Maternal bronchodilator use and the risk of orofacial clefts

Asthma in pregnancy: a review of recent literature

PURPOSE OF REVIEW

Asthma remains the most common respiratory disease in pregnancy. Identifying risk factors for asthma exacerbations during pregnancy is critical, as uncontrolled asthma can have detrimental effects for both mother and baby. In this review, we discuss recent literature exploring risk factors, fetal and maternal effects, and treatment options for asthma during pregnancy.

RECENT FINDINGS

Recent literature suggests that optimizing asthma during pregnancy improves outcomes for both mother and baby, as well as later in childhood. Current research affirms that the benefit of asthma medication use outweighs any potential risks related to the medications themselves. Limited information is available regarding the use of newer therapies such as biologics during pregnancy.

SUMMARY

Identifying risk factors for asthma exacerbations during pregnancy is critical to prevent adverse outcomes for both mother and baby. Recent evidence continues to affirm the safety of asthma medication use; more studies are needed regarding the use of new therapies during pregnancy.

Genetic Variants in Mammalian STE20-like Protein Kinase 2 were associated with risk of NSCL/P

AIM

Mammalian STE20-like protein kinase 2 (MST2) plays an important role in apoptosis and the development of many disorders. Here, we aim to explore if genetic variants in MST2 are associated with the risk of non-syndromic cleft lip with or without palate (NSCL/P).

MATERIALS AND METHODS

The association study was performed in a two-stage study of 1,069 cases and 1,724 controls to evaluate the association between genetic variants in the MST2 and NSCL/P risk. The potential function of the candidate single nucleotide polymorphism (SNP) was predicted using HaploReg, RegulomeDB, and public craniofacial histone chromatin immunoprecipitation sequencing (ChIP-seq) data. Haploview was used to perform the haplotype of risk alleles. The expression quantitative trait loci (eQTL) effect was assessed using the Genotype-Tissue Expression (GTEx) project. Gene expression in mouse embryo tissue was performed using data downloaded from GSE67985. The potential role of candidate gene in the development of NSCL/P was assessed by correlation and enrichment analysis.

RESULTS

Among SNPs in MST2, rs2922070 C allele (P_meta = 2.93E-04) and rs6988087 T allele (P_meta = 1.57E-03) were linked with significantly increased risk of NSCL/P. Rs2922070, rs6988087 and their high linkage disequilibrium (LD) SNPs constituted a risk haplotype of NSCL/P. Individuals carrying 3-4 risk alleles had an elevated risk of NSCL/P compared to those who carried less risk alleles (P = 2.00E-04). The eQTL analysis revealed a significant association between these two variants and MST2 in muscle tissue of the body. The MST2 expressed during mouse craniofacial development and over-expressed in the human orbicularis oris muscle (OOM) of NSCL/P patients compared to controls. MST2 was involved in the development of NSCL/P by regulating the mRNA surveillance pathway, the MAPK signaling pathway, the neurotrophin signaling pathway, the FoxO signaling pathway and the VEGF signaling pathway.

CONCLUSION

MST2 was associated with the development of NSCL/P.

Chronic Management of Asthma During Pregnancy

Asthma is one of the most common potentially serious medical problems to complicate pregnancy. Optimal management of asthma during pregnancy is thus important for both mother and baby. Treating asthmatic women requires understanding the effects of pregnancy on the course of asthma, and, conversely, the effects of asthma on pregnancy outcomes. Successful management also requires an understanding the barriers to asthma control in this population of patients. Evidence has shown that it is essential that the allergist-immunologist, obstetrician, and patient work as a team during pregnancy to achieve optimal maternal and neonatal outcomes.

Management of allergic diseases in pregnancy

Allergic diseases like asthma, allergic rhinitis, food allergy, hymenoptera allergy, or atopic dermatitis are highly prevalent in women of childbearing age and may affect up to 30% of this age group. This review focuses on the management of allergic diseases during pregnancy. Furthermore, we discuss the challenges of counseling women with allergic diseases in the reproductive age, including considerations relevant to the ongoing SARS-CoV-2 pandemic. To create the optimal milieu for the unborn child, a multitude of immunological changes occur during pregnancy which may favor type 2 responses and aggravate disease phenotypes. In co-occurrence with suboptimal preconception disease control, this elevated Th2 responses may aggravate allergic disease manifestations during pregnancy and pose a risk for mother and child. Due to limitations in conducting clinical trials in pregnant women, safety data on anti-allergic drugs during pregnancy are limited. The lack of information and concerns among pregnant patients demands counseling on the benefits of anti-allergic drugs and the potential and known risks. This includes information on the risk for mother and child of disease aggravation in the absence of treatment. By doing so, informed decisions and shared decision-making can take place.

