Dihydroergotamine (DHE) use during gestation and the risk of adverse pregnancy outcomes

Background.— Dihydroergotamine (DHE) is perceived to be associated with a higher risk of adverse pregnancy events, but it has significantly less vasoconstrictive and uterotonic effects compared with ergotamine, and has demonstrated no teratogenic effect in animals. The objectives of this study were to quantify the risk of major congenital malformations (MCMs), prematurity, low birth weight (LBW), and spontaneous abortions (SAs) associated with gestational use of DHE, triptans, and nonsteroidal anti‐inflammatory drugs (NSAIDs). Methods.— Four independent case–control analyses were conducted within the Quebec Pregnancy Registry: (1) MCM; (2) prematurity (<37 weeks of gestation); (3) LBW (birth weight <2500 g); (4) clinically detected SA. Exposure was defined dichotomously as use of DHE, triptan, and NSAIDs during pregnancy. Results.— Overall, 59,707 pregnant women met the eligibility criteria and were considered (53 [0.08%] used DHE, 139 [0.23%] triptans, and 2990 [5.01%] NSAIDs). Adjusting for potential confounders, gestational use of DHE was not significantly associated with the risk of MCM (odds ratio [OR]: 0.97; 95% confidence interval [CI]: 0.22‐4.28), LBW (OR: 1.41; 95%CI: 0.25‐7.80), or SA (OR: 1.97; 95% CI: 0.21‐18.57). DHE use was, however, increasing the risk of prematurity (OR: 4.18; 95% CI: 1.34‐12.99). In users of triptans, the OR for MCM was 1.49 (95% CI: 0.89‐2.52), prematurity 0.76 (95% CI: 0.34‐1.66), LBW 0.83 (95% CI: 0.31‐2.25), and SA 2.65 (95% CI: 1.57‐4.48). In users of NSAIDs, the OR for MCM was 1.20 (95% CI: 1.06‐1.36), prematurity 1.10 (95% CI: 0.95‐1.26), LBW 1.29 (95% CI: 1.08‐1.54), and SA 2.97 (95% CI: 2.63‐3.36). Conclusions.— This study showed that other than for prematurity, DHE use during pregnancy was similar to that of triptan use and was smaller than the risk associated with NSAID use.     

The effectiveness of guideline implementation strategies on improving antipsychotic medication management for schizophrenia

OBJECTIVES: To compare the effectiveness of a conceptually-based, multicomponent "enhanced" strategy with a "basic" strategy for implementing antipsychotic management recommendations of VA schizophrenia guidelines. METHODS: Two VA medical centers in each of 3 Veterans Integrated Service Networks were randomized to either a basic educational implementation strategy or the enhanced strategy, in which a trained nurse promoted provider guideline adherence and patient compliance. Patients with acute exacerbation of schizophrenia were enrolled and assessed at baseline and 6 months and their medical records were abstracted; 291 participants were included in analyses. Logistic regression models were developed for rates of: (1) switching patients from first-generation antipsychotics (FGA) to second-generation antipsychotics (SGA), and (2) guideline-concordant antipsychotic dose. RESULTS: Of participants prescribed FGAs at baseline, those at enhanced sites were significantly more likely than participants at basic sites to have an SGA added to the FGA during the study (29% vs. 8%; adjusted OR = 7.7; 95% CI: 2.0-30.1), but were not significantly more likely to be switched to monotherapy with an SGA (29% vs. 23%). Guideline-concordant antipsychotic dosing was not significantly affected by the intervention. CONCLUSIONS: The enhanced guideline implementation strategy increased addition of SGAs to FGA therapy, but did not significantly increase guideline-recommended switching from FGA to SGA monotherapy. Antipsychotic dosing was not significantly altered. The study illustrates the challenges of changing clinical behavior. Strategies to improve medication management for schizophrenia are needed, and must incorporate recommendations likely to emerge from recent research suggesting comparable effectiveness of SGAs and FGAs.     

