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Nucera B, Brigo F, Trinka E, Kalss G. Treatment and care of women with epilepsy before, during, and after pregnancy: a practical guide. Ther Adv Neurol Disord 2022; 15:17562864221101687. [PMID: 35706844 PMCID: PMC9189531 DOI: 10.1177/17562864221101687] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 05/03/2022] [Indexed: 01/16/2023] Open
Abstract
Women with epilepsy (WWE) wishing for a child represent a highly relevant subgroup of epilepsy patients. The treating epileptologist needs to delineate the epilepsy syndrome and choose the appropriate anti-seizure medication (ASM) considering the main goal of seizure freedom, teratogenic risks, changes in drug metabolism during pregnancy and postpartum, demanding for up-titration during and down-titration after pregnancy. Folic acid or vitamin K supplements and breastfeeding are also discussed in this review. Lamotrigine and levetiracetam have the lowest teratogenic potential. Data on teratogenic risks are also favorable for oxcarbazepine, whereas topiramate tends to have an unfavorable profile. Valproate needs special emphasis. It is most effective in generalized seizures but should be avoided whenever possible due to its teratogenic effects and the negative impact on neuropsychological development of in utero-exposed children. Valproate still has its justification in patients not achieving seizure freedom with other ASMs or if a woman decides to or cannot become pregnant for any reason. When valproate is the most appropriate treatment option, the patient and caregiver must be fully informed of the risks associated with its use during pregnancies. Folate supplementation is recommended to reduce the risk of major congenital malformations. However, there is insufficient information to address the optimal dose and it is unclear whether higher doses offer greater protection. There is currently no general recommendation for a peripartum vitamin K prophylaxis. During pregnancy most ASMs (e.g. lamotrigine, oxcarbazepine, and levetiracetam) need to be increased to compensate for the decline in serum levels; exceptions are valproate and carbamazepine. Postpartum, baseline levels are reached relatively fast, and down-titration is performed empirically. Many ASMs in monotherapy are (moderately) safe for breastfeeding and women should be encouraged to do so. This review provides a practically oriented overview of the complex management of WWE before, during, and after pregnancy.
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Affiliation(s)
- Bruna Nucera
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Centre for Cognitive Neuroscience, Member of the ERN EpiCARE, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University and Centre for Cognitive Neuroscience, Member of the ERN EpiCARE, Ignaz-Harrer-Str. 79, 5020 Salzburg, Austria
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González-Maciel A, Romero-Velázquez RM, Alfaro-Rodríguez A, Sanchez Aparicio P, Reynoso-Robles R. Prenatal exposure to oxcarbazepine increases hippocampal apoptosis in rat offspring. J Chem Neuroanat 2019; 103:101729. [PMID: 31794794 DOI: 10.1016/j.jchemneu.2019.101729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 11/29/2019] [Accepted: 11/29/2019] [Indexed: 01/18/2023]
Abstract
This study assessed apoptosis in the offspring of rats exposed to oxcarbazepine (OXC) from day 7 to 15 of gestation. Three groups of pregnant Wistar rats were used: 1) Control, treated with saline solution; 2) treated with 100 mg/kg OXC; 3) treated with 100 mg/kg of carbamazepine (CBZ, as a positive control for apoptosis); the route of administration was intragastric. Apoptosis was detected at three postnatal ages using the TUNEL technique in the CA1, and CA3 regions of the hippocampus and in the dentate gyrus (DG); neurogenesis was assessed in the DG using an antibody against doublecortin. The litter characteristics were recorded. OXC increased apoptosis in all regions (p < 0.01) at the three ages evaluated. Lamination disruption occurred in CA1 and CA3 due to the neuron absence and to ectopic neurons; there were also malformations in the dorsal lamina of the DG in 38% and 25% of the pups born from rats treated with OXC and CBZ respectively. CBZ also increased apoptosis. No clear effect on neurogenesis in the DG was observed. The size of the litter was smaller (p < 0.01) in the experimental groups. Nineteen-day OXC fetuses had low weight (p < 0.01), but 21 and 30 postnatal days old CBZ and OXC pups were overweight (p < 0.01). The results demonstrate that OXC administered during gestation is pro-apoptotic, alters the cytoarchitecture of the hippocampus, reduces litter size, and probably influences postnatal weight. We provide evidence of the proapoptotic effect of CBZ when administered early in gestation.
