Pregnancy outcome following gestational exposure to fluoroquinolones: a multicenter prospective controlled study

[Ophthalmic agents during pregnancy and breastfeeding]

Ocular therapy is necessary even during pregnancy but the use of pharmaceutical substances bears the risk of side effects on mother and child. The article reflects current knowledge on how to treat the most important eye diseases during pregnancy and breastfeeding. The review covers the diagnostics (tonometry, mydriasis, angiography) as well as treatment of infections of the eyes, glaucoma, allergies, diabetic retinopathy, pain and inflammation.

Gastrointestinal Conditions during Pregnancy

Pregnancy causes anatomic and physiologic changes in the gastrointestinal tract. Pregnant women with intestinal disease such as Crohn disease or ulcerative colitis pose a management challenge in clinical diagnosis, radiologic evaluation, and treatment secondary to potential risk to the fetus. Heightened physician awareness on possible etiologies such as appendicitis, diverticulitis, and rarely colorectal cancer is required for rapid diagnosis and treatment to improve maternal/fetal outcome. A multidisciplinary approach to evaluation is a necessity because radiologic procedures and treatment medications commonly used in nonpregnant patients may have a potential harmful effect on the fetus. The authors review several gastrointestinal conditions encountered during pregnancy and address presentation, diagnosis, and treatment of each condition.

Inflammatory bowel disease in pregnancy

Crohn disease and ulcerative colitis commonly affect women in their childbearing years. Fortunately, advances in the field of inflammatory bowel disease have made successful pregnancy outcomes a reality for many women. These advances have led to family planning as a common discussion between gastroenterologists and inflammatory bowel disease patients. Common discussion topics are fertility, conception, medication safety, pregnancy, delivery, and breastfeeding although there are limited available data. Education and patient awareness have become vital factors in successful pregnancy outcomes.

Gonorrhoea

INTRODUCTION

In the UK, diagnosis rates for gonorrhoea in 2008 were 152/100,000 for men aged 20 to 24 years and 135/100,000 for women aged 16 to 19 years. Resistance to one or more antimicrobial agent is reported in more than one quarter of isolates. Co-infection with Chlamydia trachomatis is reported in 10% to 40% of people with gonorrhoea in the US and UK.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for uncomplicated infections in men and non-pregnant women; and in pregnant women? What are the effects of treatments for disseminated gonococcal infection? What are the effects of dual treatment for gonorrhoea and chlamydia infection? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 24 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotic regimens (dual treatment, multiple dose, single dose).

Pneumonia complicating pregnancy

Community-acquired pneumonia (CAP) can affect pregnancy, posing risks to mother and fetus. CAP is the most common fatal nonobstetric infectious complication and a common cause of hospital readmission. Risk factors of pneumonia in pregnancy relate to anatomic and physiologic respiratory changes and immune changes. Aspiration can occur during labor, can cause life-threatening disease, and is more common in cesarean deliveries. Influenza pneumonia can cause severe disease, increasing the risk of preterm delivery, abortion, cesarean section, maternal respiratory failure, and death. CAP treatment requires considering antimicrobial appropriateness and safety, choosing therapy in line with guidelines, but considering maternal and fetal risk.

Antibiotic Treatment of Dogs and Cats during Pregnancy

The use of pharmacological agents in pregnant females poses a major clinical challenge due to the marked physiological changes that may modify the pharmacokinetics of drugs and to the potential effects on the fetus. The purpose of this paper is to review briefly our knowledge on the use of antibacterial drugs during pregnancy and to provide information for the judicious selection of an antimicrobial treatment for use in pregnant bitches and queens. The risk to the fetus is a result of the ability of a drug to reach the fetal circulation and to produce toxic effects. The placenta functions as a barrier that protects the fetus due to the presence of transporters and metabolising enzymes; however, during pregnancy, the presence and activity of both enzymes and transporters may change. Antimicrobial agents that have been shown to be safe for use during pregnancy include betalactams, macrolides, and lincosamides. Pharmacotherapy during pregnancy in all species may affect adversely the developing fetus; therefore, it should be avoided when possible.

