Pregnancies of women with epilepsy: a population-based study in Iceland

PURPOSE: Women with epilepsy who become pregnant are commonly considered to be at high risk for complications during pregnancy or delivery. The offspring are also considered to have increased risk of perinatal mortality, congenital malformations, and maturational delay. Because few of these studies are population based, potential bias exists because of selection. METHODS: We performed a historical population-based cohort study in Iceland to determine the prevalence of epilepsy among pregnant women, to identify pregnancy and delivery complications in women with epilepsy, and to determine the outcome of their pregnancies as compared with that in the general population of Iceland. We identified all women with active epilepsy who gave birth during a 19-year period in Iceland. RESULTS: In this population, 3.3 in 1,000 pregnancies involve mothers with active epilepsy. The frequency of adverse events (AE) during pregnancy in the women with epilepsy is similar to that observed among all live births in the population, but cesarean section was performed twice as frequently as in the general population. Perinatal mortality rate and mean birth weight are not significantly different in the offspring of women with epilepsy as compared with rest of the population. The risk of major congenital malformations (MGM) is increased 2.7-fold over that expected when a mother is treated with antiepileptic drugs (AEDs) during a pregnancy. CONCLUSIONS: Our study indicates that the rate of complications of pregnancy in mothers with active epilepsy is low and similar to that of the general population with epilepsy. Use of AEDs by the mother during pregnancy significantly increases the risk of MGM in the offspring.     

Thrombophilia, anticoagulant therapy and pregnancy

Thromboembolic complications during pregnancy are the most common causes of maternal death. Here we report on thromboembolic prophylaxis of 60 pregnancies of 32 pregnant women with familial thrombophilia. Long-term Fraxiparine (Sanofi-Chinoin) as thromboprophylaxis was applied in 26 cases throughout pregnancy. UFH (Heparin-Ca inj.) was used in 11 cases, and there were 23 pregnancies without thromboembolic prophylaxis in our patient's case histories. Artificial abortions were not included in this paper. The ratio of successful pregnancies were: with Fraxiparine: 24/26 (92.3%), with UFH (Heparin-Ca): 8/11 (72.7%), without prophylaxis: 4/23 (17.4%). In the patient group treated with Fraxiparine there were no foetopathy, thrombocytopenia or bleeding complication. LMWH is recommended for pregnant women with familial thrombophilia. According to literature data and our own experiences the doses of LMWH in patients with familial thrombophilia, and -antiphospholipid syndrome, and -artificial heart value are suggested.     

The use of dimethylsulfoxide for fixation of yeasts for electron microscopy

Increasing numbers of young women with ovarian failure and women of advanced reproductive age (> 40 yrs) utilize oocyte donation to treat their infertility. In both groups, women who become pregnant frequently experience multiple gestation, occurring in up to 30% of pregnancies. Advanced maternal age and high-order multiple gestations are associated with an increased risk for obstetric complications. We reviewed the pregnancies of patients with high-order multiple gestations (> or = 3 gestational sacs) with respect to their antepartum course and neonatal outcomes. Mothers were divided into two groups according to age at conception; Group I (> or = 40 yr, n = 20) and Group II (< 40 yr, n = 10). These 30 high-order multiple gestations were found among 127 successful oocyte donation cycles (23.6% of all pregnant patients). Data regarding pregnancy outcomes were gained by chart review and telephone interview. Results demonstrated spontaneous reductions in the number of implantation sites were similar between groups (Group I: 21.4% vs. Group II: 17.6%). Multifetal pregnancy reduction (MFPR) was more often chosen by older women (Group I: 45% vs. Group II: 10%; P < 0.05). Antenatal complications were commonly experienced by both groups (> 80%) as were operative deliveries (> 85%). However, neonatal outcomes were generally good, with only one death occurring in the 79 delivered infants (1.3%). We conclude transferring supernumerary embryos to women undergoing ovum donation places patients at great risk for high-order multiple gestations. These pregnancies are associated with increased antenatal and neonatal complications. Although advanced maternal age is normally an added risk factor, well-screened older patients carrying high-order multiple gestations experienced similar outcomes as younger mothers.     

