terminated (4 [21.1%]) or had a fetal death (1 [5.3%]). Conclusions. Most fetuses with prenatally diagnosed hemivertebrae have additional anomalies, often syndromic, which affect the prognosis. Affected pregnancies have high rates of cesarean delivery and growth restriction. Neonates with nonisolated hemivertebrae are more often delivered before term and have higher mortality rates.

Targeted treatment using monoclonal antibodies and tyrosine-kinase inhibitors in pregnancy

An expanding knowledge of the signalling pathways involved in the cell cycle has led to great improvements in the understanding of the molecular events involved in carcinogenesis. The past decade has seen substantial advances with the introduction of several classes of targeted therapeutics for the treatment of various cancers and autoimmune disorders. However, the question arises as to whether pregnant women can take advantage of these new treatments in view of the potential risks to the fetus. Published work suggests that biological agents, like traditional treatments, have the potential to affect the fetus, and should, therefore, be used with caution during pregnancy. However, when targeted treatment is clearly indicated the magnitude of the risk to the fetus might not reach that of standard chemotherapy. In circumstances where better alternative treatments do not exist, or where failure to use targeted treatments would result in suboptimum patient care or survival, the risk-benefit analysis might favour the use of potentially effective molecular treatment during pregnancy.

Elevated expression of serine protease HtrA1 in preeclampsia and its role in trophoblast cell migration and invasion

OBJECTIVE Aberrant expression of developmentally regulated genes during placental development could affect fetal growth and contribute to preeclampsia. Expression of serine protease HtrA1 is developmentally regulated with the highest expression in decidua capsularis, compared with ectoplacental cone, and with the highest expression during later stages of pregnancy, compared with early stages. This study was designed to determine the expression of HtrA1 in placental tissues from control and preeclamptic pregnancies and to determine the effect of HtrA1 expression in trophoblast cell migration and invasion. STUDY DESIGN HtrA1 expression was assessed by immunohistochemistry in placentas from gestational age-matched preeclamptic and control pregnancies. HtrA1 expression in extravillous trophoblast cells, HTR-8/SVneo, was assessed by immunoblotting and immunofluorescence microscopy. Finally, the effect of ectopic expression of HtrA1 on cell migration and invasion was determined in HTR-8/SVneo cells. RESULTS Higher expression of HtrA1 was detected in placental tissues collected from patients with early-onset preeclampsia, compared with those from gestational age-matched control samples. Moreover, ectopic expression of HtrA1 significantly attenuates HTR-8/SVneo cell migration and invasion. CONCLUSION Higher expression of HtrA1 is associated with early-onset preeclampsia and may affect trophoblast cell migration and invasion.

Pregnancy and delivery in patients with fontan circulation: a case report and review of obstetric management.

The Fontan connection, originally described in 1971, is used to provide palliation for patients with many forms of congenital heart disease that cannot support a biventricular circulation. An increasing number of women who have undergone these connections in childhood are now surviving into adulthood, and some are becoming pregnant. The low flow and fixed cardiac output of a Fontan circulation pose a number of problems during pregnancy. Here, we report a case of a woman who underwent a Fontan procedure at age 7 and experienced significant cardiovascular decline before successfully delivering a viable infant at 33 weeks gestation. In addition, we reviewed the pertinent published data in this area, which suggests that pregnant patients with a Fontan circulation are more likely to face obstetrical, rather than cardiovascular, complications, including preterm labor, intrauterine growth restriction, an increased risk of cesarean section, and the potential need for anticoagulation. The review provides the obstetrician with the information needed to take a prominent role in the appropriate management of this rare, but growing, patient population. Target Audience: Obstetricians & Gynecologists, Family Physicians Leaning Objectives: After completion of this article, the reader will be able to describe the Fontan circulation, describe the importance of the collaborative practice model for patients with Fontan circulation, and identify potential complications in the pregnancy of women with Fontan circulation.