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Gheysen W, Kennedy D. An update on maternal medication-related embryopathies. Prenat Diagn 2020; 40:1168-1177. [PMID: 32524623 DOI: 10.1002/pd.5764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 06/02/2020] [Accepted: 06/08/2020] [Indexed: 12/12/2022]
Abstract
There is a general perception that any exposure to medication during pregnancy poses a potential risk to the fetus. Most available data about teratogenic drugs is derived from animal studies, case reports, or cohort studies. As a result, counseling women and their partners about the safety of drugs during pregnancy can be difficult due to limited information about efficacy, pharmacokinetics, and teratogenicity of some drugs. However, this should always be done in the context of weighing up potential teratogenic risks with the perinatal risks of an untreated medical or psychiatric condition. Ideally, this counseling should occur prior to a planned pregnancy so that medications and treatment of chronic medical conditions can be optimized. It is important that clinicians providing antenatal care are able to confidently manage women including utilizing appropriate resources. This paper aims at reviewing a selected (non-exhaustive) list of the most commonly prescribed medications considered significant human teratogens and provides recommendations for pre-conception and antenatal counseling.
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Affiliation(s)
- Willem Gheysen
- Department of Maternal-Fetal-Medicine, Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Debra Kennedy
- MotherSafe, Royal Hospital for Women, Randwick, New South Wales, Australia.,School of Women's and Children's Health, University of NSW, Sydney, New South Wales, Australia
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2
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Human teratogens and genetic phenocopies. Understanding pathogenesis through human genes mutation. Eur J Med Genet 2016; 60:22-31. [PMID: 27639441 DOI: 10.1016/j.ejmg.2016.09.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 09/12/2016] [Indexed: 12/27/2022]
Abstract
Exposure to teratogenic drugs during pregnancy is associated with a wide range of embryo-fetal anomalies and sometimes results in recurrent and recognizable patterns of malformations; however, the comprehension of the mechanisms underlying the pathogenesis of drug-induced birth defects is difficult, since teratogenesis is a multifactorial process which is always the result of a complex interaction between several environmental factors and the genetic background of both the mother and the fetus. Animal models have been extensively used to assess the teratogenic potential of pharmacological agents and to study their teratogenic mechanisms; however, a still open issue concerns how the information gained through animal models can be translated to humans. Instead, significant information can be obtained by the identification and analysis of human genetic syndromes characterized by clinical features overlapping with those observed in drug-induced embryopathies. Until now, genetic phenocopies have been reported for the embryopathies/fetopathies associated with prenatal exposure to warfarin, leflunomide, mycophenolate mofetil, fluconazole, thalidomide and ACE inhibitors. In most cases, genetic phenocopies are caused by mutations in genes encoding for the main targets of teratogens or for proteins belonging to the same molecular pathways. The aim of this paper is to review the proposed teratogenic mechanisms of these drugs, by the analysis of human monogenic disorders and their molecular pathogenesis.
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Weigt S, Huebler N, Strecker R, Braunbeck T, Broschard TH. Developmental effects of coumarin and the anticoagulant coumarin derivative warfarin on zebrafish (Danio rerio) embryos. Reprod Toxicol 2011; 33:133-41. [PMID: 21798343 DOI: 10.1016/j.reprotox.2011.07.001] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 06/17/2011] [Accepted: 07/02/2011] [Indexed: 11/28/2022]
Abstract
Coumarin and warfarin, two substances which are intensively metabolized in animals and humans, were tested for teratogenicity and embryo lethality in a 3-day in vitro assay using zebrafish embryos. Warfarin is a coumarin derivative, but in contrast to the mother substance warfarin has anticoagulant properties. Both substances produced teratogenic and lethal effects in zebrafish embryos. The LC(50) and EC(50) values for coumarin are 855 μM and 314 μM, respectively; the corresponding values for warfarin are 988 μM and 194 μM. For coumarin, three main or fingerprint endpoints (malformation of head, tail and growth retardation) were identified, whereas malformation of tail was the only fingerprint endpoint of warfarin. The analysis of the ratios between the zebrafish embryo effect concentrations of both substances and human therapeutic plasma concentrations confirmed the teratogenic potential of warfarin, as well as the equivocal status of coumarin.