Venous thromboembolism, radiology by the organ, combined diagnostic imaging, clinical radiology

OBJECTIVE: To describe mortality and morbidity during a period of 2 years after coronary artery bypass grafting (CABG) in relation to a history of hypertension. PATIENTS: All patients in western Sweden in whom CABG was undertaken between June 1988 and June 1991 and in whom simultaneous valve surgery was not performed were included in the study. DESIGN: A prospective 2-year follow-up study. RESULTS: Patients with a history of hypertension (n = 777) differed from patients without such a history (n = 1348) in that the proportion of women was higher, they were older and more frequently had a history of congestive heart failure, diabetes mellitus, renal dysfunction, cerebro-vascular disease, intermittent claudication and obesity, and the number of smokers and patients with previous CABG was lower. They were also more likely to develop post-operative cerebrovascular complications and signs of myocardia damage. Patients with hypertension tended to have increased mortality during the first 30 days after CABG and the late mortality (between day 30 and 2 years) was significantly higher than in non-hypertensive participants. Whereas the development of myocardial infarction was similar in both groups, the hypertensive study participants more frequently developed stroke during 2 years of follow-up. In a multivariate analysis including age, sex, history of different cardiovascular diseases, smoking, ejection fraction, and the occurrence of three-vessel disease, hypertension did not emerge as an independent predictor of death in the early or late phase or during a total of 2 years of follow-up. CONCLUSION: Among CABG patients, those with a history of hypertension have a different pattern of risk factors. They have a higher mean age, include a higher proportion of women and have a higher prevalence of congestive heart failure, diabetes mellitus, renal dysfunction, cerebro-vascular disease, intermittent claudication, and obesity. They also have an increased frequency of immediate post-operative complications and an increased 2-year mortality, even if a history of hypertension was not an independent predictor of death during 2 years of follow-up.     

Screening for gestational diabetes: who? How?

Despite many international conferences, there is no consensus on gestational diabetes mellitus and many groups only screen those women who present risk factors or who present during pregnancy complications attributable to this condition. Nevertheless, complications secondary to gestational diabetes are equally frequent whether the mother presents risk factor or not, and these risk factors are only present in 30 to 45% of gestational diabetes. Therefore, all pregnant women should be screened ... or none at all. The type of screening test to be used is just as controversial. The test proposed by the WHO alone allows screening and diagnosing simultaneously, but the cut-off value at 7.8 millimoles for post-charge glycemia seems to be too low for a pregnant woman, at the end of the second trimester. The real question of whether screening for and treating gestational diabetes will actually decrease perinatal morbidity and long-term complications for the mother and the infant cannot be answered as of yet. A large prospective study would be needed, including a control group that would not be treated despite pathological glucose levels, which is ethically inconceivable.     

Spontaneous recovery of impaired memory span: does comprehension recover?

Low back pain is common during pregnancy and is of moderate or severe intensity in about one fourth of all pregnancies. The etiology is multifactorial but in most cases is related to the physical and physiologic changes brought about by pregnancy. For most women, the pain resolves spontaneously, although they remain at higher risk for increased LBP in future pregnancies and for the development of symptomatic disc disease in later life. Many of the common treatments for LBP are contraindicated or must be modified in this setting. Neurologically symptomatic herniated discs are rare during pregnancy, yet, when indicated, pregnant women can safely undergo surgery.     

Measles and pregnancy. Apropos of 16 cases in Burkina Faso

We report an epidemic of 16 cases of measles during pregnancy. The risk factors for such an association and the materno-fetal outcomes are presented. The mean age of the patients was 20.6 years, with a mean gravidity and parity of 2.1 and 1.1 respectively. The mean clinical features were: conjunctivitis, hyperthermia and cutaneous rash. Nine maternal complications occurred: 6 laryngitis and 3 pneumopathies. All patients were HIV negative. The outcomes of the pregnancy were the following: 2 abortions, 3 stillbirths, 1 preterm delivery and 2 full term births. Eight patients with ongoing pregnancies were lost to follow-up after their discharge from the hospital. We conclude on the need for a systematic prevention in exposed pregnant women by immunotherapy and in children by immunization.     

Sexuality, reproduction, and family planning in women with schizophrenia

This article reviews data about how schizophrenia affects sexuality, pregnancy, the puerperium, parenting, and family planning. Women with schizophrenia have high rates of coerced sex, sexual risk behavior, and unwanted pregnancies. High rates of obstetric complications and custody loss increase morbidity for women and their offspring. Since untreated psychosis increases these problems, the risks of withholding pharmacotherapy must be weighed against the risks of prescribing medications during pregnancy. The puerperium is a time when women are especially vulnerable to exacerbations of schizophrenia. Mothers with schizophrenia may have a reduced ability to read children's cues, and they often have weak social support networks. Their children may be more difficult to raise than other children. Parenting rehabilitation can address some of these problems. Often, women with schizophrenia who are sexually active and do not wish to become pregnant do not use contraception. Incorporating family planning measures into mental health care delivery systems may reduce unwanted pregnancies.     