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Affiliation(s)
- A González-Maciel
- Laboratory of Cell and Tissue Morphology, Instituto Nacional de Pediatría, Secretaría de Salud, Insurgentes Sur No. 3700-C, Mexico City, C. P. 04530, Mexico.
| | - R M Romero-Velázquez
- Laboratory of Cell and Tissue Morphology, Instituto Nacional de Pediatría, Secretaría de Salud, Insurgentes Sur No. 3700-C, Mexico City, C. P. 04530, Mexico.
| | - A Alfaro-Rodríguez
- Division of Neurosciences, Instituto Nacional de Rehabilitación, "Luis Guillermo Ibarra Ibarra", Secretaría de Salud, Col. Arenal de Guadalupe, Mexico City, C.P. 14389, Mexico.
| | - P Sanchez Aparicio
- Faculty of Veterinary Medicine, Department of Pharmacology, Universidad Autónoma del Estado de México, Mexico
| | - R Reynoso-Robles
- Laboratory of Cell and Tissue Morphology, Instituto Nacional de Pediatría, Secretaría de Salud, Insurgentes Sur No. 3700-C, Mexico City, C. P. 04530, Mexico.
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Johnson KD, Miller LN, Pouliot JD, Martin PR. Retrospective Analysis of Oxcarbazepine in Pregnant Women With Substance Use Disorders: Focus on Safety. J Pharm Pract 2019; 34:28-34. [PMID: 31232158 DOI: 10.1177/0897190019850700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Published safety data in pregnant epileptic women suggests that oxcarbazepine (OXC) may be a treatment option in nonepileptic pregnant women with substance use disorders (SUDs) and psychiatric symptomatology. OBJECTIVE To compare safety outcomes associated with OXC exposure versus non-exposure in nonepileptic pregnant women with SUD and comorbid psychiatric symptomatology. METHODS A retrospective chart review was conducted to identify pregnant women 18 years or older with a SUD who delivered at the study site. Exclusion criteria included a current diagnosis of epilepsy/seizure disorder; concurrent use of lithium, anticonvulsants, medications with a Risk Evaluation and Mitigation Strategy program or a black box warning for potential fetal toxicity; and multi-parity. Eligible patients were divided into two groups based on OXC exposure. RESULTS The OXC group included 94 mother-neonate pairs versus 194 mother-neonate pairs in the non-OXC group. Baseline characteristics differed in mean number of prior pregnancies (2.8 vs 2.2 in the OXC and non-OXC group, respectively, P = .03). No significant differences were found regarding emergent cesarean or maternal hyponatremia. Average gestational age at OXC initiation was 19.8 weeks. No significant differences were found in the rates of prematurity, physical characteristics, malformation, and neonatal abstinence syndrome. CONCLUSION OXC may be considered for management of SUD with comorbid psychiatric symptomatology in nonepileptic pregnant women. Further studies should be conducted to determine statistical significance in larger sample sizes.
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Affiliation(s)
- Kayla D Johnson
- Department of Pharmacy Practice, 458976Lipscomb University College of Pharmacy, Nashville, TN, USA.,Department of Pharmaceutical Services, 198587Vanderbilt Psychiatric Hospital, Nashville, TN, USA
| | - Lindsey N Miller
- Department of Pharmacy Practice, 458976Lipscomb University College of Pharmacy, Nashville, TN, USA.,Department of Pharmaceutical Services, 198587Vanderbilt Psychiatric Hospital, Nashville, TN, USA
| | - Jonathon D Pouliot
- Department of Pharmacy Practice, 458976Lipscomb University College of Pharmacy, Nashville, TN, USA
| | - Peter R Martin
- Department of Psychiatry, 198587Vanderbilt Psychiatric Hospital, Nashville, TN, USA
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Wang M, Li W, Tao Y, Zhao L. Emerging trends and knowledge structure of epilepsy during pregnancy research for 2000-2018: a bibliometric analysis. PeerJ 2019; 7:e7115. [PMID: 31211023 PMCID: PMC6557303 DOI: 10.7717/peerj.7115] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 05/10/2019] [Indexed: 01/07/2023] Open
Abstract