Discharge from hospital with newly administered antipsychotics after intensive care unit delirium – Incidence and contributing factors

PurposeDelirium in the intensive care unit (ICU) is often treated with haloperidol or atypical antipsychotics. Antipsychotic treatment can lead to severe adverse effects and excess mortality. After initiation in the ICU, patients are at risk of having their antipsychotics continued unnecessarily at ICU and hospital discharge. This study aims to determine the incidence of, and risk factors for antipsychotic continuation at hospital discharge after ICU delirium.MethodsThis retrospective observational study was performed in a tertiary care center. Adult patients who received antipsychotics for ICU delirium during 2016 were included. Data was extracted from patient records. After univariate testing, a multivariate binary logistic regression model was used to identify independent risk factors for antipsychotic continuation.ResultsA total of 196 patients were included, of which 104 (53.1%) and 41 (20.9%) had their antipsychotics continued at ICU and hospital discharge respectively. Medical ICU admission (odds ratio [95% confidence interval] 2.97 [1.37–6.41]) and quetiapine treatment (5.81 [1.63–20.83]) were independently associated with antipsychotic continuation at hospital discharge.ConclusionsApproximately one in five patients were discharged from the hospital with continued antipsychotics. Hospital policies should implement strategies for systematic antipsychotic tapering and better follow-up of antipsychotics at transitions of care.     

Association of types of diabetes and insulin dependency on birth outcomes

BACKGROUNDDiabetes rates among pregnant women in the United States have been increasing and are associated with adverse pregnancy outcomes.AIMTo investigate differences in birth outcomes (preterm birth, macrosomia, and neonatal death) by diabetes status.METHODSCross-sectional design, using linked Missouri birth and death certificates (singleton births only), 2010 to 2012 (n = 204057). Exposure was diabetes (non-diabetic, pre-pregnancy diabetes-insulin dependent (PD-I), pre-pregnancy diabetes-non-insulin dependent (PD-NI), gestational diabetes- insulin dependent (GD-I), and gestational diabetes-non-insulin dependent (GD-NI)]. Outcomes included preterm birth, macrosomia, and infant mortality. Confounders included demographic characteristics, adequacy of prenatal care, body mass index, smoking, hypertension, and previous preterm birth. Bivariate and multivariate logistic regression assessed differences in outcomes by diabetes status.RESULTSWomen with PD-I, PD-NI, and GD-I remained at a significantly increased odds for preterm birth (aOR 2.87, aOR 1.77, and aOR 1.73, respectively) and having a very large baby [macrosomia] (aOR 3.01, aOR 2.12, and aOR 1.96, respectively); in reference to non-diabetic women. Women with GD-NI were at a significantly increased risk for macrosomia (aOR1.53), decreased risk for their baby to die before their first birthday (aOR 0.41) and no difference in risk for preterm birth in reference to non-diabetic women.CONCLUSIONDiabetes is associated with the poor birth outcomes. Clinical management of diabetes during pregnancy and healthy lifestyle behaviors before pregnancy can reduce the risk for diabetes and poor birth outcomes.     

Magnitude of spontaneous preterm birth and its associated factors among preterm birth in NICU wards in Asella Teaching and Referral Hospital,Asella, Oromia,Ethiopia

ObjectiveTo assess the prevalence of spontaneous preterm births and to identify the associated risk factors.MethodsThis single-centre cross-sectional study enrolled women that experienced a preterm birth as registered on the neonatal log-book between 30 December 2019 and 30 December 2020. A pre-tested structured checklist was used to collect data (sociodemographic characteristics; obstetric-related factors; medical history; and pregnancy-related factors). Bivariate logistic regression analyses were applied to identify factors associated with spontaneous preterm birth. A multivariate model identified significant independent risk factors.ResultsA total of 310 patients participated in the study. The prevalence of spontaneous preterm birth in this population was 67.1% (208 of 310; 95% confidence interval [CI] 61.5, 71.9). Patients without a partner (adjusted odds ratio [AOR] = 1.470, 95% CI 1.23, 4.42), patients residing in a rural area (AOR = 2.51, 95% CI 1.123, 5.513) and those with a history of PIH during their current pregnancy (AOR = 0.104, 95% CI 0.053, 0.014) were significantly more likely to have a spontaneous preterm birth.ConclusionThe prevalence of spontaneous preterm birth in in this study was high. Healthcare providers and all stakeholders should focus on screening pregnant women at the risk of spontaneous preterm birth.     

