Menu
您现在的位置: 首页 >继续教育
What's new in obstetrics and gynecology(1)-Obstetric
时间:2012.09.28
点击数:
字体:

Hydroxychloroquine for the prevention of cardiac neonatal lupus — Findings from a retrospective study indicate that hydroxychloroquine use during pregnancy in women with anti-SSA/Ro antibodies who had previously given birth to a child with cardiac neonatal lupus (cardiac-NL) is associated with a decreased recurrence rate of cardiac-NL [1]. This study included 257 pregnancies (40 exposed and 217 unexposed to hydroxychloroquine), with data collected from neonatal lupus registries in the United States, France, and the United Kingdom. Pregnancies were included regardless of whether or not the mother had an associated autoimmune disease. Findings are consistent with results from earlier case control series. A prospective open label study to confirm these observations is ongoing. Based upon current data, we suggest preemptive treatment with hydroxychloroquine (400 mg orally once a day) in pregnant women with anti-SSA/Ro antibodies who have previously given birth to a child with cardiac-NL, regardless of maternal health. Hydroxychloroquine should be initiated between six and ten weeks gestation in women who are not already on the medication. (See "Neonatal lupus", section on 'Preemptive treatment'.)


Benzodiazepines during lactation — Benzodiazepines should be used cautiously during lactation; the main concern is sedative withdrawal in nursing infants. Although sedation in infants (and mothers) is a potential problem, the risk appears to be low. In a prospective study of mothers who used benzodiazepines (primarilylorazepam, clonazepam, and midazolam) while breastfeeding, central nervous system depression (defined as sleepiness, poor latching, limpness, or lack of response to stimuli) in infants was an infrequent finding (affecting 2 out of 124, or 1.6 percent) [2]. (See "Use of psychotropic medications in breastfeeding women", section on 'Benzodiazepines'.)

Hyperimmune globulin for treatment of primary CMV infection in pregnancy — In a prospective observational study, administration of intravenous hyperimmune globulin to pregnant women with primary cytomegalovirus infection (CMV) in early pregnancy was associated with a significant reduction in the rate of poor infant outcome at one year of age (13 percent with maternal treatment versus 43 percent without maternal treatment) [3]. Although this therapy is a promising approach for reducing poor outcomes in congenital CMV infection, these and other available data are insufficient evidence to recommend routine treatment of pregnant women with primary CMV infection in early pregnancy. Randomized trials are underway. (See "Cytomegalovirus infection in pregnancy", section on 'Hyperimmunoglobulin'.)

Insulin detemir assigned to pregnancy category B — In March 2012, insulin detemir received US Food and Drug Administration (FDA) approval for reclassification to pregnancy category B from pregnancy category C, based on data from a randomized trial that reported the safety and efficacy of detemir were not inferior to Neutral Protamine Hagedorn (NPH) in pregnant women [4]. We do not consider the available data on insulin detemir sufficiently compelling to recommend routinely using this insulin instead of NPH in pregnancy. However, if a patient has well-controlled glucose levels on insulin detemir prior to pregnancy, the provider may reasonably choose to continue it, with ongoing assessment of glycemic control during pregnancy. (See "Medical management of type 1 and type 2 diabetes mellitus in pregnant women", section on 'Type of insulin'.)

Effect of breastfeeding on the glucose tolerance test — Breastfeeding during the oral two-hour 75 gram glucose tolerance test appears to have a modest effect on glucose levels. In a prospective cohort study of nursing women with previous gestational diabetes who underwent a glucose tolerance test 6 to 9 weeks postpartum, mean two-hour glucose levels were 5 percent lower in women who breastfed during the test [5]. (See "Medical management and follow-up of gestational diabetes mellitus", section on 'Follow-up and prevention of type 2 diabetes'.)

Prevention of varicella-zoster infection after exposure — In the past, passive immunization with VariZIG was recommended within four days of exposure to varicella for nonimmune children and adults who are not candidates for varicella vaccine (eg, persons with malignancy, immunocompromise, or pregnant women). However, limited data suggest that the incidence of varicella is comparable among persons who receive passive immunization within four days of varicella exposure or within 5 to 10 days of exposure [6,7]. Based on these data, the US Food and Drug Administration (FDA) has extended the window of passive immunization after varicella exposure from 4 to 10 days [8]. When postexposure prophylaxis is indicated and active immunization is contraindicated, passive immunization with VariZIG should be offered as soon as possible. (See "Post-exposure prophylaxis against varicella-zoster virus infection", section on 'VariZIG'.)

Pessary for short cervix — A multicenter trial randomly assigned 385 pregnant women with cervical length ≤25 mm at 20 to 23 weeks to use of a cervical pessary or expectant management (no pessary) [9]. The majority of these patients (89 percent) had no history of previous preterm birth and none were treated with progesterone or cerclage. The pessary group had a significantly lower rate of spontaneous preterm birth <28 and <34 weeks than the expectant management group. Although promising, we do not recommend implementation of this approach instead of vaginal progesterone until these data are confirmed by additional randomized trials. (See "Transvaginal ultrasound assessment of the cervix and prediction of spontaneous preterm birth", section on 'Singleton, no prior preterm birth'.)