Contemporary management and treatment strategies for asthma during pregnancy

Introduction: Asthma is one of the most common conditions that afflict pregnant women. Because uncontrolled asthma in pregnancy affects both maternal and offspring outcomes, careful attention to maintaining control of asthma symptoms throughout pregnancy is of critical importance.Areas Covered: Using a search of PUBMED/MEDLINE for 'asthma and pregnancy,' this article will review the current literature regarding epidemiology and course of asthma in pregnancy, the effects of uncontrolled asthma on both the mother and offspring, and provide an overview of the management, both non-pharmacologic and pharmacologic, of asthma in pregnancy.Expert Opinion: There is a lack of adequate safety information for most medications taken during pregnancy. Future research might allow better methods to predict which women will experience worsening during pregnancy. For now, surveillance systems like pregnancy registries or observational cohort studies can provide safety information for medications used during pregnancy.

Anti-asthma Drugs Formoterol and Budesonide (Symbicort) Induce Orofacial Clefts, Gastroschisis and Heart Septum Defects in an In Vivo Model

BACKGROUND

We had a case in which three consecutive pregnancies resulted in birth of three children with an orofacial cleft. Their mother suffered from bronchial asthma and was treated using symbicort (corticosteroid budesonide plus bronchodilator formoterol) during her pregnancies. A hypothesis was assessed: these anti-asthmatics can induce an orofacial cleft in experimental model.

MATERIALS AND METHODS

A single administration of one of five increasing doses (including therapeutically used ones) of Symbicort, budesonide or formoterol was injected into the amnion of a chick embryo on day 4 or 5 of incubation. The teratogenic/lethal effects of the anti-asthmatics were assessed on a total of 600 embryos.

RESULTS

For budesonide, the teratogenic/lethal effect started at a dose 0.003 μg per embryo, for formoterol at 0.3 μg and for Symbicort 0.03 μg. Orofacial clefts and gastroschisis after exposure were found for all three anti-asthmatics. Heart septum defects occurred after exposure to formoterol.

CONCLUSION

The present results support those clinical/epidemiological studies pointing out that anti-asthmatics have the potential to induce orofacial clefts, gastroschisis and heart malformations during prenatal development in human.

The safety of asthma medications during pregnancy and lactation: Clinical management and research priorities

Asthma is one of the most common underlying diseases in women of reproductive age that can lead to potentially serious medical problems during pregnancy and lactation. A group of key stakeholders across multiple relevant disciplines was invited to take part in an effort to prioritize, strategize, and mobilize action steps to fill important gaps in knowledge regarding asthma medication safety in pregnancy and lactation. The stakeholders identified substantial gaps in the literature on the safety of asthma medications used during pregnancy and lactation and prioritized strategies to fill those gaps. Short-term action steps included linking data from existing complementary study designs (US and international claims data, single drug pregnancy registries, case-control studies, and coordinated systematic data systems). Long-term action steps included creating an asthma disease registry, incorporating the disease registry into electronic health record systems, and coordinating care across disciplines. The stakeholders also prioritized establishing new infrastructures/collaborations to perform research in pregnant and lactating women and to include patient perspectives throughout the process. To address the evidence gaps, and aid in populating product labels with data that inform clinical decision making, the consortium developed a plan to systematically obtain necessary data in the most efficient and timely manner.

Pharmacotherapeutic management of asthma in pregnancy and the effect of sex hormones

INTRODUCTION

Asthma is a common medical condition that can frequently affect pregnancy, and thus optimal management of asthma in pregnancy is important for both mother and baby. This article reviews recent developments of asthma pharmacotherapy and provides emerging data on the safety of asthma controller medications and biological therapies in pregnancy. The authors highlight the clinical outcomes of asthma during pregnancy, and summarize emerging new data related to the influence of sex hormones and fetal sex on asthma severity.

