A teratological study of aminoglycoside antibiotic treatment during pregnancy

Pregnancy Outcomes in a Cohort of Patients Who Underwent Double-J Ureteric Stenting-A Single Center Experience

Background and Objectives: Minimally invasive procedures, such as double-J ureteric stenting, could be a promising therapeutic alternative to conservative management of obstructive urinary tract pathology. We aimed to evaluate the safety and effectiveness of double-J ureteric stenting in pregnant women with ureterohydronephrosis or urolithiasis, along with their infectious complications, and to assess the pregnancy outcomes of this cohort of patients in comparison with a control group. Materials and Methods: This observational retrospective study included 52 pregnant patients who underwent double-J ureteric stenting for urologic disorders in the Urology Department of ‘C.I. Parhon’ University Hospital, and who were followed up at a tertiary maternity hospital- ‘Cuza-Voda’, Iasi, Romania. The control group (63 patients) was randomly selected from the patient’s cohort who gave birth in the same time frame at the maternity hospital, without urinary pathology. Clinical, sonographic, and laboratory variables were examined. Descriptive statistics, non-parametric tests, and a one-to-one propensity score-matched analysis were used to analyze our data. Results: The univariate analysis indicated a significant statistical difference between the control group and the interventional group regarding maternal age (p = 0.018), previous maternal history of renal colic (p = 0.005) or nephrolithiasis (p = 0.002). After applying the propensity score-matched analysis, cesarean delivery rates (p < 0.001), preterm labour (p = 0.039), premature rupture of membranes (p = 0.026), preterm birth rates (p = 0.002), and post-partum UTI rates (p = 0.012) were significantly different between the control group and the matched treatment group. Ureterohydronephrosis, whether simple (n = 37; 71.2%) or infected (n = 13; 25%), was the main indication for double-J ureteric stenting. Complications such as pain (n = 21; 40.3%), stent migration (n = 3; 5.76%) or encrustation (n = 2; 3.84%), as well as reflux pyelonephritis (n = 2; 3.84%) and gross hematuria (n = 1; 1.92%) were recorded during follow-up. Conclusions: Our results show that double-J stenting is a safe and effective treatment option for pregnant patients with obstructive urological disorders.

Safety of Antimicrobials During Pregnancy: A Systematic Review of Antimicrobials Considered for Treatment and Postexposure Prophylaxis of Plague

BACKGROUND

The safety profile of antimicrobials used during pregnancy is one important consideration in the decision on how to treat and provide postexposure prophylaxis (PEP) for plague during pregnancy.

METHODS

We searched 5 scientific literature databases for primary sources on the safety of 9 antimicrobials considered for plague during pregnancy (amikacin, gentamicin, plazomicin, streptomycin, tobramycin, chloramphenicol, doxycycline, sulfadiazine, and trimethoprim-sulfamethoxazole [TMP-SMX]) and abstracted data on maternal, pregnancy, and fetal/neonatal outcomes.

RESULTS

Of 13 052 articles identified, 66 studies (case-control, case series, cohort, and randomized studies) and 96 case reports were included, totaling 27 751 prenatal exposures to amikacin (n = 9), gentamicin (n = 345), plazomicin (n = 0), streptomycin (n = 285), tobramycin (n = 43), chloramphenicol (n = 246), doxycycline (n = 2351), sulfadiazine (n = 870), and TMP-SMX (n = 23 602). Hearing or vestibular deficits were reported in 18/121 (15%) children and 17/109 (16%) pregnant women following prenatal streptomycin exposure. First trimester chloramphenicol exposure was associated with an elevated risk of an undescended testis (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.2-28.7). Doxycycline was associated with cardiovascular malformations (OR 2.4, 95% CI 1.2-4.7) in 1 study and spontaneous abortion (OR 2.8, 95% CI 1.9-4.1) in a separate study. First trimester exposure to TMP-SMX was associated with increased risk of neural tube defects (pooled OR 2.5, 95% CI 1.4-4.3), spontaneous abortion (OR 3.5, 95% CI 2.3-5.6), preterm birth (OR 1.5, 95% CI 1.1-2.1), and small for gestational age (OR 1.6, 95% CI 1.2-2.2). No other statistically significant associations were reported.