Inflammatory bowel disease and pregnancy: an update

Women with inflammatory bowel disease have similar rates of conception to the general population unless they have had pelvic surgery. Once pregnant, regardless of disease activity, they have an increased risk of adverse pregnancy outcome and should be followed as high-risk obstetric patients. Most medications are compatible with pregnancy and lactation, as described in this article. Ideally, women should discuss their plans for pregnancy with their physician prior to conception so that risks and benefits can be reviewed, medications adjusted and healthcare maintenance updated. Once pregnant, a multidisciplinary team of gastroenterologists, obstetricians and pediatricians should help to ensure the best care for the mother and child.

Antibiotic chemotherapy during pregnancy and lactation period: aspects for consideration

BACKGROUND

Infections during gestation, delivery and the postnatal period can jeopardise not only the mother, but also the child. Along with chromosomal abnormalities and immunological diseases, infection in early pregnancy represents the most important reason for abortion. During the second and third trimester, infections are the principal cause for preterm labour, premature membrane rupture, premature delivery and the resultant complications in the newborn child. Many pregnant women are very cautious about taking antibiotics due to primarily potentially detrimental effects on the unborn child. However, there are no contraindications for antibiotic treatment during pregnancy in the event of a serious infectious disease of the mother.

MATERIALS AND METHODS

In this review the indications and contraindications of the administration of antibiotics during pregnancy are being reviewed.

RESULTS

Penicillins are a first-line antibiotic treatment during pregnancy, with the exception of cases in which there is a maternal allergy to penicillin. Cephalosporins are another first-line antibiotic used during pregnancy. In principle, more commonly used cephalosporins should be given priority. Owing to associated nephrotoxicity and ototoxicity, aminoglycosides should not be prescribed at any time during pregnancy. Systematic use of aminoglycosides should be considered solely in the event of life-threatening infections with gram-negative pathogens and/or treatment failure of recommended antibiotics during pregnancy. The use of metronidazole is also permitted during pregnancy, provided the indications for its use have been strictly verified. Lincosamides should be used only if penicillins, cephalosporins and erythromycin have failed to eradicate infection. Sulfonamides, trimethoprim and cotrimoxazole are second-line agents for the use during pregnancy. Tetracyclines should not be administered to pregnant women after the fifth week of pregnancy, and are deemed contraindicated. As a precautionary measure, gyrase inhibitors are also contraindicated for pregnant women, children and young adolescents.

CONCLUSION

On the basis of our current state of knowledge, the vast majority of antibiotics do not cause serious harm to the unborn child if used properly and at the appropriate doses during pregnancy. The treatment with an antibiotic that is contraindicated does not justify termination of pregnancy. However, ultimately no medicine, including antibiotics, can be described as absolutely safe.

[Eye and pregnancy.]

Pregnancy may cause ocular changes, for example refractive changes or contact lens intolerance. A number of ocular diseases may deteriorate. Especially preexisting diabetic retinopathy may worsen. Vaginal delivery is nearly always possible. Caesarean section is not required due to myopia, peripheral retinal degenerations or after retinal surgery. Most topically applied drugs usually used in ophthalmology are safe during pregnancy.

Food-borne illnesses during pregnancy: prevention and treatment

QUESTION

After hearing about outbreaks of illness resulting from Listeria and Salmonella, many of my patients are wondering about the risks of food-borne illnesses during pregnancy and what they can do to reduce their chances of contracting them.

ANSWER

Although heating or cooking food is the best way to inactivate food-borne pathogens, improved standards and surveillance have reduced the prevalence of contaminated foods at grocery stores. Therefore, it is no longer necessary for pregnant women to avoid foods like deli meats and soft cheeses (associated with Listeria); soft-cooked eggs (associated with Salmonella); or sushi and sashimi. Regardless of whether seafood is raw or cooked, pregnant women should choose low mercury seafood (eg, salmon and shrimp) over higher mercury varieties (eg, fresh tuna). Pregnant women should ensure that their food is obtained from reputable establishments; stored, handled, and cooked properly; and consumed within a couple of days of purchasing.