Functional insulin therapy and pregnancy

Pregnant type-I diabetic women have to be treated in an experienced diabetes center where optimal cooperation and exchange of knowledge between obstetrician, diabetologist and neonatologist is guaranteed. Given optimal preconceptional metabolic control and thorough guidance throughout pregnancy maternal and fetal risk of type-I diabetic patients without severe diabetic late complications is similar to that of healthy pregnant women. "Near-normoglycemic" metabolic control and meticulous prevention of severe and long-standing hypoglycemic episodes can be achieved throughout pregnancy by functional insulin therapy employing a basis-bolus regime of insulin administration with frequent blood glucose self control (more than 6 times a day). Non-compliant diabetic patients and those with severe diabetic late complications represent a high-risk group for complications in pregnancy. To avoid such risks special care and preconceptional information is mandatory.     

Pregnancy outcomes among women with and without diabetic microvascular disease (White's classes B to FR) versus non-diabetic controls

The objective of this paper is to evaluate the impact of contemporary management on the maternal and neonatal outcomes of pregnancies complicated by diabetes in women with microvascular disease versus women without microvascular disease. The study population consisted of two hundred and eighty-eight (288) pregnant women with pregestational diabetes and one hundred and fifty (150) healthy pregnant controls. Diabetic women were grouped according to the presence (n = 103) or absence of diabetic microvascular disease (n = 185). Data were collected regarding diabetes management, level of glycemic control, and the development of antenatal complications. Maternal and neonatal outcomes were compared among the three groups. Women in the diabetes groups were stratified according to mean blood glucose levels and glycosylated hemoglobin during each trimester. There was no significant difference found between the two diabetes groups in terms of preterm labor, polyhydramnios, pyelonephritis, and growth restriction. The only maternal complications that occurred with increased incidence among women with microvascular disease were acute hypertensive complications (51.6 vs. 32.9%; p<0.05). However, when the diabetes groups were compared to healthy controls, a significant difference was seen in all maternal and neonatal complications. Preterm delivery, polyhydramnios, and large-for-gestational-age (LGA) infants were associated with poor third-trimester metabolic control as compared with others in satisfactory metabolic controls: 30.8 vs. 11.4% for preterm delivery; 17.3 vs. 5.1% for polyhydramnios; 51.9 vs. 33.9% for LGA; p<0.05. Congenital malformations were associated with poor first-trimester glucose control (5.8 vs. 1.3% anomalies in well-controlled women). Furthermore, major congenital malformations were also significantly increased in the offspring of women with diabetic microvascular disease 6.8%, as compared to 1.69% in diabetic women without microvascular disease; p<0.01. The incidence of hypertensive complications did not differ between the two diabetic groups. Pregestational diabetic women with and without microvascular disease can be counseled to anticipate comparably favorable pregnancy outcomes, although maternal and neonatal complications may exceed that experienced by pregnant women without diabetes mellitus.     

Scleroderma and pregnancy

Pregnancy in systemic sclerosis may be uneventful, with both good maternal and fetal outcomes. Because scleroderma is a multisystem disease and complications do occur, however, careful antenatal evaluations, discussion of potential problems, and participation in a high-risk obstetric monitoring program is very important to optimize the best outcome. Because women with diffuse scleroderma are at greater risk for developing serious cardiopulmonary and renal problems early in the disease, they should be encouraged to delay pregnancy until the disease stabilizes. All patients who become pregnant during this high-risk time should be monitored extremely carefully. Although there are some suggestions that there are increases in infertility and miscarriages before disease onset, recent studies show that these issues probably do not have major impact for women with established scleroderma who plan to become pregnant. The high risk of premature and small infants may be minimized with specialized obstetric and neonatal care, however. Renal crisis in scleroderma is the only truly unique aspect of these pregnant, which, unlike blood pressure elevation in nonscleroderma pregnancies, must be treated aggressively with ACE inhibitors. Other pregnancy problems may not be unique to scleroderma, but because it is a chronic illness, any complication carries higher risks for both mother and child. Careful planning, close monitoring, and aggressive management should allow women with scleroderma to have a high likelihood of a successful pregnancy.     