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Affiliation(s)
- Stefan Weigt
- Institute of Toxicology, Merck KGaA, 64293 Darmstadt, Germany.
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Downie AC, Mackey DA, Vote BJ. Isolated corneal opacification and microphthalmia: a suspected warfarin embryopathy. Clin Exp Ophthalmol 2009; 37:624-5. [PMID: 19702715 DOI: 10.1111/j.1442-9071.2009.02072.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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5
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Brunetti-Pierri N, Hunter JV, Boerkoel CF. Gray matter heterotopias and brachytelephalangic chondrodysplasia punctata: a complication of hyperemesis gravidarum induced vitamin K deficiency? Am J Med Genet A 2007; 143A:200-4. [PMID: 17163521 DOI: 10.1002/ajmg.a.31573] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Nicola Brunetti-Pierri
- Departments of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA.
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Raghav S, Reutens D. Neurological sequelae of intrauterine warfarin exposure. J Clin Neurosci 2006; 14:99-103. [PMID: 17107801 DOI: 10.1016/j.jocn.2006.03.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2006] [Accepted: 03/08/2006] [Indexed: 11/24/2022]
Abstract
Warfarin embryopathy is a well-defined manifestation of intrauterine warfarin exposure. The embryopathy phenotype as it relates to the nervous system is broad and poorly recognised. We describe an adult with neurological sequelae of fetal warfarin exposure. We review previous cases with neurological sequelae and discuss the pathogenetic mechanism in light of recent research.
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Affiliation(s)
- Sanjay Raghav
- Department of Neurology, Monash Medical Centre, 246 Clayton Road, Clayton, Victoria 3168, Australia
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Hetzel PG, Glanzmann R, Hasler PW, Ladewick A, Bührer C. Coumarin embryopathy in an extremely low birth weight infant associated with neonatal hepatitis and ocular malformations. Eur J Pediatr 2006; 165:358-60. [PMID: 16411088 DOI: 10.1007/s00431-005-0064-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2005] [Revised: 11/19/2005] [Accepted: 11/28/2005] [Indexed: 10/25/2022]
Abstract
Coumarin embryopathy (CE) is a well-documented sequelae of prenatal exposure to vitamin K antagonists. We report on a female premature infant (25 weeks' gestation) born to a mother who had received phenprocoumon during pregnancy following mechanical heart valve replacement. The infant presented with impaired coagulation, intraventricular and minor parenchymal cerebral haemorrhages and midface hypoplasia typical of CE. In addition, there was hepatopathy with conjugated hyperbilirubinemia, elevated liver enzymes and repeated episodes of hypoglycemia upon attempts to discontinue glucose supplementation, all lasting for 4 months. There was corneal opacity with anterior segment dygenesis in the left eye, and persistent pupillary membrane, cataract and persistent hyperplastic primary vitreous in the right eye. While liver disease is an uncommon but serious side effect of vitamin K antagonists, this is the first report describing neonatal hepatopathy as part of CE. In anticoagulation of pregnant women with mechanical heart valves, vitamin K antagonists should be used with utmost restraint.
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Affiliation(s)
- Patrick G Hetzel
- Department of Neonatology, University Children's Hospital, Basel, Switzerland.
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Finkelstein Y, Chitayat D, Schechter T, Keating S, Toi A, Koren G. Motherisk rounds. Warfarin embryopathy following low-dose maternal exposure. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2005; 27:702-6. [PMID: 16100627 DOI: 10.1016/s1701-2163(16)30550-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yaron Finkelstein
- Motherisk Program, Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON
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9
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van Driel D, Wesseling J, Sauer PJJ, Touwen BCL, van der Veer E, Heymans HSA. Teratogen update: fetal effects after in utero exposure to coumarins overview of cases, follow-up findings, and pathogenesis. TERATOLOGY 2002; 66:127-40. [PMID: 12210474 DOI: 10.1002/tera.10054] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Dieneke van Driel
- Department of Pediatrics, Beatrix Children's Hospital, University Hospital Groningen, Groningen, The Netherlands.