Background Epilepsy during pregnancy presents a unique set of challenges for pregnant women, the fetus, and the health care community. As research in this area advances rapidly, it is critical to keep up with the emerging trends and key turning points of the development of the domain knowledge. This study aimed to construct a series of science maps to quantitatively and qualitatively evaluate the intellectual landscape and research frontiers in the field of epilepsy during pregnancy research. Methods All publications were extracted from the Web of Science Core Collection database. Bibliometric analysis was used to analyze the scientific research outputs, including journals, countries/regions, institutions, authors (cited authors), intellectual base and research hotspots. Results A total of 2,225 publications related to epilepsy during pregnancy were identified as published between 2000 and 2018. The overall trend of the number of publications showed a fluctuating growth from 59 articles in 2000 to 198 in 2018. Neurology was the leading journal in the field of epilepsy and pregnancy research both in terms of impact factor score (8.055) and H-index value (77). The US retained its leading position and exerted a pivotal influence in this area. The University of Melbourne was identified as a good research institution for research collaboration. Prof. Pennell and Tomson have made great achievements in this area, and Prof. Tomson laid a foundation for the development of this domain. The keyword “neonatal seizures” ranked first in research hotspots, and the keyword “autism spectrum disorders (ASD)” ranked first in research frontiers. Conclusions Epilepsy during pregnancy is a fascinating and rapid development of subject matter. A more recent emerging trend focused on comprehensive management of pregnant and lactating women, evaluation of the safety and efficacy of newer antiepileptic drugs. The keywords “management issue,” “brain injury,” “meta-analysis,” “in utero exposure,” and “ASD” were the latest research frontiers and should be closely observed.
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Affiliation(s)
- Minglu Wang
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Weitao Li
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yuying Tao
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Limei Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
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Erisgin Z, Ayas B, Nyengaard JR, Ercument Beyhun N, Terzi Y. The neurotoxic effects of prenatal gabapentin and oxcarbazepine exposure on newborn rats. J Matern Fetal Neonatal Med 2017; 32:461-471. [PMID: 28931341 DOI: 10.1080/14767058.2017.1383378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
AIM Teratogenicity is a problematic issue for pregnant women because of X-ray radiation, drugs, and genetic and unknown variables. First-generation antiepileptic drugs (AED) like valproic acid are well-known teratogens for developing fetuses. However, their usage is necessary in order to prevent maternal seizures. The underlying mechanism of birth defects associated with AED exposure remains unclear and information about the neurotoxic effects of prenatal exposure to AED is still limited. Oxcarbazepine (OXC) and gabapentin (GBP) are second-generation AED. It still remains unclear how much these drugs are safe during pregnancy. This study aimed to investigate whether any neurotoxic effect of OXC and GBP in utero exposure on the developing brain. METHODS Eighteen pregnant Wistar albino rats were divided into six groups. The first group was exposed to OXC at 100 mg/kg/day, the second to GBP at 50 mg/kg/day, and third to saline (0.9% NaCl) at 1.5 ml/day between the first and the fifth days of gestation. The same procedure was applied at the same dosages between the 6th and the 15th days of gestation for the 2nd three groups. Five female offspring (total n = 30, 45 days old) were taken from each group and stereological methods were applied in order to analyze the total and dopaminergic neuron number of the substantia nigra pars compacta (SNc). CONCLUSION The result is that the OXC and GBP exposure at different gestational periods may not give rise to congenital malformation and it appears that the GBP exposure during the organogenesis period proliferatively affects the total number of neurons.