Fetal survival in abdominal pregnancy: a review of 11 cases

PURPOSE: Little has been written regarding the ultrasound imaging features that might allow prediction of fetal viability in abdominal pregnancies. Toward this goal, we present our experience with a series of 11 abdominal pregnancies. MATERIALS AND METHODS: From 1981 to 1993, 11 patients presented to Universidad Catolica, Santiago, and Universidad de Austral, Valdivia, Chile, with third trimester abdominal pregnancies. Five had complete ultrasound examinations, and these five patients were managed expectantly. The other six women presented as acute abdominal emergencies and underwent emergent surgery. RESULTS: Four of five fetuses that survived had a complete placental attachment to the uterus, and one surviving neonate had a partial attachment of the placenta to the uterus. Three fetuses died prior to delivery, and all three had a complete mesenteric placental attachment. Two died in the early neonatal period. One had a complete uterine placental attachment, and the other had a partial attachment. CONCLUSIONS: The survival rate of abdominal pregnancies may be better than is generally believed. Placental attachment to the uterus appears to be a factor related to fetal survival and maternal morbidity. More cases are necessary to determine the feasibility of managing women with abdominal pregnancies expectantly.     

Uterine leiomyosarcoma with subsequent pregnancy]

Leiomyosarcoma are malignant tumors showing smooth muscle differentiation, they are rare, representing only about 25 percent of all uterine sarcomas and mixed malignant tumors and slightly more than 1 percent of all corporeal malignant tumors. Usually they arise in postmenopausal women and are not known to be related to the known risk factors for endometrial carcinoma (nulliparity, obesity, diabetes mellitus, hypertension, etc.) or carcinosarcoma (prior radiation therapy). They may occur in uteri that also bear typical benign leiomyomas, but leiomyosarcoma rarely can be proven to have arisen in or from benign leiomyomas. We report on two premenopausal women with leiomyosarcoma--out of totally 31 cases in our clinic from 1975-1995 who got pregnant after surgical treatment preserving the uterus. The patients are alive without evidence of disease 3 and 6 years after surgical resection.     

Behavioral adjustment in children of diabetic mothers

The aim of this study was to evaluate whether maternal diabetes in pregnancy may adversely affect the children's behavioral adjustment, in a sample of 201 mothers (68 with pre-gestational diabetes, 50 with gestational diabetes, and 83 with non-diabetic pregnancies) and their singleton offspring. After accounting for socioeconomic status, ethnicity and maternal attitudes, none of the Child Behavior Checklist ratings correlated significantly with maternal patient group or several indices of antepartum maternal metabolism. Child obesity, a common sequela of diabetic pregnancies, correlated positively with Internalizing Behavior problems and three narrow-band sub-scales: Somatic Complaints, Anxious/Depressed, and Social Problems. Results suggest that children of diabetic mothers are at increased risk for a variety of developmental disturbances. Screening for learning and behavioral difficulties should be made at regular pediatric visits, with follow-up evaluations warranted by positive indications, excessive weight gain, or other evolving medical concerns.     

Family planning: an essential component of prenatal care

This nation's traditional approach to improving maternal and infant health has been prenatal care. But evidence is mounting that additional progress in reducing maternal and infant morbidity and mortality will depend, at least in part, on the care that a woman receives before she conceives. The studies reviewed in this paper indicate that increasing the interval between deliveries and preventing or delaying pregnancies among women at high risk could lower the rate of low birthweight (LBW). Since reducing the rate of unintended pregnancies would also reduce the number of pregnancies in women at high risk of LBW because of race, age, late or no prenatal care, and unhealthy behaviors, the prevention of unintended pregnancies would also reduce LBW. Unfortunately, prenatal care, as experienced by many women, devotes little attention to these family planning issues. Many women do not realize the importance of family planning to their own health and that of their children. Prenatal care providers should include instruction about the importance of pregnancy planning and encourage women to continue receiving health care between pregnancies. If the health of women and infants is to be improved, society must be willing to provide health services to women of reproductive age even when they are not pregnant.     

Hypothyroid women need more thyroxine when pregnant

BACKGROUND: There have been several published reports that hypothyroid women do not need to increase the dose of levothyroxine when they become pregnant. METHODS: For this study, 20 pregnant women who were hypothyroid as a result of surgical thyroidectomy, radio-iodine therapy, or combination therapy were followed for the duration of their pregnancies. These patients were seen regularly, and evaluated clinically and by measurement of free thyroxine (FT4) and thyrotropin (thyroid-stimulating hormone [TSH]). RESULTS: The amount of levothyroxine that was adequate in the nonpregnant state was found to be inadequate during pregnancy. The dosage of levothyroxine given to these patients was increased by an average of 36 micrograms and returned to earlier levels after delivery. There was considerable individual variation in the requirement for additional levothyroxine during pregnancy. CONCLUSIONS: For hypothyroid pregnant patients, thyroid function tests, especially TSH, are recommended during each trimester to determine the need for additional levothyroxine.     