AREAS COVERED

This review of asthma pharmacotherapy during pregnancy examines the recent guidelines and reports the most pertinent publications on safety data and asthma management.

EXPERT OPINION

Asthma management during pregnancy follows the same principles as that of non-pregnant asthma. The available data for most asthma medications are reassuring, however there is a lack of adequate safety data available because pregnant women are generally excluded from clinical trials. More clarity is needed in guidelines regarding the management of asthma in pregnancy, and high-quality randomized control trials are required to strengthen the evidence base and inform future guidelines. In particular, safety studies examining biological therapies in pregnant women with severe asthma are needed.

Asthma Medication Use and Risk of Birth Defects: National Birth Defects Prevention Study, 1997-2011

BACKGROUND

Evidence regarding associations between maternal asthma medication use and birth defects is mixed.

OBJECTIVE

Estimate associations between asthma medciation use and 52 birth defects using National Birth Defects Prevention Study data from 1997 to 2011.

METHODS

We compared self-reported maternal asthma medication use for 28,481 birth defect cases and 10,894 nonmalformed controls. We calculated adjusted odds ratios (95% CIs) to estimate the risk of birth defects associated with early pregnancy asthma medication use (the month before through the third month of pregnancy), controlling for maternal age, race/ethnicity, body mass index, smoking, folic acid-containing supplement use, and parity. We calculated risks by medication groupings: bronchodilators, anti-inflammatories, and both.

RESULTS

Overall, 1304 (5%) case and 449 (4%) control women reported early pregnancy asthma medication use. We observed an association between asthma medication use and longitudinal limb deficiency (1.81; 95% CI, 1.27-2.58). Early pregnancy bronchodilator-only use was associated with cleft palate (1.50; 95% CI, 1.11-2.02), cleft lip (1.58; 95% CI, 1.12-2.23), longitudinal limb deficiency (2.35; 95% CI, 1.55-3.54), and truncus arteriosus (2.48; 95% CI, 1.13-5.42). Although early pregnancy anti-inflammatory-only use was not associated with the birth defects studied, use of both medications was associated with biliary atresia (3.60; 95% CI, 1.55-8.35) and pulmonary atresia (2.50; 95% CI, 1.09-5.78).

CONCLUSIONS

Consistent with previous National Birth Defects Prevention Study analyses, asthma medication use was not associated with most birth defects examined, but we observed modest risks for bronchodilator use and several birth defects. Our findings support maintaining adequate asthma treatment during pregnancy, because early pregnancy asthma exacerbations have been associated with adverse birth outcomes, including birth defects.

Effects of phenytoin spray in prevention of fistula formation following cleft palate repair

BACKGROUND

The effectiveness of topical phenytoin has been reported for the treatment of oral biopsy ulcers, chemotherapy-induced oral mucositis, and chronic periodontitis. This study aimed to investigate the effects of topical phenytoin 2% on the prevention of fistula formation after cleft palate repair.

METHOD

This randomized clinical trial studied patients with nonsyndromic cleft palate who were referred to a tertiary center and underwent cleft palate repair from March 2010 to February 2015. Patients in the phenytoin group received phenytoin spray 2% for 8 weeks and were compared with an age- and sex-matched control group.

RESULTS

A total of 160 patients in two phenytoin and control groups (n = 80 for each group) were recruited to the study. The mean ages of patients in the phenytoin and control groups were 11.42 ± 1.30 and 11.08 ± 1.25 months, respectively. The results showed that six patients (7.5%) in the phenytoin group and 15 patients (18.8%) in the control group formed fistulas during the 6-month follow-up period. There was a significant difference in fistula formation between the phenytoin and control groups (p = 0.035). Furthermore, fistula size was significantly smaller in the phenytoin group compared with the control group (p < 0.001).

CONCLUSION

More frequent use of phenytoin spray can be considered, although there is insufficient information on the long-term side-effects of the chosen drug.

Medications that Cause Fetal Anomalies and Possible Prevention Strategies

Many conditions that require frequent medication use are common during pregnancy. The purpose of this article is to list some of the most common of these disorders and to discuss the risk to the developing fetus of the medications used most frequently to treat them. Included are drugs used for the treatment of asthma, nausea and vomiting, hyperthyroidism, pain and fever, and depression during pregnancy.