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Wesseling J, Van Driel D, Smrkovsky M, Van der Veer E, Geven-Boere LM, Sauer PJ, Touwen BC. Neurological outcome in school-age children after in utero exposure to coumarins. Early Hum Dev 2001; 63:83-95. [PMID: 11408097 DOI: 10.1016/s0378-3782(01)00140-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The effect of prenatal exposure to coumarins (acenocoumarol, phenprocoumon) on neurological outcome was assessed in a cohort of 306 children aged 7-15 years. Findings were compared with those in a non-exposed cohort of 267 children, matched for sex, age, and demographic region. We used a neurological examination technique which pays special attention to minor neurological dysfunction (MND). None of the children was found to be neurologically abnormal. However, exposure to coumarins during gestation increases the risk for MND in children of school age, odds ratio (OR) 1.9 (CI(95) 1.1-3.4), predominantly after exposure in the second or third trimester, odds ratio 2.1 (CI(95) 1.2-3.8). We found a dose-response relationship with an odds ratio of 1.2 (CI(95) 1.0-1.5) per mg coumarin derivative prescribed per day. The results suggest that coumarins have an influence on the development of the brain which can lead to mild neurological dysfunctions in children of school age.
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Affiliation(s)
- J Wesseling
- Department of Paediatrics, Beatrix Children's Hospital, University Hospital Groningen, P.O. Box 30.001, 9700 RB Groningen, Netherlands
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Kulman JD, Harris JE, Xie L, Davie EW. Identification of two novel transmembrane gamma-carboxyglutamic acid proteins expressed broadly in fetal and adult tissues. Proc Natl Acad Sci U S A 2001; 98:1370-5. [PMID: 11171957 PMCID: PMC29263 DOI: 10.1073/pnas.98.4.1370] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The proline-rich gamma-carboxyglutamic acid (Gla) proteins (PRGPs) 1 and 2 are the founding members of a family of vitamin K-dependent single-pass integral membrane proteins characterized by an extracellular amino terminal domain of approximately 45 amino acids that is rich in Gla. The intracellular carboxyl terminal region of these two proteins contains one or two copies of the sequence PPXY, a motif present in a variety of proteins involved in such diverse cellular functions as signal transduction, cell cycle progression, and protein turnover. In this report, we describe the cloning of the cDNAs for two additional human transmembrane Gla proteins (TMG) of 20-24 kDa named TMG3 and TMG4. These two proteins possess extracellular Gla domains with 13 or 9 potential Gla residues, respectively, followed by membrane-spanning hydrophobic regions and cytoplasmic carboxyl terminal regions that contain PPXY motifs. This emerging family of integral membrane Gla proteins includes proline-rich Gla protein (PRGP) 1, PRGP2, TMG3, and TMG4, all of which are characterized by broad and variable distribution in both fetal and adult tissues. Members of this family can be grouped into two subclasses on the basis of their gene organization and amino acid sequence. These observations suggest novel physiological functions for vitamin K beyond its known role in the biosynthesis of proteins involved in blood coagulation and bone development. The identification and characterization of these proteins may allow a more complete understanding of the teratogenic consequences of exposure in utero to vitamin K antagonists, such as warfarin-based anticoagulants.
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Affiliation(s)
- J D Kulman
- Department of Biochemistry, Box 357350, University of Washington, Seattle, WA 98195, USA.
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Abstract
We investigated the etiology of hydrocephalus present at birth, i.e. of fetal hydrocephalus. Both inherited and dysraphic major malformations are very rare. Intraventricular hemorrhages and viral infections during pregnancy are among the proposed etiologies; they are supported more by anatomical, physiopathological and experimental findings than by clinical evidence. Cases of fetal intraventricular hemorrhages cited in the literature are anecdotical, and the reports fail to identify maternal or fetal predisposing factors. The role of viruses in the etiology of connatal hydrocephalus has been postulated on the basis of epidemiological considerations in human pathology and of a considerable amount of experimental studies in animals. Investigations were generally focused on aqueduct ependyma, but research should also address other structures involved in the genesis of hydrocephalus (choroid plexus, extraventricular CSF pathways, including arachnoid villi). Furthermore, experimental evidence has emerged concerning a number of toxins and of drugs administered during pregnancy, which are thought to be involved in the genesis of hydrocephalus: once more, the conclusions reached in these experimental trials lend further credence to the human epidemiological data linking pregnancy disturbances with fetal hydrocephalus. Since most of these toxic agents are also thought to induce major malformations, we could assume the degree of their effect to depend on the embryonal stage affected: the earlier the action, the worse the malformation.