Pregnancy and inflammatory bowel disease

This review covers important questions that arise for physicians caring for women with inflammatory bowel disease. Fertility, pregnancy outcomes and the safety of medications in pregnancy and lactation are discussed.

Effects of moxifloxacin and clinafloxacin on murine limb buds cultured in regular and in magnesium-deficient medium

Evaluation of the prenatal toxicity of a substance in rats or other animals according to the current guidelines is often hampered by the rapid metabolism of the test compound and/or by maternal toxicity. One example for such a compound is moxifloxacin. In vitro systems offer the possibility to study the direct effects of the test compound on embryonic tissues. The aim of this study was to evaluate the embryotoxic potential of moxifloxacin in vitro using the murine limb bud culture. Clinafloxacin, which was found to be teratogenic when tested in rats, was used for comparison. The effects of various concentrations of moxifloxacin (10, 30, 60 and 100 mg/L) and clinafloxacin (3, 10 and 30 mg/L) on growth and differentiation of 12-day-old murine limb buds were studied in a standard and in a magnesium-deficient medium. After termination of the culture, the respective front limb buds were examined by different methods. Clinafloxacin showed clear-cut effects at a concentration of 30 mg/L in both media. Effects were similarly pronounced as the effects observed with moxifloxacin at a concentration of 100 mg/L. Lower concentrations of moxifloxacin, which are achieved during therapy in humans, did not impair growth and differentiation of limb buds. Using electron microscopy, slight ultrastructural changes could be seen after exposure to 3 mg clinafloxacin/L medium. Ultrastructurally, clinafloxacin caused a concentration-dependent decrease of the extracellular matrix, swelling of cell organelles and at higher concentrations necrotic chondrocytes. These effects were significantly enhanced in a magnesium-deficient medium. In conclusion, the effects of moxifloxacin on murine limb buds in vitro were definitely less pronounced than those of clinafloxacin. Effects on growth and differentiation occurred with moxifloxacin only at concentrations that are higher than plasma concentrations observed during therapy. This result is of special interest, because due to rapid metabolism of moxifloxacin in rats results from a routinely performed segment II type study cannot be used for a risk assessment.

Pregnancy and inflammatory bowel disease

This review covers important questions that arise for physicians caring for women with inflammatory bowel disease. Fertility, pregnancy outcomes and the safety of medications in pregnancy and lactation are discussed.

Teratogen risk counselling by internet: A prospective cohort study

Although the internet may play a role in providing proper teratogen-risk counselling for pregnant women, the experience with this type of service has not been reported. We aimed to compare the pregnancy outcome of women counselled by the internet to women that received typically in-clinic teratogen risk counselling in the clinic. In a prospective cohort design, 1,011 patients were counselled in the clinic and 235 patients were counselled via the internet. Teratogen risk counselling was provided according with the information obtained from medical literature and specialised software. Information about pregnancy outcome (delivery, spontaneous abortion, or termination of pregnancy and major malformations) was obtained from 903 (89.3%) patients from the clinic group and 141 (60%) from the internet group. The amount of alcohol, cigarettes smoked, and millirads of X-ray were greater ( p < 0.05) in patients counselled by internet than in clinic. The rate of deliveries, ongoing pregnancies, pregnancy terminations, and spontaneous abortions were similar between clinic and internet (chi2 = 1.32; p = 0.7). Of 498 babies born to mothers counselled in the clinic, major malformations were identified in 3.6%. Of 67 babies born to mothers counselled by internet, major malformations were present in 1.5% ( p = 0.6). Teratogen-risk counselling by internet and clinic seems to have a similar efficacy in pregnancy outcome.

The safety of quinolones--a meta-analysis of pregnancy outcomes

OBJECTIVE

We conducted a meta-analysis of all published data in order to evaluate the risk for birth defects, stillbirths, preterm births and low birth weight following exposure to quinolones in the first trimester of pregnancy.

