The outcome of pregnancy in 689 women exposed to therapeutic doses of antidepressants. A collaborative study of the European Network of Teratology Information Services (ENTIS)

The European Network of the Teratology Information Services (ENTIS) has collected and evaluated data on 689 pregnancies in which exposure to tricyclic and nontricyclic antidepressants occurred. Data were collected prospectively from the time of in utero exposure and all the cases were followed up to the first few weeks of postnatal life using standardized procedures. In most cases, no longer term follow-up data were available. Approximately two-thirds of the mothers were on multidrug therapy, and of those, half took a benzodiazepine. About 95% of the patients were exposed during the first trimester. The most striking feature of the pregnancy outcomes is that 97% of live-born babies were morphologically normal. The incidence of spontaneous abortion and late fetal/neonatal deaths were within the normal range. Fourteen live-born babies and one fetus had either major or minor malformations, and six had minor anomalies. However, there was no increase in either a particular type of malformation or a specific pattern of defects. Another 31 infants without malformations had neonatal problems; these were usually associated with chronic multidrug therapy, especially near term. Elective termination of pregnancy occurred more frequently in the multidrug groups (86 out of 488) than in the monotherapy groups (20 out of 201), but data concerning the condition of the fetus are not available in the majority of the cases. Overall, no causal relationship could be established between in utero exposure to antidepressants and adverse pregnancy outcome.

What proportion of multiple births are due to ovulation induction? A register-based study in Italy

OBJECTIVES

This study evaluated the increase in risk of multiple births associated with ovulation induction and calculated the proportion of multiple births attributable to this treatment.

METHODS

Cases were 350 multiple births and controls were 737 single births enrolled from April 1993 to March 1994 in the Mercurio Project, an investigation of reproductive outcomes in Italy.

RESULTS

Ovulation induction was used in 45 case births (12.9%) and 24 control births (3.3%); the adjusted odds ratio was 4.1 (95% confidence interval [CI] = 2.4, 6.9). The odds ratio for triplet or higher order births was 72.2 (95% CI = 25.7, 202.8). When unlike-sexed multiple births were considered, the odds ratio increased for twin births, but not for triplet or higher births. The highest odds ratios were found when ovulation induction was used with assisted reproduction. The proportion of multiple births attributable to ovulation induction was 9.7% overall, 5.4% for twin births, and 69.8% for triplet or higher births.

CONCLUSIONS

Ovulation induction increases the risk of multiple births and has been responsible for the rise in the rate of triplet or higher order births in Italy in the last decade. Its indiscriminate and improper use should be avoided.

Severe form of Freeman-Sheldon syndrome associated with brain anomalies and hearing loss

We describe a child with whistling face and multiple contractures, including ulnar deviation of fingers, compatible with a diagnosis of Freeman-Sheldon syndrome (FSS). This patient also presented severe hypertonicity, multiple episodes of pneumonia, difficulty in swallowing, and poor weight gain, which are characteristic of the most severe cases of FSS. A brain CT scan showed cerebellar and brainstem atrophy. Auditory brainstem responses were absent. The child died at 5 months of respiratory failure. This case suggests the possibility that, especially in the most severe forms, brain abnormalities may be responsible for some of the clinical manifestations of this syndrome, i.e., respiratory problems, difficulty in swallowing and severe hypertonicity. We assume that there is more than one pathogenetic mechanism (muscular, skeletal, and neurological) underlying FSS, which, together with the genetic heterogeneity and the wide range of clinical symptoms leads us to suggest that it is more appropriate to speak of a Freeman-Sheldon spectrum rather than syndrome and that thorough investigation for CNS and auditory abnormalities should be part of the initial work-up of these patients.

Chorionic villus sampling and transverse digital deficiencies: evidence for anatomic and gestational-age specificity of the digital deficiencies in two studies

Several but not all studies indicate that chorionic villus sampling (CVS) is associated with an increased risk for transverse limb deficiencies, including digital deficiencies. It has been suggested that variations in results regarding the transverse digital deficiencies (TDDs) may be due to the use of different classification criteria. We present the combined analysis of two case-control studies, the U.S. Multistate CVS (US) study and the Italian Multicentric Birth Defects (IP-IMC) study, using two different definitions of TDDs. We compared the frequency of CVS exposure in control infants with that among those infants with any number of affected digits (any TDD), and those with all five digits of at least one limb affected (extensive TDDs). The estimated relative risk (RR) for any TDD following CVS was 10.6 (IPIMC) and 6.6 (US). For the extensive TDDs, the RR was 30.5 (IPIMC) and 10.7 (US). In both studies, extensive TDDs were less than 25% of all TDDs. Compared to all TDDs, extensive TDDs were more likely to occur after CVS performed earlier in the first trimester (before 10-11 weeks' gestation). These findings suggest a relationship between the timing of CVS and the severity of TDDs; indicate that using a restrictive definition of TDDs (all five digits affected) may limit the ability to evaluate the association between CVS and TDDs in populations in whom CVS is usually performed at or after 10 weeks' gestation; and highlight the necessity to consider gestational age in any evaluation of the relative risk for limb deficiencies associated with CVS.