CONCLUSIONS

For most antimicrobials reviewed, adverse maternal/fetal/neonatal outcomes were not observed consistently. Prenatal exposure to streptomycin and TMP-SMX was associated with select birth defects in some studies. Based on limited data, chloramphenicol and doxycycline may be associated with adverse pregnancy or neonatal outcomes; however, more data are needed to confirm these associations. Antimicrobials should be used for treatment and PEP of plague during pregnancy; the choice of antimicrobials may be influenced by these data as well as information about the risks of plague during pregnancy.

Topical antibiotics in pregnancy: A review of safety profiles

Medications should be used with caution in women of childbearing age who are pregnant, or are contemplating pregnancy. Although topical medications are considered safer than oral or parenteral agents, their safety data in pregnancy must be assessed carefully. The available information on medication use in pregnancy is limited, and not always aided by the FDA pregnancy letter category system. Thus, in this article, we aggregate human studies, animal studies, and pharmacokinetics data to provide recommendations on utilizing topical antibiotics in pregnancy.

Cutaneous Surgery in Patients Who Are Pregnant or Breastfeeding

Dermatologic surgery in pregnant/postpartum patients requires deliberate consideration. Although surgery can be safely performed during any trimester, the second trimester and immediate postpartum period is optimal. Surgery should not be delayed for melanoma/high-risk skin cancers. Perioperative positioning, analgesic, antiseptic, and antibiotic selection should be deliberate to avoid risk to the patient/fetus/infant. The left lateral tilt position reduces aortocaval compression syndrome. Lidocaine and epinephrine can be used safely. Alcohol and chlorhexidine are considered safe. Antibiotics commonly used in skin surgery are safe in pregnancy and lactation. Acetaminophen is first line for pain management. Nonsteroidal antiinflammatory drugs should be avoided.

Renal teratogens

In utero exposure to certain drugs early in pregnancy may adversely affect nephrogenesis. Exposure to drugs later in pregnancy may affect the renin-angiotensin system, which could have an impact on fetal or neonatal renal function. Reduction in nephron number and renal function could have adverse consequences for the child several years later. Data are limited on the information needed to guide decisions for patients and providers regarding the use of certain drugs in pregnancy. The study of drug nephroteratogenicity has not been systematized, a large, standardized, global approach is needed to evaluate the renal risks of in utero drug exposures.

When one drug affects 2 patients: a review of medication for the management of nonlabor-related pain, sedation, infection, and hypertension in the hospitalized pregnant patient

One of the most difficult challenges health care providers encounter is drug selection for pregnant patients. Drug selection can be complex as efficacy and maternal side effects must be weighed against potential risk to the embryo or fetus. Verification of an individual drug's fetal safety is limited as most evidence is deduced from epidemiologic, prospective cohort, or case-control studies. Medication selection for the pregnant inpatient is a particularly complex task as the illnesses and conditions that require hospitalization mandate different medications, and the risk versus benefit ratio can vary significantly compared to the outpatient setting. Some degree of acute pain is not uncommon among inpatients. Acetaminophen is generally considered the drug of choice in pregnancy for mild to moderate acute pain, while most opioids are thought to be safe for short-term use to manage moderate to severe pain. Providing sedation is particularly challenging as the few options available for the general population are further limited by either known increased risk of congenital malformations or very limited human pregnancy data. Propofol is the only agent recommended for continuous sedation, which has a Food and Drug Administration classification as a pregnancy category B medication. Treatment of infections in hospitalized patients requires balancing the microbiology profile against the fetal risk. Older antimicrobials proven generally safe include beta-lactams, and those with proven fetal risks include tetracyclines. However, little to no information regarding gestational use is available on the newer antimicrobials that are frequently employed to treat resistant infections more commonly found in the inpatient setting. Management of maternal blood pressure is based on the severity of blood pressure elevations and not the hypertensive classification. Agents generally considered safe to use in hypertensive pregnant patients include methyldopa, labetolol, and hydralazine, while angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, hydrochlorothiazide, and atenolol should be avoided.

[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.