Use of enzyme replacement therapy for Gaucher disease during pregnancy

OBJECTIVE: To date there has been little published experience with enzyme replacement therapy in pregnant women with symptomatic type I Gaucher disease. STUDY DESIGN: We describe six patients, including three with repeated early pregnancy loss, five of whom successfully carried pregnancies to term; the last pregnancy was terminated because of pulmonary hypertension. RESULTS: All pregnancies were uneventful and five resulted in healthy newborns. CONCLUSION: We concluded that in patients with Gaucher disease of childbearing age,for whom obstetric complications are an important symptom of the disease, pregnancy is not contraindicated (unless there is evidence or suspicion of pulmonary hypertension) and treatment should not be interrupted because the clinical improvement engendered by enzyme replacement therapy is conducive to fewer complications during pregnancy and delivery and post partum.     

Electroneurography during facial nerve expansion

BACKGROUND: The use of plasma-exchange therapy has increased the longevity of patients with homozygous familial hypercholesterolemia (HFH), and pregnancy in affected women is expected to become more common. We describe the clinical course, feasibility and risks of repeated pregnancies in patients with HFH treated by long-term plasma exchange. METHODS: We followed the clinical course of five pregnancies in two HFH patients, with attention to the effect of repeated plasma exchange on maternal and fetal status; specifically, lipid profile, hemodynamics, and uteroplacental circulation on Doppler flow study. RESULTS: Increasing the frequency of plasma-exchange therapy prevented the extreme serum cholesterol elevation that occurs in pregnant HFH patients and was associated with a significant improvement in uteroplacental circulation. In four pregnancies the clinical course was uneventful, ending in normal deliveries of full-term infants with heterozygous familial hypercholesterolemia. The third pregnancy of one of the patients had to be terminated owing to the development of hypotension and syncope during plasma exchange because of severe aortic stenosis. CONCLUSIONS: Repeated pregnancies in HFH patients treated by long-term plasma exchange are feasible but may be associated with untoward effects, especially hemodynamic compromise. The frequency of plasma exchange therapy should be increased to prevent marked hypercholesterolemia and its possible deleterious effect on maternal and fetal status. Cardiac evaluation with close hemodynamic monitoring are needed during pregnancy to detect complications of the cardiac valvular lesion and the coronary atherosclerosis that are associated with HFH.     

Ectopic pregnancy in women who use intrauterine contraceptive devices]

This study analyzes occurrence of ectopic pregnancies in women using intrauterine contraceptive devices. During a 5-year period, 1990-1994, 524 women with ectopic pregnancies underwent surgery at our Clinic, while 22 (4.2%) had intrauterine devices. At admission most patients had signs of heavy intraabdominal bleeding, so in 77.27% cases the diagnosis was made by punction of the Douglas area, and only in 9.09% by laparoscopy, that is other methods for early detection of diseases. Rupture of the fallopian tube occurred in 50% of patients, tubal abortions in 36.36% and ovarian pregnancies in 13.64%, whereas 18 salpingectomies and 4 adnexectomies were performed. Late diagnosis and impossibility of performing conservative operations on fallopian tubes are the consequence of disregarding the possibility of getting pregnant by the users of intrauterine devices themselves, as well as by physicians whose help is asked for after symptoms appear.     

The influence of sex hormones on obesity across the female life span

Women have a higher prevalence of obesity than men in most developed countries. Obesity affects many aspects of women's health by increasing risk for heart disease, diabetes, breast cancer, and infertility. One reason for the gender difference in obesity may be that fluctuations in reproductive hormone concentrations throughout women's lives uniquely predispose them to excess weight gain. Studies in experimental animals and women have shown that hormonal changes across the menstrual cycle affect calorie and macronutrient intake and alter 24-hour energy expenditure. Pregnancy is a significant factor in the development of obesity for many women. Various factors are associated with excess weight retention following pregnancy, including weight gain during pregnancy, ethnicity, dietary patterns, and interval between pregnancies. There is a need to tailor recommendations for energy intake during pregnancy to individual women, and recent evidence also suggests that the timing of weight gain during pregnancy is a critical factor. Menopause is also a high-risk time for weight gain in women. Although the average woman gains 2-5 pounds during menopausal transition, some women are at risk for greater weight gains. There is also a hormonally driven shift in body fat distribution from peripheral to abdominal at menopause, which may increase health risks in older women. Hormone therapies have varying impacts on body weight and fat distribution. In summary, hormonal fluctuations across the female life span may explain the increased risk for obesity in women. Awareness of these factors allows development of targets for prevention and early intervention.