A discriminant analysis prediction model of non-syndromic cleft lip with or without cleft palate based on risk factors

BACKGROUND

A risk prediction model of non-syndromic cleft lip with or without cleft palate (NSCL/P) was established by a discriminant analysis to predict the individual risk of NSCL/P in pregnant women.

METHODS

A hospital-based case-control study was conducted with 113 cases of NSCL/P and 226 controls without NSCL/P. The cases and the controls were obtained from 52 birth defects' surveillance hospitals in Hunan Province, China. A questionnaire was administered in person to collect the variables relevant to NSCL/P by face to face interviews. Logistic regression models were used to analyze the influencing factors of NSCL/P, and a stepwise Fisher discriminant analysis was subsequently used to construct the prediction model.

RESULTS

In the univariate analysis, 13 influencing factors were related to NSCL/P, of which the following 8 influencing factors as predictors determined the discriminant prediction model: family income, maternal occupational hazards exposure, premarital medical examination, housing renovation, milk/soymilk intake in the first trimester of pregnancy, paternal occupational hazards exposure, paternal strong tea drinking, and family history of NSCL/P. The model had statistical significance (lambda = 0.772, chi-square = 86.044, df = 8, P < 0.001). Self-verification showed that 83.8 % of the participants were correctly predicted to be NSCL/P cases or controls with a sensitivity of 74.3 % and a specificity of 88.5 %. The area under the receiver operating characteristic curve (AUC) was 0.846.

CONCLUSIONS

The prediction model that was established using the risk factors of NSCL/P can be useful for predicting the risk of NSCL/P. Further research is needed to improve the model, and confirm the validity and reliability of the model.

Risk of congenital anomalies after exposure to asthma medication in the first trimester of pregnancy - a cohort linkage study

Objective

To examine the effect of maternal exposure to asthma medications on the risk of congenital anomalies.

Design

Meta‐analysis of aggregated data from three cohort studies.

Setting

Linkage between healthcare databases and EUROCAT congenital anomaly registries.

Population

519 242 pregnancies in Norway (2004–2010), Wales (2000–2010) and Funen, Denmark (2000–2010).

Methods

Exposure defined as having at least one prescription for asthma medications issued (Wales) or dispensed (Norway, Denmark) from 91 days before to 91 days after the pregnancy start date. Odds ratios (ORs) were estimated separately for each register and combined in meta‐analyses.

Main outcome measures

ORs for all congenital anomalies and specific congenital anomalies.

Results

Overall exposure prevalence was 3.76%. For exposure to asthma medication in general, the adjusted OR (adjOR) for a major congenital anomaly was 1.21 (99% CI 1.09–1.34) after adjustment for maternal age and socioeconomic position. The OR of anal atresia was significantly increased in pregnancies exposed to inhaled corticosteroids (3.40; 99% CI 1.15–10.04). For severe congenital heart defects, an increased OR (1.97; 1.12–3.49) was associated with exposure to combination treatment with inhaled corticosteroids and long‐acting beta‐2‐agonists. Associations with renal dysplasia were driven by exposure to short‐acting beta‐2‐agonists (2.37; 1.20–4.67).

Conclusion

The increased risk of congenital anomalies for women taking asthma medication is small with little confounding by maternal age or socioeconomic status. The study confirmed the association of inhaled corticosteroids with anal atresia found in earlier research and found potential new associations with combination treatment. The potential new associations should be interpreted with caution due to the large number of comparisons undertaken.

Tweetable abstract

This cohort study found a small increased risk of congenital anomalies for women taking asthma medication.

This cohort study found a small increased risk of congenital anomalies for women taking asthma medication.

Safety of Drugs during Pregnancy and Breastfeeding in Cystic Fibrosis Patients

Health management of cystic fibrosis (CF) patients should be maximized during pregnancy and breastfeeding because of its significant impact on the maternal and newborn outcomes. Thus, numerous drugs will have to be continued during pregnancy and lactation. Most of the drugs representing CF treatment lines cross the placenta or are excreted into human milk. Research addressing the risks and benefits of drugs used in CF patients during pregnancy and lactation is often incomplete or challenged by limited methodology, which often leads to conflicting or inconclusive results. Yet, potential treatment benefits for CF pregnant patients most often outbalance potential risks for the unborn child.