Phase 4 pharmacovigilance trial of paromomycin injection for the treatment of visceral leishmaniasis in India

Background. A phase 3 study demonstrated the safety and efficacy of paromomycin (paromomycin IM injection) for treatment of VL in an inpatient setting. Methods. This phase 4 study was conducted to assess the safety and efficacy of paromomycin in children and adults in an outpatient setting in Bihar, India. Results. This study enrolled 506 adult and pediatric patients. Of the 494 patients in the intent-to-treat (ITT) population, 98% received a full course of treatment. The overall study completion rate was 94% (462/494) for the ITT population and 96% (461/479) for the efficacy-evaluable (EE) population. Initial clinical cure was 99.6%, and final clinical cure 6 months after treatment was 94.2%. Grade 3 or 4 adverse events occurred in 5% of patients; events with a frequency of ≥1% were increases in alanine aminotransferase and aspartate aminotransferase. Conclusions. This study confirms the safety and efficacy of paromomycin to treat VL in an outpatient setting.

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.

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.

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.

Injectable paromomycin for Visceral leishmaniasis in India

BACKGROUND

Visceral leishmaniasis (kala-azar) affects large, rural, resource-poor populations in South Asia, Africa, and Brazil. Safe, effective, and affordable new therapies are needed. We conducted a randomized, controlled, phase 3 open-label study comparing paromomycin, an aminoglycoside, with amphotericin B, the present standard of care in Bihar, India.

METHODS

In four treatment centers for visceral leishmaniasis, 667 patients between 5 and 55 years of age who were negative for the human immunodeficiency virus and had parasitologically confirmed visceral leishmaniasis were randomly assigned in a 3:1 ratio to receive paromomycin (502 patients) at a dose of 11 mg per kilogram of body weight intramuscularly daily for 21 days or amphotericin B (165 patients) at a dose of 1 mg per kilogram intravenously every other day for 30 days. Final cure was assessed 6 months after the end of treatment; safety assessments included daily clinical evaluations and weekly laboratory and audiometric evaluations. Noninferiority testing was used to compare 6-month cure rates, with a chosen margin of noninferiority of 10 percentage points.

RESULTS

Paromomycin was shown to be noninferior to amphotericin B (final cure rate, 94.6% vs. 98.8%; difference, 4.2 percentage points; upper bound of the 97.5% confidence interval, 6.9; P<0.001). Mortality rates in the two groups were less than 1%. Adverse events, which were more common among patients receiving paromomycin than among those receiving amphotericin B (6% vs. 2%, P=0.02), included transient elevation of aspartate aminotransferase levels (>3 times the upper limit of the normal range); transient reversible ototoxicity (2% vs. 0, P=0.20); and injection-site pain (55% vs. 0, P<0.001); and in patients receiving amphotericin B, as compared with those receiving paromomycin, nephrotoxicity (4% vs. 0, P<0.001), fevers (57% vs. 3%), rigors (24% vs. 0, P<0.001), and vomiting (10% vs. <1%, P<0.001).

CONCLUSIONS

Paromomycin was shown to be noninferior to amphotericin B for the treatment of visceral leishmaniasis in India. (ClinicalTrials.gov number, NCT00216346.)

Is Gentamicin Ototoxic to the Fetus?

BACKGROUND

Gentamicin is used in pregnancy to treat infections that cause complications to the mother and fetus if left untreated. In 2003, Schering, the manufacturer of Garamycin Injectable, amended the product monograph in the Compendium of Pharmaceuticals and Specialties to state that gentamicin should be avoided in pregnancy due to cases of "total irreversible bilateral congenital deafness" in babies exposed to gentamicin in utero. Because we have identified, after an intensive literature search, only two cases over many years of availability, it is questionable whether the outcome can be attributed to drug use rather than other factors.

OBJECTIVES

The main objective of this study was to determine whether any infant exposed in utero to intravenous gentamicin and born between January 2002 and April 2006 at Victoria General Hospital demonstrated audiologic deficits on routine hearing testing. Such testing has been universally available since late 2001. Our secondary objectives were to examine patterns of gentamicin use, including indication, dosage, duration, and to determine whether or not monitoring of serum gentamicin levels was done.