STUDY DESIGN

Medline, Embase, Scopus, Biological Abstracts and Proquest Thesis Dissertation databases were searched. Other papers and abstracts were located from the retrieved articles' references, meeting booklets, internet web sites and books on teratology.

RESULTS

Five studies met the inclusion criteria. The summary odds ratio for all the included studies was 1.05 (95% CI 0.90-1.22) for major malformations, 2.6 (95% CI 0.36-18.67) for stillbirths, 1.15 (95% CI 0.69-1.91) for preterm births and 0.73 (95% CI 0.30-1.79) for low birth weight. In an additional analysis including only fluoroquinolones (nalidixic acid was removed), the summary odds ratio for major malformations remained non-significant (1.11, 95% CI 0.57-2.15).

CONCLUSIONS

The use of quinolones during the first trimester of pregnancy does not appear to represent an increased risk for major malformations recognized after birth, stillbirths, preterm births or low birth weight.

Pneumonia in the Pregnant Patient

Community acquired pneumonia is a common illness, and pneumonia and influenza serve as the seventh leading cause of death in the United States. In the pregnant patient, pneumonia is the most common cause of fatal non-obstetric infection (1–3). Pneumonia can have adverse consequences for both the mother and her fetus, with certain infections (particularly viral and fungal) assuming greater virulence and mortality than in non-pregnant women of similar age (2, 3). Pneumonia is a relatively common cause of respiratory failure in pregnant patients, but in contrast to older studies, newer data suggest that not all pneumonias are more common or more serious in pregnant women than in other populations. However, because pneumonia can impact both the mother and fetus, it may lead to an increased likelihood of complicated preterm delivery, compared to pregnancies in which infection is absent.

The pathogens responsible for community-acquired pneumonia (CAP) are similar in pregnant and non-pregnant patients, with Streptococcus pneumoniae, Hemophilus influenzae, Mycoplasma pneumoniae, Legionella spp., Chlamydophila pneumoniae, and influenza A accounting for the majority of cases (2–4). However, reduction in cell-mediated immunity associated with pregnancy (especially during the third trimester) places women at an increased risk of more severe forms of pneumonia and disseminated diseases from pathogens normally contained by this type of immune response, including herpes virus, influenza, varicella, and coccidioidomycosis (3, 5–7).

Antibiotics potentially used in response to bioterrorism and the risk of major congenital malformations

This study was designed to assess the association between pregnancy-related exposures to antibiotics recommended for use in the event of a bioterrorism attack and major congenital malformations. A retrospective cohort study included 30 049 infants from Tennessee Medicaid born between 1985 and 2000 identified from computerised state databases. Infants with fetal exposures to ciprofloxacin, azithromycin, doxycycline and amoxicillin (antibiotics recommended for potential bioterrorism attacks) (n = 24 521) and erythromycin (included as a positive control) (n = 2128) were compared with infants with no fetal exposure to any antibiotics (n = 3400). Major congenital malformations identified from computerised records were confirmed through medical record review. Overall, 869 (2.9%) of infants in the cohort had a confirmed major congenital malformation, with major malformations ranging from 2.5% to 3.0% among the antibiotic-specific exposure groups. No increased risk was present in multivariable analyses for any malformations and for malformations of specific organ systems. In conclusion, these data suggest that ciprofloxacin, azithromycin, doxycycline or amoxicillin use by pregnant women should not result in a greater incidence of overall major congenital malformations in infants whose mothers take these medications, though a large increase in risk cannot be ruled out.

Management of the pregnant IBD patient

Women with inflammatory bowel disease (IBD) and the physicians who care for them must make difficult decisions on issues of conception, pregnancy, and breastfeeding with very limited and often contradictory information. This review provides the most current information on the inheritance of IBD, fertility, pregnancy outcomes, the management of disease during pregnancy, and the safety of medications in pregnancy and breastfeeding. We would like to emphasize that the information presented here must be individualized to the specific situation of each patient, their acceptance of risk, and their degree of disease severity.