Ultrasonography in pregnancy and fetal abnormalities: screening or diagnostic test? IPIMC 1986-1990 register data. Indagine Policentrica Italiana sulle Malformazioni Congenite

The aim of the present study was to assess the sensitivity of ultrasound diagnosis used as a screening test in detecting major congenital anomalies in the prenatal period in a large nation-based multicentre setting. Data from the IPIMC register were collected in the period 1986-1990. One hundred and thirty-five hospitals, located in 17 out of the 20 regions in Italy, participated in the register. Study cases were 3479 infants with major congenital anomalies diagnosed at birth or in the first week of life. Subjects with chromosomal anomalies or multiple defects were excluded. The sensitivity of ultrasound prenatal diagnosis was 49.5 per cent for central nervous system anomalies, 3.8 per cent for congenital heart diseases, 17.1 per cent for gastrointestinal tract defects, 46.6 per cent for abdominal wall defects, 74.8 per cent for urinary tract anomalies, and 22.9 per cent for skeletal abnormalities. The detection rate for diaphragmatic hernia was 24.2 per cent. Overall, only 18 per cent of the defects diagnosed in utero were detected before 24 weeks' gestation. The sensitivity of prenatal diagnosis was 30.1 and 19.0 per cent in the northern, central, and southern regions, respectively. In light of its low sensitivity, ultrasonography as a screening test in the general population should be abandoned, although some improvement in its performance should be expected following adequate training of the ultrasound staff and the use of good technical equipment.

Effect of paternal age in achondroplasia, thanatophoric dysplasia, and osteogenesis imperfecta

The paternal ages of nonfamilial cases of achondroplasia (AC) (n = 78), thanatophoric dysplasia (TD) (n = 64), and osteogenesis imperfecta (OI) (n = 106), were compared with those of matched controls, from an Italian Indagine Policentrica Italiana sulle Malformazioni Congenite and a South American Estudio Colaborativo Latinoamericano de Malformaciones Congénitas series. The degree of paternal age effect on the origin of these dominant mutations differed among the three conditions. Mean paternal age was highly elevated in AC, 36.30 +/- 6.74 years in the IPIMC, and 37.19 +/- 10.53 years in the ECLAMC; less consistently elevated in TD, 33.60 +/- 7.08 years in the IPIMC, and 36.41 +/- 9.38 years in the ECLAMC; and only slightly elevated in OI in the ECLAMC, 31.15 +/- 9.25 years, but not in the IPIMC, 32.26 +/- 6.07 years. Increased maternal age or birth order in these conditions disappeared when corrected for paternal age. Approximately 50% of AC and TD cases, and only 30% of OI cases, were born to fathers above age 35 years. For AC and TD, the increase in relative incidence with paternal age fitted an exponential curve. The variability of paternal age effect in these new mutations could be due, among other reasons, to the high proportion of germ-line mosaicism in OI parents, or to the localization of the AC gene, mapped to the 4p16.3 region, in the neighborhood of an unstable DNA area.

Social and geographical inequalities in prenatal care in Italy

The purpose of this study was to find out possible differences in prenatal diagnosis (PD) by amniocentesis or chorionic villus sampling and ultrasound examination before 16 weeks' gestation (early ultrasound examination, EUE), according to area of residence and level of education of the mothers. Data come from a multicentre study in Italy involving 43 maternity hospitals (Mercurio project) and were collected through structured interviews a few days after delivery. Study subjects were 1541 mothers of single non-malformed infants born between April 1992 and March 1994. Overall, the incidence of PD and EUE was 5.8 and 80 per cent, respectively. After adjustment for maternal age and other possible confounders, the odds ratios for PD were 2.19 (95 per cent confidence interval (CI) = 1.26-3.81) when women residing in the northern regions were compared with those residing in the southern regions, and 2.06 (95 per cent CI = 1.12-3.79) and 4.08 (95 per cent CI = 1.97-8.42) when women with medium and high levels of education were compared with those with low level. For EUE, the odds ratios were 1.77 (95 per cent CI = 1.32-2.36) and 2.88 (95 per cent CI = 1.56-5.29) when comparing women with medium and high levels of education with those with low level. No relationship was found between area of residence and EUE. These geographical and social inequalities in prenatal care in Italy should be taken into account for the organization, delivery, and evaluation of pregnancy services in the coming years.