Asthma medication prescribing before, during and after pregnancy: a study in seven European regions

OBJECTIVES

To explore utilisation patterns of asthma medication before, during and after pregnancy as recorded in seven European population-based databases.

DESIGN

A descriptive drug utilisation study.

SETTING

7 electronic healthcare databases in Denmark, Norway, the Netherlands, Italy (Emilia Romagna and Tuscany), Wales, and the Clinical Practice Research Datalink representing the rest of the UK.

PARTICIPANTS

All women with a pregnancy ending in a delivery that started and ended between 2004 and 2010, who had been present in the database for the year before, throughout and the year following pregnancy.

MAIN OUTCOME MEASURES

The percentage of deliveries where the woman received an asthma medicine prescription, based on prescriptions issued (UK) or dispensed (non-UK), during the year before, throughout or during the year following pregnancy. Asthma medicine prescribing patterns were described for 3-month time periods and the choice of asthma medicine and changes in prescribing over the study period were evaluated in each database.

RESULTS

In total, 1,165,435 deliveries were identified. The prevalence of asthma medication prescribing during pregnancy was highest in the UK and Wales databases (9.4% (CI95 9.3% to 9.6%) and 9.4% (CI95 9.1% to 9.6%), respectively) and lowest in the Norwegian database (3.7% (CI95 3.7% to 3.8%)). In the year before pregnancy, the prevalence of asthma medication prescribing remained constant in all regions. Prescribing levels peaked during the second trimester of pregnancy and were at their lowest during the 3-month period following delivery. A decline was observed, in all regions except the UK, in the prescribing of long-acting β-2-agonists during pregnancy. During the 7-year study period, there were only small changes in prescribing patterns.

CONCLUSIONS

Differences were found in the prevalence of prescribing of asthma medications during and surrounding pregnancy in Europe. Inhaled β-2 agonists and inhaled corticosteroids were, however, the most popular therapeutic regimens in all databases.

Maternal asthma medication use during pregnancy and risk of congenital heart defects

BACKGROUND

Asthma affects 4% to 8% of pregnant women and studies suggest maternal asthma, particularly when uncontrolled, may be associated with adverse reproductive outcomes.

METHODS

We examined self-reported asthma medication use and the risk of congenital heart defects (CHD) in the National Birth Defects Prevention Study, a multi-center, population-based case-control study of selected major structural defects. We evaluated maternal use of bronchodilators and anti-inflammatories during the periconceptional period (1 month before conception through the first 3 pregnancy months) among 7638 infants with CHDs and 8106 nonmalformed controls with estimated delivery dates from 1997 to 2007. We used logistic regression to estimate odds ratios and 95% confidence intervals for 20 types of CHDs.

RESULTS

Among asthma medications reported during the periconceptional period among controls, albuterol accounted for 85.1% of all bronchodilator use, and fluticasone, prednisone, and montelukast accounted for 46.1%, 15.6%, and 14.9% of anti-inflammatory use, respectively. Of the women who reported bronchodilators during the periconceptional period, 71.1% reported use throughout pregnancy and only 29.4% reported concurrent use of an anti-inflammatory. We observed one statistically significant association between maternal bronchodilator use only and anomalous pulmonary venous return (odds ratio 2.3, 95% confidence interval 1.1-4.8) among numerous comparisons.

CONCLUSION

We did not observe statistically significant associations between the reported use of asthma medications during pregnancy and most specific types of CHDs. Despite limitations in our inability to evaluate asthma status and severity, our study suggests that maternal asthma medication use does not substantially, if at all, increase the risk of CHDs.

Use of asthma medication during pregnancy and risk of specific congenital anomalies: A European case-malformed control study

BACKGROUND

Pregnant women with asthma need to take medication during pregnancy.

OBJECTIVE

We sought to identify whether there is an increased risk of specific congenital anomalies after exposure to antiasthma medication in the first trimester of pregnancy.

METHODS

We performed a population-based case-malformed control study testing signals identified in a literature review. Odds ratios (ORs) of exposure to the main groups of asthma medication were calculated for each of the 10 signal anomalies compared with registrations with nonchromosomal, nonsignal anomalies as control registrations. In addition, exploratory analyses were done for each nonsignal anomaly. The data set included 76,249 registrations of congenital anomalies from 13 EUROmediCAT registries.