Pre-travel vaccination and medical prophylaxis in the pregnant traveler

BACKGROUND

Practitioners are often fearful of giving vaccinations and prophylactic medications to pregnant travelers. And yet pregnancy is often a time of heightened danger from travel-related infections and illnesses.

METHOD

Literature search and communication with researchers.

RESULTS

With a few exceptions, there is little systematic research regarding the use of prophylactic medications and vaccines during pregnancy. Case reports and small studies do, however, indicate an increased risk in pregnancy from many of the preventable illnesses, and there is some data to support the use of preventive measures.

CONCLUSIONS

The authors present some non-medical interventions that may be used to limit exposure to a number of disease processes. They then review the available information regarding the safety and efficacy of routine and travel-related vaccines as well as prophylactic medications for malaria, diarrhea, motion sickness and altitude sickness. When there are no obstetrical or medical contraindications, travel-related illness can usually be safely prevented during pregnancy in much the same ways as in the non-pregnant state.

Pregnancy and cirrhosis

As the treatment of cirrhosis improves, pregnancy in patients with cirrhosis is likely to become more common. Although maternal and fetal mortality is expected to similarly improve, pregnant patients with cirrhosis face unique risks. These include higher rates of spontaneous abortion and prematurity and a potential for life-threatening variceal hemorrhage, hepatic decompensation, splenic artery aneurysm rupture, and postpartum hemorrhage. Pregnancy outcome may be influenced by the underlying etiology of liver disease, as in viral and autoimmune hepatitis. Medications also impact the course of pregnancy, and must be tailored appropriately during this time.

Urinary tract infections in pregnancy

QUESTION

My pregnant patients often present with urinary tract infections. Are the medications commonly used for the management of urinary tract infections safe to use during pregnancy?

ANSWER

Existing data indicate that exposure to penicillins, cephalosporins, fluoroquinolones, nitrofurantoin, or phenazopyridine during pregnancy is not associated with increased risk of fetal malformations. Trimethoprim-sulfamethoxazole should be avoided, if possible, during the first trimester of pregnancy because of the antifolate effect associated with neural tube defects.

Drug therapy for inflammatory bowel disease in pregnancy and the puerperium

Inflammatory bowel disease (IBD) has a peak age of onset in the 3rd decade and a peak prevalent age in the fourth decade in most studies. As a result many patients affected by Crohn's disease and ulcerative colitis are females of reproductive age interested in bearing children. It has been shown that the most important factor in the success of a pregnancy in patients with IBD is the state of disease activity. Therefore, the goal prior to and during pregnancy is to best optimise control of the disease through medical therapy. Unfortunately, many medications utilised to treat IBD are potentially toxic and/or teratogenic, leaving many physicians and patients without a clear answer as to the safest methods of therapy. This review attempts to summarise the medical literature to date, as it pertains to the safety of medical therapy for IBD during pregnancy and the puerperium.

Gastrointestinal medications in pregnancy

Management of the pregnant patient presents unique challenges to the treating physician. Current Food and Drug Administration classifications do not necessarily reflect clinical experience or recent literature. Ideally, one should use the lowest-risk drug possible, with attention to the appropriate level of efficacy for the patient's condition, the stage of pregnancy and dose adjustment. Every treatment decision should be fully discussed with the patient and a multidisciplinary team that should include the obstetrician and, if appropriate, the paediatrician. This review will cover the medications commonly used to treat gastrointestinal disease. The majority of medications can be categorised as 'low risk' or 'should be avoided'. The following medications should never be used during pregnancy due to the clear risk of teratogenicity or adverse events: bismuth, castor oil, sodium bicarbonate, methotrexate, ribavirin, doxycycline, tetracycline, and thalidomide.

Review article: Reproduction in the patient with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) affects mainly the young population. The effect of IBD and its treatment on fertility and pregnancy is therefore an important clinical consideration.