METHODS

Women who had received gentamicin were identified through pharmacy records and their charts reviewed for factors that might contribute to fetal deafness including substance abuse, use of other potentially ototoxic medications, genetic predisposition, and intrauterine infections. We reviewed audiology test result and the infants' charts for potential confounding factors, including prematurity, low birth weight, low Apgar scores, anoxia, hyperbilirubinemia, sepsis, and meningitis.

RESULTS

Fifty-two charts were reviewed, 40 of which documented live births. There was no case of hearing loss documented. Of the eight fetal losses, six (11.5%) were preterm births before viability, and two were elective terminations. Pyelonephritis was the main indication for gentamicin use (48%), followed by chorioamnionitis (31%) and other miscellaneous indications (21%). Three times daily dosing was used for a mean duration of 2.7 +- 2.3 days, resulting in an average cumulative dose of 764 +- 600 mg gentamicin. The average gestational age at exposure was 28 weeks. Maternal serum gentamicin levels were obtained in 72.5% of cases, and no trough level was above 2 mg/L. Other potentially ototoxic medications were administered to the mother in 17.5% of pregnancies, and to 17.5% of babies in the immediate newborn period. With the exception of one infant who died before additional testing could be carried out, all the infants passed hearing tests, 89% on initial screening.

CONCLUSION

In utero exposure to gentamicin did not cause an increase in audiologic impairment in the infants tested in this cohort.

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.

Rifaximin, a poorly absorbed antibiotic: pharmacology and clinical potential

Rifaximin (4-deoxy-4'-methylpyrido[1',2'-1,2]imidazo- [5,4-c]-rifamycin SV) is a synthetic antibiotic designed to modify the parent compound, rifamycin, in order to achieve low gastrointestinal (GI) absorption while retaining good antibacterial activity. Both experimental and clinical pharmacology clearly show that this compound is a nonsystemic antibiotic with a broad spectrum of antibacterial action covering Gram-positive and Gram-negative organisms, both aerobes and anaerobes. Being virtually nonabsorbed, its bioavailability within the GI tract is rather high with intraluminal and fecal drug concentrations that largely exceed the minimal inhibitory concentration values observed in vitro against a wide range of pathogenic organisms. The GI tract represents, therefore, the primary therapeutic target and GI infections the main indication. The appreciation of the pathogenic role of gut bacteria in several organic and functional GI diseases has increasingly broadened its clinical use, which is now extended to hepatic encephalopathy, small intestine bacterial overgrowth, inflammatory bowel disease and colonic diverticular disease. Potential indications include the irritable bowel syndrome and chronic constipation, Clostridium difficile infection and bowel preparation before colorectal surgery. Because of its antibacterial activity against the microorganism and the lack of strains with primary resistance, some preliminary studies have explored the rifaximin potential for Helicobacter pylori eradication. Oral administration of this drug, by getting rid of enteric bacteria, could also be employed to achieve selective bowel decontamination in acute pancreatitis, liver cirrhosis (thus preventing spontaneous bacterial peritonitis) and nonsteroidal anti-inflammatory drug (NSAID) use (lessening in that way NSAID enteropathy). This antibiotic has, therefore, little value outside the enteric area and this will minimize both antimicrobial resistance and systemic adverse events. Indeed, the drug proved to be safe in all patient populations, including young children. Although rifaximin has stood the test of time, it still attracts the attention of both basic scientists and clinicians. As a matter of fact, with the advancement of the knowledge on microbial-gut interactions in health and disease novel indications and new drug regimens are being explored. Besides widening the clinical use, the research on rifaximin is also focused on the synthesis of new derivatives and on the development of original formulations designed to expand the spectrum of its clinical use.

Risk and benefit of drug use during pregnancy

Environmental teratogenic factors (e.g. alcohol) are preventable. We focus our analysis on human teratogenic drugs which are not used frequently during pregnancy. The previous human teratogenic studies had serious methodological problems, e.g. the first trimester concept is outdated because environmental teratogens cannot induce congenital abnormalities in the first month of gestation. In addition, teratogens usually cause specific congenital abnormalities or syndromes. Finally, the importance of chemical structures, administrative routes and reasons for treatment at the evaluation of medicinal products was not considered. On the other hand, in the so-called case-control epidemiological studies in general recall bias was not limited. These biases explain that the teratogenic risk of drugs is exaggerated, while the benefit of medicine use during pregnancy is underestimated. Thus, a better balance is needed between the risk and benefit of drug treatments during pregnancy. Of course, we have to do our best to reduce the risk of teratogenic drugs as much as possible, however, it is worth stressing the preventive effect of drugs for maternal diseases (e.g. diabetes mellitus and hyperthermia) related congenital abnormalities.