RESULTS

Cleft palate (OR, 1.63; 95% CI, 1.05-2.52) and gastroschisis (OR, 1.89; 95% CI, 1.12-3.20) had significantly increased odds of exposure to first-trimester use of inhaled β2-agonists compared with nonchromosomal control registrations. Odds of exposure to salbutamol were similar. Nonsignificant ORs of exposure to inhaled β2-agonists were found for spina bifida, cleft lip, anal atresia, severe congenital heart defects in general, or tetralogy of Fallot. None of the 4 literature signals of exposure to inhaled steroids were confirmed (cleft palate, cleft lip, anal atresia, and hypospadias). Exploratory analyses found an association between renal dysplasia and exposure to the combination of long-acting β2-agonists and inhaled corticosteroids (OR, 3.95; 95% CI, 1.99-7.85).

CONCLUSIONS

The study confirmed increased odds of first-trimester exposure to inhaled β2-agonists for cleft palate and gastroschisis and found a potential new signal for renal dysplasia associated with combined long-acting β2-agonists and inhaled corticosteroids. Use of inhaled corticosteroids during the first trimester of pregnancy seems to be safe in relation to the risk for a range of specific major congenital anomalies.

Next steps for birth defects research and prevention: The birth defects study to evaluate pregnancy exposures (BD-STEPS)

BACKGROUND

The Birth Defects Study To Evaluate Pregnancy exposureS (BD-STEPS) is a population-based, multi-Center case-control study of modifiable risk factors for selected birth defects in the United States. BD-STEPS is the second major research effort of the Centers for Birth Defects Research and Prevention, which extends and expands the initial research effort, the National Birth Defects Prevention Study (NBDPS).

METHODS

BD-STEPS focuses on 17 categories of structural birth defects selected based on severity, prevalence, consistent ascertainment, and previous findings that warrant additional research. Cases are identified through existing birth defects surveillance programs; controls are from vital records or birth hospital logs from the same catchment area. BD-STEPS uses a standardized computer-assisted telephone interview to collect information from case and control mothers on topics including demographics, health conditions, and medication use. Following the maternal interview, selected Centers request permission to sample residual newborn screening blood spots from state repositories for genetic analyses. New components planned for BD-STEPS include linkages with external datasets and use of online questionnaires to collect in-depth information on selected exposures.

RESULTS

BD-STEPS extends NBDPS by continuing to collect data on many exposures that were assessed in NBDPS, allowing data from both studies to be combined and providing an unprecedented sample size to analyze rare exposures. BD-STEPS expands upon NBDPS by collecting more detailed information on existing exposures as well as new exposures.

CONCLUSION

The goal of BD-STEPS is to provide women and healthcare providers with information they need to make decisions to promote the healthiest pregnancy possible.

Asthma in pregnancy: Physiology, diagnosis, and management

Asthma is a common, potentially serious, medical condition that affects an estimated 8% of pregnant patients, with 4% of all pregnant patients experiencing an exacerbation in the past year. Practitioners must be able to diagnose, educate, and treat such patients as they undergo significant physiological and immunologic change. But staying current can be challenging given over 3000 citations for "asthma and pregnancy" in a recent PubMed search, with 750 described as review articles. Patients have even more difficulty navigating information, with 29 million Google search results for this same query and 1.2 million alone for the question whether asthma medications are safe during pregnancy. This review provides brief answers to important management questions followed by supporting background literature.

Risk factors involved in orofacial cleft predisposition - review

Clefts that occur in children are a special topic. Avoiding risk factors, and also an early diagnosis of cleft possibility can result in minimizing or avoiding them. If on the other hand when clefts occur they require a long-term, multistage specialized treatment. Etiology of clefts seems to be related to many factors. Factors such as genetic, environmental, geographic and even race factors are important. Identification of risk factors can lead to prevention and prophylactic behaviors in order to minimize its occurrence. Exposure to environmental factors at home and work that lead to cleft predisposition should not be disregarded. It seems that before planning a family it would be wise to consult with doctors of different specializations, especially in high-risk families with cleft history in order to analyze previous lifestyle. Clefts are very common in hereditary facial malformations and are causing a lot of other irregularities in the head and neck region. In this paper after a brief papers review authors present socio-geographic, environmental and also work place related factors that are influencing pregnant women condition and should be taken under serious consideration.