AIM

To review the best management of IBD in the reproductive and pregnant population.

METHODS

A MEDLINE and an EMBASE search were performed using mainly the search phrases 'pregnancy AND IBD,''sulphasalazine AND male fertility,''abdominal surgery AND female fertility,''AZA AND placenta' and 'infliximab AND pregnancy.' No language or date restrictions were placed. References of review articles were examined.

RESULTS

Overall male and female fertility are not affected by IBD. Sulphasalzine reduces male fertility. No other drugs used in IBD affect significantly fertility in humans. The risk of pregnancy-related complications and the disease behaviour during pregnancy depends mainly on disease activity at time of conception. Proactive treatment for maintenance of disease remission during gestation is recommended. Except for methotrexate, drugs used in IBD appear safe in pregnancy. Breast feeding should be encouraged.

CONCLUSION

The management of IBD in the young and pregnant population remains controversial because the literature comes mostly from retrospective studies. Further studies particularly large prospective trials are needed to guide clinicians in decision making.

Fertility and pregnancy: common concerns of the aging cystic fibrosis population

Due to dramatically improved survival, cystic fibrosis (CF) is now considered a chronic disease of adults. Many men and women who have CF are interested in starting families and have questions regarding fertility and pregnancy, making discussion of these issues important in routine CF care. This article addresses key issues of fertility in men and women who have CF and discusses pregnancy, including maternal and fetal outcomes, highlighting advances over the last decade.

Pediatric uses of fluoroquinolone antibiotics

Current data, although incomplete, suggest that pediatric administration of a fluoroquinolone, especially the best-studied ciprofloxacin, is safe. However, many experts have raised concerns regarding the emergence of fluoroquinolone-resistant pathogens such as pneumococcus if more children are treated with fluoroquinolones. Examination of the available data suggests that these concerns remain valid. Therefore, most experts continue to advise against expanded pediatric use of fluoroquinolones, except in those selected clinical situations where the benefits clearly outweigh the risks of therapy and there are few other antibiotic choices.

Gonorrhoea

INTRODUCTION

In the UK, diagnoses rates for gonorrhoea in 2005 were 196/100,000 for 20-24 year old men, and 133/100,000 for 16-19 year old women. Co-infection with Chlamydia trachomatis is reported in 10-40% of people with gonorrhoea in the USA and UK.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for uncomplicated infections in men and non-pregnant women; and in pregnant women? What are the effects of treatments for disseminated gonococcal infection? What are the effects of dual treatment for gonorrhoea and chlamydia infection? We searched: Medline, Embase, The Cochrane Library and other important databases up to July 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 21 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotic regimens (dual treatment, multiple dose, single dose).

Pharmaceutical Agents and Pregnancy in Urology Practice

Urologic medical conditions are not frequently encountered during pregnancy. Still, urologists often are asked to treat pregnant patients for conditions that require prescriptions. In the generally healthy population of pregnant women, the use of pharmaceutical agents is usually reserved for women who have either infections or necessary surgical procedures. This article addresses the implications for pregnancy of common urologic conditions in generally healthy pregnant women, namely simple urinary tract infections that demand nitrofurantoin and complex urinary tract infections that necessitate fluoroquinolones treatment. It also examines the implications of nonobstetric surgical intervention.

Drug therapy of inflammatory bowel disease in fertile women

Inflammatory bowel disease (IBD) is a disease that affects women of childbearing age. Active disease at conception increases the risk for adverse outcomes and thus postponement of pregnancy until the disease is in remission is the best advice that physicians can give their IBD patients. The majority of medications used to treat IBD are safe in pregnancy and breastfeeding; active, untreated, or undertreated disease is more deleterious than active therapy.

Antibiotic Treatment of Intra-Amniotic Infection with Ureaplasma urealyticum

BACKGROUND

Ureaplasma urealyticum is the most common pathogen cultured from the amniotic cavity of women with preterm labor and intact membranes. However, experience with antibiotic eradication of the pathogen in this setting is limited.