Neoatherosclerosis assessed with optical coherence tomography in restenotic bare metal and first- and second-generation drug-eluting stents

Although reported in bare metal stents (BMS) and first-generation drug-eluting stents (DES), little is known about neoatherosclerosis in second-generation DES. We used optical coherence tomography to evaluate neoatherosclerosis among different stent generations. Overall, 274 in-stent restenosis (ISR) lesions (duration from implantation 56.9?±?47.2 months) in 274 patients were assessed for the presence of neoatherosclerosis. Neoatherosclerosis was identified in 38.7% of lesions (106/274): 23.0% second-generation DES (38/165), 65.1% first-generation DES (54/83), and 53.8% BMS (14/26). In the neoatherosclerosis cohort (n?=?106), more stent underexpansion or fracture/deformation was observed in second-generation DES, whereas thrombus, without plaque rupture, or evagination was more common in first-generation DES. In multivariable analyses, duration from implantation >1 year (OR: 2.44, 95% CI 1.12–5.31; p?=?0.03), absence of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (OR 1.95, 95% CI 1.10–3.44; p?=?0.02) or statins at the time of ISR (OR 3.12, 95% CI 1.42–6.84; p?=?0.01), and first-generation vs first-generation DES (OR 5.32, 95% CI 2.82–10.10; p?<?0.001) correlated with a higher prevalence of neoatherosclerosis. Duration from implantation <1 year (OR 2.17, 95% CI 1.03–4.55; p?=?0.04) and thin fibrous cap, thrombus, or rupture (OR 2.72, 95% CI 1.15–6.39; p?=?0.02) were independent predictors for acute coronary syndromes presentation. Neoatherosclerosis is an important ISR mechanism, especially in first generation DES.     

Effects of the Dietary Approaches to Stop Hypertension (DASH) on Pregnancy/Neonatal Outcomes and Maternal Glycemic Control: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Background & objectiveNo systematic review to date has appraised the impact of the Dietary Approaches to Stop Hypertension (DASH) eating plan on maternal glycemic control and pregnancy outcomes. Thus, we conducted a systematic review and meta-analysis of randomized clinical trials (RCTs) to ascertain whether the DASH diet in pregnant women ameliorates their glycemic control and neonatal outcomes when compared to standard diets.MethodsWe performed a comprehensive systematic review and meta-analysis of RCTs on PubMed/MEDLINE, Web of Science, SCOPUS, and Embase from the inception until October 2019.ResultsSix studies met the eligibility criteria and were included in the quantitative meta-analysis. The pregnant women had cardiometabolic disorders such as gestational diabetes, obesity, and hypertension. The meta-analysis suggested a significant effect of DASH diet on fasting plasma levels of glucose (WMD = -6.239 mg/dl; 95% CI: -11.915, -0.563, p = 0.031), but not for the homeostasis model assessment of insulin resistance (WMD = -1.038; 95% CI: -2.704, 0.627, p = 0.22). Following the DASH diet during pregnancy decreased the risk of gestational preeclampsia (RR = 0.667; 95% CI: 0.451, 0.987, p = 0.043), macrosomia (birth weight >4000 g) (RR = 0.294; 95% CI: 0.120, 0.721, p = 0.043), and large for gestational age (RR = 0.452; 95% CI: 0.211, 0.969, p = 0.041). Consuming DASH diet during pregnancy neither increased nor decreased the risk of cesarean section, polyhydramnios, preterm birth (<37 weeks), and small for gestational age. The mean newborn head circumference (cm) (WMD = -0.807; 95% CI: -1.283, -0.331, p = 0.001) and ponderal index (kg/m³) (RR = -0.396; 95% CI: -0.441, -0.350, p = 0.000) in the group receiving the DASH diet were lower than in the control group.ConclusionThe adherence of pregnant women with cardiometabolic disorders to DASH eating pattern has a significant effect on decreasing fasting plasma glucose levels, ponderal index, incidence of preeclampsia, fetal macrosomia, large for gestational age, and newborn head circumference.     