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Affiliation(s)
- Zuleyha Erisgin
- a Department of Histology and Embryology , Giresun University, Faculty of Medicine , Giresun , Turkey
| | - Bulent Ayas
- b Department of Histology and Embryology , Ondokuz Mayıs University, Faculty of Medicine , Samsun , Turkey
| | - Jens R Nyengaard
- c Stereology and Electron Microscopy Laboratory , Aarhus University Hospital , Aarhus , Denmark
| | - N Ercument Beyhun
- d Department of Public Health , Black Sea Technical University, Faculty of Medicine , Trabzon , Turkey
| | - Yuksel Terzi
- e Department of Statistic, Faculty of Fine and Art , Ondokuz Mayıs University , Samsun , Turkey
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Chen CY, Li X, Ma LY, Wu PH, Zhou Y, Feng Q, Cui YM. In Utero Oxcarbazepine Exposure and Neonatal Abstinence Syndrome: Case Report and Brief Review of the Literature. Pharmacotherapy 2017; 37:e71-e75. [PMID: 28543284 PMCID: PMC5575550 DOI: 10.1002/phar.1955] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Oxcarbazepine is a second‐generation antiepileptic drug that is used to treat partial seizures. Although it has been increasingly used in pregnant women, its fetal safety has not been fully validated. We describe a 12‐hour‐old neonate who developed neonatal abstinence syndrome (NAS) after intrauterine exposure to oxcarbazepine. The neonate was born via cesarean section to a mother who took oxcarbazepine 300 mg/day for treatment of seizures throughout her pregnancy. Approximately 12 hours after birth, the infant developed paroxysmal jitter, which mainly presented as increased excitability, irritability, limb shaking, and increased muscle tone. These symptoms resolved by day 9 of life. Although NAS occurs most often after in utero exposure to opioids, exposure to other drugs during pregnancy may contribute to a small proportion of NAS cases. To our knowledge, this is the second case report of oxcarbazepine‐induced NAS. Pregnant women with epilepsy should weigh the pros and cons of continuing oxcarbazepine during their pregnancy when they are prescribed this drug. For infants with in utero oxcarbazepine exposure, comprehensive assessments and examinations are necessary for screening oxcarbazepine‐induced NAS.
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Affiliation(s)
- Chao-Yang Chen
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Xing Li
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Ling-Yue Ma
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Peng-Hui Wu
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Ying Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qi Feng
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Yi-Min Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China
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Passia E, Rock N, Pfister RE, Ing Lorenzini KR, Desmeules J, Samer CF. "Late" Withdrawal Syndrome after Carbamazepine In Utero Exposure in a CYP2C9 Slow Metabolizer Newborn. Front Pharmacol 2017; 8:217. [PMID: 28484392 PMCID: PMC5399605 DOI: 10.3389/fphar.2017.00217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/06/2017] [Indexed: 12/02/2022] Open
Abstract
We report a case of carbamazepine withdrawal syndrome following in utero exposure to carbamazepine related to a pharmacogenetic predisposition factor. The infant was born at 37 1/7 weeks’ gestation by cesarean section to a mother treated for epilepsy with carbamazepine. One hour and thirty minutes after birth, the infant presented a respiratory distress with severe oxygen desaturation requiring intubation 5 h after birth. On the third day of life the infant developed clinical signs of a withdrawal syndrome which resolved progressively after 16 days and symptomatic treatment. The infant genotype analysis showed two low activity CYP2C9 allelic variants (∗2/∗3 heterozygote) predicting a CYP2C9 slow metabolizer phenotype which could explain reduced carbamazepine elimination and a late and long-lasting withdrawal symptoms observed 3 days after birth. The association of a withdrawal syndrome with carbamazepine exposure has not been previously reported and pharmacogenetic tests might therefore be useful in identifying patients at risk.
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Affiliation(s)
- Evangelia Passia
- Department of General Internal Medicine, Geneva University HospitalsGeneva, Switzerland
| | - Nathalie Rock
- Department of Pediatrics, Geneva University HospitalsGeneva, Switzerland
| | - Riccardo E Pfister
- Department of Pediatrics, Geneva University HospitalsGeneva, Switzerland
| | - Kuntheavy R Ing Lorenzini
- Clinical Pharmacology and Toxicology, Geneva University Hospitals and Swiss Centre for Applied Human ToxicologyGeneva, Switzerland
| | - Jules Desmeules
- Clinical Pharmacology and Toxicology, Geneva University Hospitals and Swiss Centre for Applied Human ToxicologyGeneva, Switzerland
| | - Caroline F Samer
- Clinical Pharmacology and Toxicology, Geneva University Hospitals and Swiss Centre for Applied Human ToxicologyGeneva, Switzerland