CASE

We report a case of U. urealyticum isolation from the amniotic cavity of a woman with preterm labor at 27 weeks gestation. The patient was treated with erythromycin base for 1 week, followed by fluoroquinolones and clindamycin for 10 days. A healthy neonate was delivered after spontaneous labor began at 33 weeks. The cultures obtained from the placenta and membranes were sterile, but the histopathology of the placenta revealed acute chorioamnionitis with acute funisitis.

CONCLUSION

We suggest that intra-amniotic colonization with Mycoplasma spp. remote from term may be managed expectantly, and that therapy with fluoroquinolones and/or clindamycin may be an appropriate choice.

American gastroenterological association institute technical review on the use of gastrointestinal medications in pregnancy

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on February 22, 2006 and by the AGA Institute Governing Board on April 20, 2006.

Antibiotic use in pregnancy and lactation: what is and is not known about teratogenic and toxic risks

OBJECTIVE

Over ten million women are either pregnant or lactating in the United States at any time. The risks of medication use for these women are unique. In addition to normal physiologic changes that alter the pharmacokinetics of drugs, there is the concern of possible teratogenic and toxic effects on the developing fetus and newborn. This article reviews the risks and pharmacokinetic considerations for 11 broad-spectrum antibiotics that can be used to treat routine and life-threatening infections during pregnancy and lactation.

DATA SOURCES

Information from the U.S. Food and Drug Administration (FDA) product labels, the Teratogen Information Service, REPROTOX, Shepard's Catalog of Teratogenic Agents, Clinical Pharmacology, and the peer-reviewed medical literature was reviewed concerning the use of 11 antibiotics in pregnant and lactating women. The PubMed search engine was used with the search terms "[antibiotic name] and pregnancy," "[antibiotic name] and lactation," and "[antibiotic name] and breastfeeding" from January 1940 to November 2005, as well as standard reference tracing.

METHODS OF STUDY SELECTION

One hundred twenty-four references had sufficient information concerning numbers of subjects, methods, and findings to be included.

TABULATION, INTEGRATION, AND RESULTS

The teratogenic potential in humans ranged from "none" (penicillin G and VK) to "unlikely" (amoxicillin, chloramphenicol, ciprofloxacin, doxycycline, levofloxacin, and rifampin) to "undetermined" (clindamycin, gentamicin, and vancomycin). Assessments were based on "good data" (penicillin G and VK), "fair data" (amoxicillin, chloramphenicol, ciprofloxacin, doxycycline, levofloxacin, and rifampin), "limited data" (clindamycin and gentamicin), and "very limited data" (vancomycin). Significant pharmacokinetic changes occurred during pregnancy for the penicillins, fluoroquinolones and gentamicin, indicating that dosage adjustments for these drugs may be necessary. With the exception of chloramphenicol, all of these antibiotics are considered compatible with breastfeeding.

CONCLUSION

Health care professionals should consider the teratogenic and toxic risk profiles of antibiotics to assist in making prescribing decisions for pregnant and lactating women. These may become especially important if anti-infective countermeasures are required to protect the health, safety, and survival of individuals exposed to pathogenic bacteriologic agents that may occur from bioterrorist acts.

The Use of Dermatologic Drugs in Pregnancy and Lactation

Physicians are generally reluctant to prescribe dermatologic drugs to pregnant or nursing women because treatment is often elective and can be harmful to the patient, her fetus, or nursing infant; concerns for potential litigation also give pause. Yet, some effective dermatologic drugs have been determined to be safe during pregnancy and lactation. Of great practicality is an easily accessed reference guide that condenses information on such drugs into a set of tables that list pregnancy and teratogenicity ratings. Indications and contraindications are ordered in relation to the phases and trimesters of pregnancy. A discussion of the necessity of considering stages of childbearing in choosing drug therapies introduces the tables. A summary list of cautions spells out the steps physicians should take in treating women of childbearing age.

Do we have a knowledge transfer and translation plan at Teratogen Information Services?