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Affiliation(s)
- R Guiffrè
- Institute of Neurosurgery, University of Rome, Tor Vergata, Italy
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Chitayat D, Moore L, Del Bigio MR, MacGregor D, Ben-Zeev B, Hodgkinson K, Deck J, Stothers T, Ritchie S, Toi A. Familial Dandy-Walker malformation associated with macrocephaly, facial anomalies, developmental delay, and brain stem dysgenesis: prenatal diagnosis and postnatal outcome in brothers. A new syndrome? AMERICAN JOURNAL OF MEDICAL GENETICS 1994; 52:406-15. [PMID: 7538262 DOI: 10.1002/ajmg.1320520404] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Brothers are reported with an apparently new constellation of manifestations including Dandy-Walker complex (DWC), migrational brain disorder, macrocephaly, and facial anomalies. The first brother presented at birth, the second was detected prenatally with DWC and the pregnancy terminated. Fetal brain histopathology showed DWC associated with brainstem dysgenesis. Inheritance is likely autosomal or X-linked recessive. An extensive review of the differential diagnosis of DWC is provided.
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Affiliation(s)
- D Chitayat
- Prenatal Diagnosis Program, Toronto Hospital, Ontario, Canada
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Abstract
The warfarin embryopathy is a well-defined complex of fetal anomalies generally accepted to result from first trimester exposure. Optic atrophy and dilation of the cerebral cerebral ventricles associated with blindness, microcephaly, and mental retardation have been reported following second and third trimester exposure. In contrast to the consistent clinical features observed in the warfarin embryopathy, the CNS effects seen in fetuses exposed in the later trimesters share little in terms of specific lesion or long-term clinical outcome. A case of schizencephaly in a coumadin-exposed fetus is presented. This report offers supportive evidence that the CNS sequellae of this agent are the result of vascular accident and hemorrhage, not a direct effect on CNS morphogenesis. The molecular basis for the adverse effects of warfarin derivatives on the fetus are reviewed. Warfarin derivatives exert both their embryopathic and their fetopathic effects via pharmacologic action: inhibition of gamma carboxylation of osteocalcin and a similar carboxylation of the vitamin K dependent clotting factors. Therefore, we believe that warfarin exposure in the second or third trimesters of pregnancy is equally dangerous to the fetus as that in the first. Heparin may be a superior alternative to warfarin for the prevention of thromboembolic disease in pregnant women with cardiac valve prostheses.
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Affiliation(s)
- S Pati
- Department of Obstetrics and Gynecology, Georgetown University Medical Center, Washington, DC 20007
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Wong V, Cheng CH, Chan KC. Fetal and neonatal outcome of exposure to anticoagulants during pregnancy. AMERICAN JOURNAL OF MEDICAL GENETICS 1993; 45:17-21. [PMID: 8418652 DOI: 10.1002/ajmg.1320450107] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
We studied fetal and neonatal outcome of women maintained on anticoagulants (warfarin and/or heparin) during pregnancy. Among 22 Chinese families, 13 mothers (59%) had a history of recurrent abortion or stillbirth while being maintained on warfarin treatment. Twenty-nine liveborn children (17 boys, 12 girls), ages 0.6-11.3 years at follow-up, were analysed for evidence of embryopathy. These were subdivided into 2 groups. Group 1 consisted of 18 children (12 boys, 6 girls) whose mothers were only given warfarin during pregnancy. Five were small for gestational age, and 12 had features of warfarin embryopathy such as nasal hypoplasia. One had subependymal intraventricular hemorrhage shown on neonatal ultrasonography. Group 2 consisted of 11 children (5 boys, 6 girls) whose mothers were maintained on warfarin and heparin during pregnancy. Three were premature deliveries, and 4 had nasal hypoplasia. One had cleft lip, cleft palate, cataract, microphthalmia, intraventricular hemorrhage, and hydrocephalus. We found that despite the high risk of fetal wastage, there was a relative lower risk of major complications, except for some minor cosmetic defects such as nasal hypoplasia. This might lead to readjustment of advice concerning contraception given to pregnant women who were maintained on anticoagulant therapy.