Epidemiology and genetics of microtia-anotia: a registry based study on over one million births

The epidemiology and genetics of microtia-anotia (M-A) were studied using data collected from the Italian Multicentre Birth Defects Registry (IPIMC) from 1983 to 1992. Among 1,173, 794 births, we identified 172 with M-A, a rate of 1.46/10,000; 38 infants (22.1%) had anotia. Of the 172 infants, 114 (66.2%) had an isolated defect, 48 (27.9%) were multiformed infants (MMI) with M-A, and 10 (5.8%) had a well defined syndrome. The frequency of bilateral defects among non-syndromic cases was 12% compared to 50% of syndromic cases (p = 0.007). Among the MMI only holoprosencephaly was preferentially associated with M-A (four cases observed upsilon 0.7 expected, p = 0.005). No significant variations were identified in the prevalence of non-syndromic cases by geographical area (range 0.62-2.37/10,000 births) or by five month time periods (range 0.21-2.58/10,000 births), nor was there evidence of time trends. When M-A cases were compared to controls, we found that mothers with parity 1 had a higher risk of giving birth to an MMI with M-A, and that mothers with chronic maternal insulin dependent diabetes were at significantly higher risk for having a child with M-A. MMI with M-A had higher rates of prematurity, low birth weight, reduced intrauterine growth, and neonatal mortality than infants with isolated M-A and controls. Babies with isolated M-A had, on average, a lower birth weight than controls; the difference was higher for females. The analysis of pedigrees and familial cases suggests an autosomal dominant trait with variable expression and incomplete penetrance in a proportion of cases, or a multifactorial aetiology. Three cases had consanguineous parents, but the absence of M-A among previous sibs does not support autosomal recessive inheritance.

Plasmatic values of some antioxidant vitamins on healthy children

The serum of 60 healthy children aged 1-16 years was analysed for vitamin A, vitamin E, beta-carotene and cholesterol contents. The study group consisted in 33 females and 27 males, living in the area of Rome, Italy. The mean serum values are 37.2 +/- 12.3 micrograms/dl for beta-carotene and 0.83 +/- 0.25 micrograms/dl for vitamin E. According to sex distribution, mean values of studied micronutrients levels are higher in boys than in girls, but not significantly. The cholesterol does not show alterations among the different groups in relation to sex or age. Vitamin A and vitamin E serum levels increased with age. Vitamin E level is strongly correlated with total cholesterol serum value. The beta-carotene increases significantly in the age group from 7 to 12 years and this value holds then steady until the age of 16.

Chorionic villus sampling and transverse limb deficiencies: maternal age is not a confounder

Advanced maternal age is a frequent indication for performing chorionic villus sampling (CVS) and it might be a confounder of the association between transverse limb deficiencies (TLD) and early CVS. We have first analyzed the maternal age-specific rates of TLD in the population monitored by the Italian Multicentric Birth Registry; then we updated a case control study controlling for maternal age. The rate of all limb deficiencies (LD) was 5.9 per 10,000 births. No trend for an excess risk for TLD or other LD with advancing maternal age was found. The relative risk for women 35 years of age and older vs. those under 35 was 0.92 (95% CI, 0.72-1.19) for any LD and 0.99 (95% CI, 0.71-1.39) for TLD. In the case control study, 11 mothers of case patients with a TLD had been exposed to CVS out of a total of 206 (5.3%), compared to 54 mothers of control patients with defects other than TLD out of a total of 12,140 (0.4%). The risk estimate for TLD associated with CVS was high in the overall analysis (OR, 12.63) and did not decrease after stratification, both in the overall sample (Mantel-Haenszel OR, 14.01) and in each gestational age stratum. Thus, advanced maternal age does not explain the association between CVS and TLD found in this study and it is unlikely to explain that observed in the several other positive studies. We recommend that any study addressing the relationship between CVS and LD should include a careful evaluation of the type of LD and the timing of CVS, and present the results for specific gestational age periods.