Progesterone for short cervix — In a meta-analysis of individual patient data from five placebo-controlled randomized trials of progesterone supplementation of women with asymptomatic midtrimester sonographic short cervix, progesterone supplementation was associated with a 30 to 50 percent reduction in preterm birth <28, <33, and <35 weeks and a 40 percent reduction in composite neonatal morbidity and mortality [10]. These benefits were similar at progesterone doses of 90, 100, and 200 mg daily and for women with and without a history of prior preterm birth. Beneficial effects were noted at cervical lengths <10 mm, 10 to 20 mm, and 21 to 25 mm, but only the 10 to 20 mm group reached statistical significance. (See "Progesterone supplementation to reduce the risk of spontaneous preterm birth", section on 'Short cervix in current pregnancy'.)

Hypothyroidism during pregnancy — A randomized trial compared neurocognitive outcomes in children of women with subclinical hypothyroidism who were or were not treated with levothyroxine during pregnancy [11]. Twenty-one thousand eight hundred and forty-six pregnant women (gestational age <15 weeks), without known thyroid disease, were randomly assigned to a screening or control group. All women had blood drawn for thyrotropin (TSH) and free T4, but only serum samples from the screening group were immediately assayed. Serum samples from the control group were stored and assayed after delivery. Patients in the screening group who had TSH above the 97.5th percentile (>3.65 mU/L), serum free T4 below the 2.5th percentile, or both were treated with levothyroxine to achieve a TSH between 0.1 and 1.0 mU/L. IQ testing was performed in the children of mothers in the screening and control groups who had tested positive for thyroid dysfunction. There was no difference in the IQ of the children at three years of age or in the proportion of children with IQ score <85. (See"Hypothyroidism during pregnancy: Clinical manifestations, diagnosis, and treatment", section on 'Cognitive impairment'.)

Prenatal SSRI exposure and PPHN — In a population-based study that included more than 1.6 million live births from five Nordic countries, filling a prescription for selective serotonin reuptake (SSRI) use after 20 weeks of gestation was associated with a two-fold increase in persistent pulmonary hypertension of the newborn (PPHN) [12]. This resulted in a small absolute increase of PPHN (1.2 per 1000 births for the unexposed population to 2.9 per 1000 births for late prenatal exposure to SSRI).

In a 2011 review of their 2006 public health advisory regarding the possibility of an increased risk of PPHN in infants with late prenatal exposure to SSRIs, the US Food and Drug Administration (FDA) concluded that it was not yet possible to establish a link between SSRI use in pregnancy and PPHN and recommended that health care professionals not alter their clinical management of depression during pregnancy based on a concern of PPHN in the offspring [13]. Of note, the FDA report did not include the Nordic study, as it was published after the FDA review. However, the reported absolute increase in the incidence of PPHN is so small that we continue to suggest following the 2011 FDA recommendation of not altering effective SSRI therapy during pregnancy. (See"Infants with antenatal exposure to serotonin reuptake inhibitors", section on 'Persistent pulmonary hypertension'.)


1. zmirly PM, Costedoat-Chalumeau N, Pisoni CN, et al. Maternal Use of Hydroxychloroquine Is Associated With a Reduced Risk of Recurrent Anti-SSA/Ro-Antibody-Associated Cardiac Manifestations of Neonatal Lupus. Circulation 2012; 126:76.

2. elly LE, Poon S, Madadi P, Koren G. Neonatal Benzodiazepines Exposure during Breastfeeding. J Pediatr 2012; 161:448.

3. isentin S, Manara R, Milanese L, et al. Early primary cytomegalovirus infection in pregnancy: maternal hyperimmunoglobulin therapy improves outcomes among infants at 1 year of age. Clin Infect Dis 2012; 55:497.

4. athiesen ER, Hod M, Ivanisevic M, et al. Maternal efficacy and safety outcomes in a randomized controlled trial comparing insulin determir with NPH insulin in 310 pregnant women with type 1 diabetes mellitus. Diabetes Care 2012; :in press.

5. Gunderson EP, Crites Y, Chiang V, et al. Influence of breastfeeding during the postpartum oral glucose tolerance test on plasma glucose and insulin. Obstet Gynecol 2012; 120:136.

6. Koren G, Money D, Boucher M, et al. Serum concentrations, efficacy, and safety of a new, intravenously administered varicella zoster immune globulin in pregnant women. J Clin Pharmacol 2002; 42:267.

7. vans EB, Pollock TM, Cradock-Watson JE, Ridehalgh MK. Human anti-chickenpox immunoglobulin in the prevention of chickenpox. Lancet 1980; 1:354.

8. enters for Disease Control and Prevention (CDC). FDA approval of an extended period for administering VariZIG for postexposure prophylaxis of varicella. MMWR Morb Mortal Wkly Rep 2012; 61:212.

9. oya M, Pratcorona L, Merced C, et al. Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial. Lancet 2012; 379:1800.

10. omero R, Nicolaides K, Conde-Agudelo A, et al. Vaginal progesterone in women with an asymptomatic sonographic short cervix in the midtrimester decreases preterm delivery and neonatal morbidity: a systematic review and metaanalysis of individual patient data. Am J Obstet Gynecol 2012; 206:124.e1.

11. azarus JH, Bestwick JP, Channon S, et al. Antenatal thyroid screening and childhood cognitive function. N Engl J Med 2012; 366:493.

12. Kieler H, Artama M, Engeland A, et al. Selective serotonin reuptake inhibitors during pregnancy and risk of persistent pulmonary hypertension in the newborn: population based cohort study from the five Nordic countries. BMJ 2012; 344:d8012.

13. DA safety alert. Selective serotonin reuptake inhibitor (SSRI) antidepressants: Drug safety communication - Use during pregnancy and potential risk of persistent pulmonary hypertension of the newborn http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm283696.htm (Accessed on December 29, 2011).