Recently, a new field in science is emerging, which addresses the issue of ensuring that information that is generated from research, reaches the right people in the right format. This has been coined as knowledge transfer and translation and public health leaders worldwide are finding out ways to carry this out effectively. Ultimately, this should ensure greater investment in knowledge syntheses and transfer initiatives, that involve potential users of research to improve the quality of health for everyone. In this brief review/comment, an attempt will be made to help the readers understand the meaning of this new terminology and how it impacts Teratogen Information Services.

European evidence based consensus on the diagnosis and management of Crohn's disease: special situations

This third section of the European Crohn's and Colitis Organisation (ECCO) Consensus on the management of Crohn's disease concerns postoperative recurrence, fistulating disease, paediatrics, pregnancy, psychosomatics, extraintestinal manifestations, and alternative therapy. The first section on definitions and diagnosis reports on the aims and methods of the consensus, as well as sections on diagnosis, pathology, and classification of Crohn's disease. The second section on current management addresses treatment of active disease, maintenance of medically induced remission, and surgery of Crohn's disease.

Inhibition of cell differentiation by quinolones in micromass cultures of rat embryonic limb bud and midbrain cells

Micromass cultures (MMC) of rat embryonic limb bud (LB) and midbrain (CNS) cells were applied to compare the developmental toxicity of three quinolone antimicrobials: norfloxacin (Nor), enrofloxacin (Enr) and ciprofloxacin (Cip). Cultures were exposed for 5 days to seven concentrations of drugs. Cytotoxicity was assessed by quantifying neutral red uptake; differentiation-by quantifying alcian blue uptake (LB) or by image analysis of Gill's haematoxylin stained foci (CNS). Both, LB and CNS cultures showed dose-dependent reduction in total cell number and differentiation. To distinguish specific effect on differentiation, IC(50) for proliferation (P) and differentiation (D) were calculated and P/D ratios were compared. In LB cultures all three drugs were cytotoxic (P/D ratios were 1). In CNS cultures P/D ratios were 1 (up to 2.7 for Nor, up to 4.4 for Enr and up to 16 for Cip) what can suggest specific action on differentiation. Ciprofloxacin was the most toxic and CNS cells were more sensitive than LB. The ranges of IC(50)-D values (microg/ml) were as follows: Nor (79-14), Enr (127-179), Cip (91-101) in LB cultures; Nor (22-52), Enr (38-91), Cip (3-17) in CNS cultures. With one exception (Cip in CNS culture) all drugs were classified as weak embryotoxic.

Further analysis of the risk of adverse birth outcome after maternal use of fluoroquinolones

In a database cohort study, the risk of adverse birth outcome in Danish women who redeemed a fluoroquinolone prescription during pregnancy was examined. Among 87 women who redeemed a fluoroquinolone prescription at any time during the pregnancy, the prevalence ratio of preterm birth was 1.4 (95% confidence interval (CI), 0.6-3.2), one woman had a stillbirth, and no children died during the perinatal period. Among 130 women who redeemed a prescription during the first trimester or 30 days before conception, the prevalence ratio of congenital malformation was 0.7 (95% CI, 0.3-2.0) and the prevalence ratio of bone malformations was 2.2 (95% CI, 0.7-6.7). Our study raises the concern that prenatal fluoroquinolone exposure may be associated with an increased risk of bone malformations.

The use of medications for inflammatory bowel disease during pregnancy and nursing

Inflammatory bowel disease includes two primary disorders, ulcerative colitis and Crohn's disease. These diseases mainly affect young adults, with a peak occurrence between 15 and 25 years of age. The causes of these diseases are largely unknown, with current treatments targeted against the heightened inflammatory response witnessed in the intestinal mucosa of both conditions. With the peak age ranges for pregnancy and inflammatory bowel disease overlapping, it is important to weigh the benefits of treating a mother during pregnancy against the potential risks to the fetus and the course of the pregnancy. This review examines the current safety data on medications used in women with inflammatory bowel disease during pregnancy.