International study of sex ratio and twinning of neural tube defects

The goal of this study, based on information collected from eight congenital malformation registry programs around the world, was to analyze sex and twinning of affected infants and fetuses, according to type of neural tube defect (NTD) and other variables. The type of defect and its location, whether it occurred in isolated form or was associated with other malformations, population from which data were retrieved, vital status of the infant, and gestational age of the fetus/infant were considered. The material included 3,416 infants and 168 selectively aborted fetuses with anencephaly, 4,830 infants and 76 fetuses with spina bifida, and 1,022 infants and 19 fetuses with encephalocele. Less than 20% of infants with anencephaly or spina bifida and more than one-third of infants with encephalocele had associated malformations. A female excess was found among all infants with NTD but a male excess in fetuses delivered spontaneously before week 20, indicating selective male late fetal deaths. Sex ratio varied by type of NTD, vital status at birth, presence of associated malformations, and year of birth, with an increasing sex ratio for anencephaly during the 1960s and 1970s. Twinning was positively associated with NTD but the extent of this association varied with NTD type and program, while the distribution by sex type of pair of twin appeared to be similar to that of all births. Twins concordant for anencephaly or encephalocele were mainly found when the defect occurred as part of a syndrome, and only in like-sexed pairs. Twins concordant for spina bifida had the isolated form of the defect and 5 of 6 pairs were like-sexed.(ABSTRACT TRUNCATED AT 250 WORDS)

Anophthalmia and benomyl in Italy: a multicenter study based on 940,615 newborns

Following the report on clusters of anophthalmia and microphthalmia in England and Wales and their possible relation to the pesticide Benomyl, we analyzed the situation in Italy for the period 1986 to 1990 using data from the Italian registries of congenital malformations and national data on Benomyl use. Of 940,615 consecutive births, 33 cases of clinical anophthalmia and 78 cases of microphthalmia were reported (birth prevalence: 0.35 and 0.83/10,000). Birth prevalence by region for 18 of Italy's 20 political regions was evaluated for the two malformations, grouped together after exclusion of defects associated with chromosomal anomalies, no dishomogeneity in space or time among registries or among regions was observed for the study period. In no region was a statistically significant difference identified between observed and expected overall birth prevalence. Correlation analysis between the prevalence of micro/anophthalmia and Benomyl use by region showed a negative, nonsignificant coefficient, and an inverse correlation was found when the 18 regions were divided into four groups by increasing levels of Benomyl use. Parental occupation in agriculture did not seem to be associated with micro/anophthalmia when compared to a control group affected with isolated prearicular tags (odds ratio 0.63; CL 0.07-2.52). On the basis of these results, though the limits intrinsic to ecologic correlation studies must be taken into account, an association between Benomyl use and congenital micro/anophthalmia appears to be unlikely.

The Mercurio Project and Twins. How to use a registry

An essential element in any investigation of environment-genetics interaction is twin registries. At present there exist two types, one based on the whole population and another relying on voluntary participation. The second type is an important source of epidemiological information regarding the presence or absence of a disease (concordance) between members of monozygotic and dizygotic pairs. However, this type presents two serious drawbacks: the data do not cover all twins, and since the twins enrolled are those who require the greatest assistance, this results in a serious selection bias [2]. On the contrary, the first type has neither of these defects and represents an invaluable source of information for epidemiological studies on the concordance of pysiological features, morbidity and mortality, together with genetic and environmental influences and their interaction [1, 3-5].

April 1993 saw the first enrolment in a Multiple Pregnancies Registry designed to collect data from 47 Italian hospitals. This registry forms part of a larger survey, the “Mercurio Project”, originally set up in April 1992 under the aegis of the Italian Multicentre Birth Defects Registry (IPIMC). The aims of the registry are the following:

(a) to set up longitudinal epidemiological studies on the health, morbidity and mortality of twins

(b) to assess the role of environmental-genetic interaction in determining childhood behaviour and disease (using case-control studies where each twin is matched with his or her cotwin)

(c) to draw the attention of socio-sanitary personnel to twins and their special needs.

Structural congenital defects in multiple births

The prevalence of twinning and higher order multiple births is high and is increasing in many countries, due at least in part to fertility-enhancing medical therapies. About 1 in 40-45 births is a twin; it is thus important to investigate whether the twinning status confers a higher risk for morbidity and mortality, particularly early in life. Birth defects are a major cause of morbidity and mortality in the pediatric age-group. The purpose of this review is to consider the evidence for an increased risk of some birth defects associated with twinning, using data from the literature and the Italian Multicentre Birth Defects Registry (IPIMC), to illustrate some of the challenging aspects of the study of birth defects in twins, and to suggest some guidelines for future investigations.