First-generation versus second-generation drug-eluting stents in patients with chronic kidney disease: a systematic review and meta-analysis

Background: Chronic kidney disease (CKD) patients are associated with very high rate of adverse cardiovascular outcomes after drug-eluting stents (DES) implantation. The clinical outcomes of second-generation DES versus first-generation DES in CKD patients remain controversial.

Objective: The aim of the current study was to perform a systematic review and meta-analysis to assess the safety and efficacy of second-generation DES versus first-generation DES in CKD patients.

Methods: A systematical search of databases of PubMed, EMBASE, and Cochrane Library was conducted for eligible studies comparing the clinical outcomes of first-generation DES versus second-generation DES. Sirolimus-eluting and paclitaxel-eluting stents were classified as first-generation DES, and everolimus-eluting, zotarolimus-eluting, and biolimus-eluting stent (BES) were classified as second-generation DES. A pooled odds ratio (OR) and 95% confidence interval (CI) were used to summary the estimates. Heterogeneity, subgroup analysis, sensitivity analysis and publication bias were also performed.

Results: We identified 14 trials involving 9,542 patients with CKD undergoing percutaneous coronary intervention. First-generation DES implantation was associated with higher risk of long-term all-cause mortality (OR, 1.31; 95% CI, 1.02–1.69; P = 0.04; I² = 0%), in stent restenosis (OR, 1.69; 95% CI, 1.14–2.49; P = 0.008; I² = 49%) and stent thrombosis (OR, 1.64; 95% CI, 1.00–2.69; P = 0.05; I² = 49%) compared with second-generation DES implantation. First-generation DES and second-generation DES showed similar efficacy in decreasing risk of repeat revascularization, myocardial infarction (MI), or major adverse cardiac events (MACE) between first-generation and second-generation DES implantation.

Conclusions: In CKD patients, the use of second-generation DES was associated with lower risk of long-term all-cause mortality, in stent restenosis and stent thrombosis as compared with first-generation DES. No differences were found regarding repeat revascularization, MI, and MACE.     

2016－2020年海口市新生儿出生缺陷的监测结果及危险因素研究

  目的   了解2016—2020年海南省海口市新生儿出生缺陷发生情况及相关危险因素，为制定预防措施提供参考依据。  方法   选取2016年1月至2020年12月在海南省妇幼保健院和海口市妇幼保健院出生的新生儿31 860名进行回顾性分析，对新生儿出生缺陷的检出率进行统计。 将有出生缺陷患儿设为病例组，另选取与病例组性别、年龄、出生时间匹配的健康新生儿为对照组，采用logistic逐步回归分析新生儿出生缺陷的危险因素。  结果   31 860名新生儿中共检出出生缺陷患儿419例，出生缺陷发生率1.32%。 出生缺陷发生率前5位依次为先天性心脏病、多指（趾）、唇腭裂、神经管缺陷、尿道下裂。 logistic逐步回归分析显示，2016—2017年（OR=2.903，95%CI:1.815～4.612）、异常生育史（OR=2.518，95% CI:1.604～3.805）、出生体质量（OR=5.182，95% CI:3.627～8.519）、孕期饮酒（OR=4.257，95% CI:3.106～6.115）、孕期吸烟（OR=4.613，95% CI:3.327～7.185）、孕早期病毒感染（OR=3.526，95% CI:2.413～5.114）、孕期服药史（OR=8.903，95% CI:5.275～15.927）、孕期有毒物质接触史（OR=7.602，95% CI:4.713～13.165）、孕期营养不良（OR=6.127，95% CI:3.952～11.864）及孕期不良精神刺激（OR=2.308，95% CI:1.462～3.287）是发生出生缺陷的危险因素。  结论   海南省海口市新生儿出生缺陷发生率仍较高，影响新生儿出生缺陷发生的危险因素众多，应针对性地加强孕期健康教育，降低出生缺陷的发生率。     

Statin Use and Risk of Community-Acquired Staphylococcus aureus Bacteremia: A Population-Based Case-Control Study

Objective

To ascertain whether persons treated with statins experience a decreased risk of community-acquired Staphylococcus aureus bacteremia (CA-SAB) as compared with nonusers.