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Affiliation(s)
- V Wong
- Department of Paediatrics, Queen Mary Hospital, University of Hong Kong
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Abstract
Discovered early in this century consequent to investigations of a bovine hemorrhagic disease, the oral anticoagulants inhibit a post translational modification required for various hepatically derived serine proteases to become active. These include Factors II, V, VII and X. Through their effect on Proteins S and C, the extrinsic pathway is also effected. While most of these agents exist as optically active enantiomers, with differing kinetics and pharmacologic profiles, they are generally administered in the clinic as racemic mixtures. Over the last 45 years, various studies have sought to better evaluate the role of the oral anticoagulation in both prevention and treatment of various types of thrombo-occlusive and -embolic disease. Such exercises have allowed us to better understand the pathophysiology of those diseases as well as to better characterize the pre-thrombotic state.
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Abstract
The principles of teratology are described, and animal models for research in abnormal ocular development and clinical studies of human teratogens are surveyed. A review is made of presumed ocular teratogenic agents: radiation; external environmental teratogens; maternal conditions such as infections, diabetes, and epilepsy; alcohol and drugs such as thalidomide, retinoic acid, and coumarin anticoagulants; and other agents, such as cigarettes.
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Affiliation(s)
- K Strömland
- Department of Ophthalmology, University of Gothenburg, Sweden
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Howe AM, Webster WS. Exposure of the pregnant rat to warfarin and vitamin K1: an animal model of intraventricular hemorrhage in the fetus. TERATOLOGY 1990; 42:413-20. [PMID: 2256004 DOI: 10.1002/tera.1420420410] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Pregnant Sprague-Dawley rats were given daily oral doses of sodium warfarin (100 mg/kg) and concurrent intramuscular injections of vitamin K1 (10 mg/kg). This dosing regimen did not have any apparent deleterious effect on the dams and did not affect the fetuses when administered from day 1 to day 12 of pregnancy. However, similar treatment from day 9 to 20 caused hemorrhage in the fetuses examined on day 21 of gestation. There were no hemorrhages in the control fetuses from dams receiving vitamin K1 only. The lowest effective dose of warfarin, in conjunction with daily doses of vitamin K1, was 3 mg/kg. This dose caused hemorrhage in 28% of fetuses; the incidence of affected fetuses was not further increased by doses of warfarin up to 100 mg/kg. Hemorrhages affected the fetal brain, face, eyes, and ear and occasionally the limbs. Brain hemorrhages were frequently intraventricular and caused various degrees of hydrocephaly. Bony defects were not a feature of prenatal exposure to warfarin. These results show that prenatal exposure of the rat to warfarin and vitamin K duplicates the hemorrhagic abnormalities and pathology associated with prenatal exposure to warfarin in the human. It did not induce bony or facial defects probably because the vitamin K-dependent components of bone development occur postnatally in the rat. This model should allow detailed determination of the role of vitamin K-dependent proteins in development.
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Affiliation(s)
- A M Howe
- Department of Anatomy, University of Sydney, N.S.W., Australia
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Hall BD. Warfarin embryopathy and urinary tract anomalies: possible new association. AMERICAN JOURNAL OF MEDICAL GENETICS 1989; 34:292-3. [PMID: 2817012 DOI: 10.1002/ajmg.1320340234] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Ruthnum P, Tolmie JL. Atypical malformations in an infant exposed to warfarin during the first trimester of pregnancy. TERATOLOGY 1987; 36:299-301. [PMID: 3424218 DOI: 10.1002/tera.1420360305] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We report a dysmorphic female infant whose mother took warfarin in therapeutic doses during the first 6 weeks of pregnancy. At birth the infant was small for dates and had a triangular facial appearance, micrognathia, microglossia, short fingers and toes, and hypoplastic nails. A skeletal survey revealed hypoplastic distal phalanges in the fingers and toes; there was no epiphyseal stippling. The pattern of malformations present in this infant may either represent the earliest teratogenic effects of warfarin or the fortuitous association of exposure to warfarin and unexplained dysmorphic features.
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Affiliation(s)
- P Ruthnum
- Southern General Hospital, Glasgow, Scotland
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