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Neonatal Adaptation Issues After Maternal Exposure to Prescription Drugs: Withdrawal Syndromes and Residual Pharmacological Effects. Drug Saf 2016; 39:903-24. [DOI: 10.1007/s40264-016-0435-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Lopalco A, Ali H, Denora N, Rytting E. Oxcarbazepine-loaded polymeric nanoparticles: development and permeability studies across in vitro models of the blood-brain barrier and human placental trophoblast. Int J Nanomedicine 2015; 10:1985-96. [PMID: 25792832 PMCID: PMC4362902 DOI: 10.2147/ijn.s77498] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Encapsulation of antiepileptic drugs (AEDs) into nanoparticles may offer promise for treating pregnant women with epilepsy by improving brain delivery and limiting the transplacental permeability of AEDs to avoid fetal exposure and its consequent undesirable adverse effects. Oxcarbazepine-loaded nanoparticles were prepared by a modified solvent displacement method from biocompatible polymers (poly(lactic-co-glycolic acid) [PLGA] with or without surfactant and PEGylated PLGA [Resomer® RGPd5055]). The physical properties of the developed nanoparticles were determined with subsequent evaluation of their permeability across in vitro models of the blood–brain barrier (hCMEC/D3 cells) and human placental trophoblast cells (BeWo b30 cells). Oxcarbazepine-loaded nanoparticles with encapsulation efficiency above 69% were prepared with sizes ranging from 140–170 nm, polydispersity indices below 0.3, and zeta potential values below -34 mV. Differential scanning calorimetry and X-ray diffraction studies confirmed the amorphous state of the nanoencapsulated drug. The apparent permeability (Pe) values of the free and nanoencapsulated oxcarbazepine were comparable across both cell types, likely due to rapid drug release kinetics. Transport studies using fluorescently-labeled nanoparticles (loaded with coumarin-6) demonstrated increased permeability of surfactant-coated nanoparticles. Future developments in enzyme-prodrug therapy and targeted delivery are expected to provide improved options for pregnant patients with epilepsy.
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Affiliation(s)
- Antonio Lopalco
- Department of Obstretrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA ; Department of Pharmaceutical Chemistry, University of Kansas, Lawrence, KS, USA ; Department of Pharmacy - Drug Sciences, University of Bari Aldo Moro, Bari, Italy
| | - Hazem Ali
- Department of Obstretrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - Nunzio Denora
- Department of Pharmacy - Drug Sciences, University of Bari Aldo Moro, Bari, Italy
| | - Erik Rytting
- Department of Obstretrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA ; Center for Biomedical Engineering, University of Texas Medical Branch, Galveston, TX, USA ; Department of Pharmacology and Toxicology, University of Texas Medical Branch, Galveston, TX, USA
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Karataş Z, Karataş A, Özlü T, Goksugur SB, Varan B. Bicuspid aortic valve and severe aortic stenosis in a newborn exposed to carbamazapine during pregnancy. J Turk Ger Gynecol Assoc 2014; 15:259-61. [PMID: 25584038 DOI: 10.5152/jtgga.2014.89577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 11/22/2013] [Indexed: 11/22/2022] Open
Abstract
The use of antiepileptic drugs increases the risk of major congenital malformations during pregnancy. Here, we report an infant who had a history of in-utero carbamazepine exposure and who was born with a cardiac malformation. The infant was born at 39 weeks of gestation vaginally to an epileptic mother who had been treated with carbamazepine throughout her pregnancy. He was referred due to cardiac murmur in the second week of his life. The mother had not received folic acid supplementation. Transthoracic echocardiography revealed bicuspid aortic valve, mild aortic stenosis, patent ductus arteriosus, patent foramen ovale and the renal ultrasound revealed mild left hydronephrosis. Follow-up echocardiography performed 14 weeks later showed increased severity of aortic stenosis and percutaneous balloon aortic valvuloplasty was performed. To our knowledge, there is only one case report in the literature mentioning the association of a bicuspid aortic valve and aortic stenosis with oxcarbazepine exposure, which is a structural derivative of carbamazepine. However, there are no reports for association with carbamazepine itself. Bicuspid aorta and aortic stenosis may be among the cardiac malformations that result from the teratogenic effect of carbamazepine.
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Affiliation(s)
- Zehra Karataş
- Department of Pediatric Cardiology, Abant İzzet Baysal University Faculty of Medicine, Bolu, Turkey
| | - Ahmet Karataş
- Department of Obstetrics and Gynecology, Abant İzzet Baysal University Faculty of Medicine, Bolu, Turkey
| | - Tülay Özlü
- Department of Obstetrics and Gynecology, Abant İzzet Baysal University Faculty of Medicine, Bolu, Turkey
| | - Sevil B Goksugur
- Department of Pediatrics, Abant İzzet Baysal University Faculty of Medicine, Bolu, Turkey
| | - Birgül Varan
- Department of Pediatric Cardiology, Başkent University Faculty of Medicine, Ankara, Turkey
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