The role of preterm placental calcification in high-risk pregnancy as a predictor of poor uteroplacental blood flow and adverse pregnancy outcome

This prospective cohort study aims to clarify the role of preterm placental calcification in high-risk (i.e., hypertension, diabetes, placenta previa or severe anemia) pregnant women as a predictor of poor uteroplacental blood flow (absent or reverse end-diastolic velocity [AREDV]) and adverse pregnancy outcome. Monthly ultrasound was performed starting at 28 weeks' gestation to establish the diagnosis of Grade III placental calcification, with measurement of Doppler velocimetry in the umbilical vessels at 32 weeks' gestation. The participants were classified into three groups: Group A (n = 776), a low-risk group without antenatal complication; group B (n = 42), a high-risk group with preterm (28 to 36 weeks) placental calcification; and group C (n = 71), a high-risk control group without preterm (<36 weeks) placental calcification. Analyzed by logistic regression, the risks of AREDV (OR 4.32, 95%CI 1.25 to 14.94), adverse maternal outcome including postpartum hemorrhage (OR 3.98, 95% CI 1.20 to 13.20), placental abruption (OR 4.80, 95% CI 1.19 to 19.35), maternal transfer to intensive care unit (OR 3.83, 95% CI 1.10 to 13.33) and adverse fetal outcome including preterm birth (OR 3.86, 95% CI 1.32 to 11.29), low birth weight (OR 2.99, 95% CI 1.11 to 8.03), low Apgar score (OR 5.14, 95% CI 1.64 to 16.08) and neonatal death (OR 4.52, 95% CI 1.15 to 17.73) were greater in group B compared with group C. In contrast, the risks of AREDV and adverse pregnancy outcome were significantly lower in group A than those in group C, except postpartum hemorrhage (OR 0.53, 95% CI 0.19 to 1.46). We conclude that in high-risk pregnant women, the presence of preterm placental calcification is a predictor of poor uteroplacental flow and adverse pregnancy outcome, requiring closer surveillance for maternal and fetal well-being. This finding helps identify the most dangerous population among high-risk pregnant women.     

Investigation of Metronidazole Use during Pregnancy and Adverse Birth Outcomes

To assess whether treatment with metronidazole during pregnancy is associated with preterm birth, low birth weight, or major congenital anomalies, we conducted chart reviews and an analysis of electronic data from a cohort of women delivering at an urban New York State hospital. Of 2,829 singleton/mother pairs, 922 (32.6%) mothers were treated with metronidazole for clinical indications, 348 (12.3%) during the first trimester of pregnancy and 553 (19.5%) in the second or third trimester. There were 333 (11.8%) preterm births, 262 (9.3%) infants of low birth weight, and 52 infants (1.8%) with congenital anomalies. In multivariable analysis, no association was found between metronidazole treatment and preterm birth (odds ratio [OR], 1.02 [95% confidence interval [CI], 0.80 to 1.32]), low birth weight (OR, 1.05 [95% CI, 0.77 to 1.43]), or treatment in the first trimester and congenital anomalies (OR, 0.86 [0.30 to 2.45]). We found no association between metronidazole treatment during the first or later trimesters of pregnancy and preterm birth, low birth weight, or congenital anomalies.     

Risk of preterm birth in primiparous women with exposure to antidepressant medication before pregnancy and/or during pregnancy – impact of body mass index

Introduction: Preterm birth is a major cause of infant mortality. It is unknown whether body mass index (BMI) influences the risk of preterm birth in women, who prenatally use antidepressants.Materials and methods: The study cohort (N = 6920) consists of all primiparous European born women without previously diagnosed diabetes from the city of Vantaa, Finland, who delivered a singleton child between 2009 and 2015. Data on births, pre-pregnancy BMI and purchases of antidepressants from 12 months before conception until delivery were obtained from Finnish National Registers.Results: Of the primiparous women, 9.9% used antidepressants. The overall prevalence of preterm birth was 5.2%. In women with a pre-pregnancy BMI <18.5 kg/m², the Odds Ratio (OR) for preterm birth among antidepressant users compared with those who were non-users was 1.91 (95% confidence intervals [CI] 0.40 to 9.15, adjusted for age, smoking, education, use of fertility treatments and number of previous pregnancies) while in women with a pre-pregnancy BMI ≥30 kg/m², the OR was 0.53 (95% CI 0.21–1.36), respectively.Discussion: Primiparous women using antidepressants, who were underweight before conception should be closely monitored and provided tailored care in a maternity clinic to minimize the risk of preterm birth.