Urinary tract infections in unplanned pregnancies and fetal outcome

AIM

Many pregnant women are exposed to antibiotics for urinary tract infections during pregnancy. Our aim is to bring attention to antibiotherapy in unplanned pregnancies.

METHOD

Among the 511 cases followed by our 'Toxicology Information and Follow-up Service' for drug exposure during pregnancy, 101 cases, unaware of their pregnancy, had been prescribed antibiotics and urinary antiseptic drugs in the first trimester of their unplanned pregnancies. The data on the outcome of these pregnancies and the babies were evaluated in this study.

RESULTS

Of the 511 cases, 101 pregnant women were exposed to nine kinds of drugs. Seventy-five cases had healthy babies; two had babies with major malformations; one had a baby with congenital hypothyroidism; five had spontaneous abortions; and eight cases underwent induced abortions. The outcomes of eight pregnancies are unknown. Two pregnancies are still continuing without any problem. One baby had a fetal renal anomaly; however, the physical examination did not reveal any other malformations. The baby died 4 hours after delivery. Another baby had atrial septal defect, a major malformation, and one baby had congenital hypothyroidism.

CONCLUSION

Urinary tract infection is one of the most frequently seen complications of pregnancy. Our study indicated that the possibility of pregnancy should be considered when prescribing antibiotics for urinary tract infections in women of reproductive age.

The pregnant wilderness traveler

BACKGROUND

Travel during pregnancy, especially, when it involves potentially hazardous activities in remote areas, often raises serious concerns regarding the health and safety risks involved.

METHOD

The authors have researched the available medical literature to identify these risks and present the current recommendations for their prevention and treatment.

RESULTS

Topics addressed include some political and social issues, insurance, basic comfort measures, complications of pregnancy, infectious diseases, environmental exposures, and trauma. Preventive measures include pre-travel evaluation and teaching, possible modifications of the itinerary, vaccinations and medications. Also briefly discussed are the handling of obstetrical emergencies in the field and medical evacuation of the pregnant patient.

CONCLUSIONS

The authors conclude that many trips of this nature can be made relatively safe for the pregnant traveler, but she may need to accept some precautions and modifications of the itinerary that might not otherwise be necessary.

The fetal safety and clinical efficacy of gastrointestinal endoscopy during pregnancy

More than 12,000 pregnant patients in the United States per annum have conditions that are normally evaluated by EGD. More than 6000 pregnant patients in the United States per annum have conditions that are normally evaluated by sigmoidoscopy or colonoscopy. About one thousand more have symptomatic choledocholithiasis during pregnancy, which is a strong indication for endoscopic sphincterotomy in nonpregnant patients. Endoscopy during pregnancy raises the unique issue of fetal safety. Endoscopic medications comprise a significant component of fetal endoscopic risks. Safety of EGD during pregnancy has been examined in a case-controlled study of 83 patients, a mailed survey of 73 patients, and 28 case reports. Safety of sigmoidoscopy during pregnancy has been examined in a case-controlled study of 46 patients, a mailed survey of 13 patients, and 10 case reports. Safety of therapeutic ERCP during pregnancy has been analyzed in studies of 23, 10, 6, and 5 patients, and in 32 case reports. These studies suggested that EGD, sigmoidoscopy, and ERCP should be performed when strongly indicated: EGD for significant upper gastrointestinal bleeding, sigmoidoscopy for nonhemorrhoidal rectal bleeding, and ERCP for symptomatic choledocholithiasis when sphincterotomy is contemplated. PEG and colonoscopy are currently considered experimental during pregnancy because of insufficient data on fetal safety. Several cases of PEG and colonoscopy were successfully performed during pregnancy. Performance of endoscopy during pregnancy should increase with further technical refinements, and greater awareness of procedure safety.