Twins are a heterogeneous group. They may differ in origin and genetic similarity, as for monozygotic (MZ) and dizygotic (DZ) twins; and in placentation (monochorial monoamniotic, monochorial diamniotic, dichorial with separate or fused placentae). Likewise, birth defects are known to be heterogeneous in presentation, pathogenesis, and etiology. Thus, the question raised here is not whether or not birth defects ‘in general’ are more common in twins, but rather whether or not there are any specific types of defects that are more frequent among specific types of twins. To maintain the generality of the discussion, this review will focus on those structural defects which are not unique to twins; conjoined twins and arcadia, defects which are unique to the twinning process, will not be discussed.

Cerebro-facio-articular syndrome of Van Maldergem: confirmation of a new MR/MCA syndrome

Van Maldergem et al. (1992) described a new syndrome in an 11-year-old girl, characterized by: mental retardation, hypotonia, dysmorphic facies with telecanthus, epicanthus, broad flattened nose, large inverted W-shaped mouth, malformed ears, finger camptodactyly, and joint hyperlaxity. In this report we present a 5-year-old girl with very similar clinical findings. We confirm the existence of this condition as an independent clinical entity, and we propose that, based on the major clinical manifestations, it should be defined as "cerebro-facio-articular" syndrome.

Variability of the Brachmann-de Lange syndrome

Brachmann-de Lange syndrome (BDLS) is a relatively common multiple congenital anomaly/mental retardation syndrome, whose cause is unknown. The clinical variability of this condition is well-known. Recently some reports suggested the possible existence of a mild BDLS phenotype. We report on 30 patients in whom a diagnosis of BDLS was made or strongly suspected in 12 different Italian hospitals. Based on clinical evaluation we divided them into two groups, classical and mild BDLS cases. We compare the clinical data of these patients and we discuss the problems which arise in trying to define clear criteria of distinction between these two groups.

Transverse limb reduction defects after chorion villus sampling: a retrospective cohort study. GIDEF--Gruppo Italiano Diagnosi Embrio-Fetali

A retrospective cohort study was performed in five Italian obstetrical centres from 1984 to 1991 in order to verify the association between chorionic villus sampling (CVS) and transverse limb reduction defects (TLRDs). TLRD rates by period of gestation at CVS were calculated, and the study's results were compared with data from the general population. Of the 3430 pregnancies for which CVS was performed, 2759 had a known outcome. The overall rate for TLRDs was 1 in 1143 CVS pregnancies, four times higher than that of the general population in Italy (1 in 4458). The rate of TLRDs was 2.9/1000 for CVS performed at 9 weeks' gestation and 1.0/1000 for CVS at 10 weeks' gestation. A scalp defect was detected in a pregnancy in which CVS was performed at 10 weeks. A high proportion of pregnancies lost to follow-up and the poor quality of the data may have affected the results. Nevertheless, our results suggest an association between CVS carried out at less than 10 weeks' gestation and TLRDs which is consistent with the findings of other studies. CVS should not be prepared at less than 10 weeks' gestation until additional evidence is obtained.

An international collaborative study of the epidemiology of esophageal atresia or stenosis

Epidemiologic data were analyzed for a total of 2,693 infants with esophageal atresia registered in nine congenital malformation registries around the world. The average recorded prevalence at birth was 2.6 per 10,000 births, with a significant variability among programs--and sometimes within a program--and a maximum prevalence of above 3 per 10,000 births. Clusters of infants with esophageal atresia were observed but may be random. An increasing rate was seen during the period 1965 to 1975 (Norway, South America, Sweden). The type of esophageal atresia was specified in only 439 cases, but no major differences were seen in the epidemiologic characteristics of infants with the most common type (distal fistula) and infants with other types. There was an excess of low birth weight and preterm birth, and infants with esophageal atresia had a birth weight 500 to 1,000 g less than normal infants in each gestational week. There was an excess of twins, apparently mainly or exclusively due to monozygotic twinning, but in only two pairs did both twins have esophageal atresia. There was no effect seen of maternal age, but low parity, irrespective of maternal age, was associated with an increased risk for esophageal atresia. Infant survival varied among programs and depended heavily on associated malformations. Among 1,107 sibs born before the proband and 385 born after the proband, only 25 (1.7%) had a serious malformation; three had esophageal atresia. In 57.3% of the infants with esophageal atresia, no other malformations were present, in 36.4% other major malformations were recorded, and in 6.3% there were chromosomal anomalies. The malformations present associated with esophageal atresia were analyzed: a large proportion entered the constellation sometimes called "caudal mesoderm spectrum of malformations": VATER, Potter, and caudal regression sequences.