Key messages

• In primiparous women, one in ten used antidepressant medications before pregnancy and/or during pregnancy.
• In primiparous women, the prevalence of preterm birth was 5%.
• Underweight primiparous women using antidepressants should be closely monitored and provided tailored care in a maternity clinic.

     

Neonatal Outcomes Associated With in Utero Exposure to Oxycodone,Overall and by Trimester of Exposure: A Retrospective Cohort Study

Oxycodone is commonly used by pregnant women for the treatment of pain. However, the potential risk associated with its use in pregnancy have not been robustly evaluated. The objective of this study was to examine neonatal outcomes associated with prenatal oxycodone exposure. State dispensing records were matched with midwives records to identify women who had been dispensed oxycodone during pregnancy (n=302). A matched comparison group of women who had been prescribed oxycodone prior to pregnancy was also identified (n=604). Hospital, mortality and congenital abnormality data were obtained for each mother-child dyad. Neonatal outcomes were examined for association with any exposure during pregnancy and trimester specific exposure, using generalized linear models. First trimester exposure was not associated with a significant increased risk of congenital anomalies (OR: 1.74 95%CI: 0.78, 3.87). Second trimester exposure to oxycodone was associated with reduction in average length of gestation (aCoef:-0.83, 95%CI: -1.26, -0.41) and birth weight (aCoef:-188, 95%CI: -299, -76). Second trimester exposure was also associated with an increased risk of very preterm birth (<32 weeks) (OR: 5.03, 95%CI: 1.95, 12.98) and admission to the special care nursery (aOR:1.99, 95%CI: 1.30, 3.03). Third trimester exposure to oxycodone was associated with a reduction in average length of gestation (aCoef:-0.33, 95%CI: -0.63, -0.02) compared with the comparison group. The use of oxycodone in pregnancy was not associated with an increased risk of congenital anomalies. However, oxycodone exposure was associated with a short period of gestation, preterm birth, and NAS, which likely contributed to a longer period of hospitalization following birth.PerspectiveThis article assesses the neonatal risks associated with prenatal exposure to oxycodone, providing clinicians and patients with important information on the safety of oxycodone in the treatment of pain in pregnancy.     

Prenatal exposure to loratadine in children with hypospadias: a nested case-control study within the Danish National Birth Cohort

The aim of this study was to examine the risk of hypospadias after reported exposure to loratadine and other antihistamines during pregnancy, based on data from the Danish National Birth Cohort. We examined the risk of hypospadias in a nested case-control design based on women enrolled in the Danish National Birth Cohort from 1998 to 2002 ( approximately 95,000 pregnant women). Data on maternal use of medicine in pregnancy were retrieved from questionnaires and telephone interviews, and data on birth outcomes were obtained from the Hospital Discharge Registry (HDR). Within the Danish National Birth Cohort, we identified cases with a diagnosis of hypospadias and randomly selected 10 controls per case without such a diagnosis (matched by date of birth). We identified 203 cases of hypospadias recorded in the HDR within 1 year postpartum and 2030 controls. One case (0.5%) and 25 (1.2%) controls reported exposure to loratadine in the first trimester or up to 30 days before the time of conception. The adjusted odds ratio (OR) for hypospadias among users of loratadine relative to nonusers was 0.9 (95% CI: 0.1-6.9) and the corresponding OR for other antihistamines was 0.5 (95% CI: 0.1-1.9). These data do not indicate an increased risk of hypospadias associated with maternal exposure to loratadine. In addition, this study does not suggest any risk differential between maternal exposure to loratadine and other antihistamines. However, the statistical precision of the risk estimates was low.