Asthma in pregnancy

Asthma affects approximately 8% of women during pregnancy. Pregnancy results in a variable course for asthma control, likely contributed to by physiological changes affecting the respiratory, immune, and hormonal systems. While asthma during pregnancy has been associated with an increased risk of maternal and fetal complications including malformations, available data also suggest that active asthma management and monitoring can decrease the risk of adverse outcomes. The diagnosis, disease classification, and goals for asthma management in the pregnant woman are the same as for nonpregnant patients. However, evidence shows that pregnant asthmatics are more likely to be undertreated, resulting in asthma exacerbations occurring in approximately one third and hospitalization in one tenth of patients. Pharmacotherapeutic management of asthma exacerbations in pregnant patients follows standard treatment guidelines. In contrast, the principles of asthma maintenance therapy are slightly modified in the pregnant patient. Patients and practitioners may avoid use of asthma medications due to concern for a risk of fetal complications and malformations. A variable amount of information is available regarding the risk of a given asthma medication to cause adverse fetal outcomes, and it is preferable to use an inhaled product. Nevertheless, based on available data, the majority of asthma medications are regarded as safe for use during pregnancy. And, any increased risk to either the mother or fetus from medication use appears to be small compared to that associated with poor asthma control.

A miRNA-binding-site SNP of MSX1 is Associated with NSOC Susceptibility

MSX1 is a favorable candidate gene for susceptibility to non-syndromic orofacial clefts (NSOCs). However, the roles of MSX1 genetic variants in the development of NSOC are controversial and vary among human populations. In the present study, the roles of 4 potentially functional single-nucleotide polymorphisms (SNPs) of MSX1 (rs12532 in 3′-untranslated region [UTR], and rs3821947, rs3821949, and rs4464513 in 5′ upstream) were investigated in a case-control study of 602 NSOC cases and 605 healthy controls. The findings showed that rs12532 located within 3′-UTR of MSX1 could influence the risk of developing NSOC. Individuals who carried the variant genotype (rs12532AA genotype) showed a decreased possibility of developing NSOC (AA vs. GG: OR = 0.69, 95% CI = [0.49, 0.98]). Interestingly, similar effects were also observed on cleft lip with palate (CLP), in a stratified analysis (allelic comparison-12532A allele vs. 12532G allele, OR = 0.80, 95% CI = [0.66, 0.99]; genotypic comparison-AA vs. GG, OR = 0.58 95% CI = [0.37, 0.91]). Sequence analysis indicated that this SNP might alter the binding ability of miR-3649, confirmed by luciferase activity assay showing a lower expression level of rs12532 A allele compared with that of the G allele ( p < .001 for 293A and COS7 cell lines). Furthermore, an in vivo study showed that MSX1 expression among individuals carrying the AA genotype of rs12532 was markedly lower than that in those with the GG genotype, while the inverse correlation was observed for miR-3649, thus providing a possible interaction between MSX1 and miR-3649 in the etiology of NSOC. Taken together, these findings indicate that SNPs in the miRNA-binding sites might play an important role in the development of NSOCs. Furthermore, if confirmed in subsequent studies, the polymorphisms may be considered as additional markers for the evaluation of infants’ risk of NSOCs.

Beta2-agonists use during pregnancy and perinatal outcomes: a systematic review

BACKGROUND

Short and long-acting beta2-agonists (SABA and LABA) have a crucial role in asthma management during pregnancy, as stated in the current guidelines.

OBJECTIVE

To systematically review the evidence on beta2-agonists use during pregnancy and adverse perinatal outcomes.

DATA SOURCES AND STUDY SELECTION

Six databases were searched before January 1, 2013 for beta2-agonists use during pregnancy and congenital malformations, small for gestational age, mean and low birth weight, gestational age and preterm delivery. Original English language articles were included with no cut-off date. Quality assessment and post-hoc power calculations were performed.

RESULTS

Twenty-one original studies were identified. Four studies reported a significant increased risk of congenital malformations with SABA, while one study reported a significant decreased risk with high doses of SABA. One study reported a significant increased risk of congenital malformations with LABA and four studies reported a significant increased risk of congenital malformations with beta2-agonists (SABA and/or LABA). One study reported a decrease in birth weight centiles among LABA users.

LIMITATIONS

All studies reporting significant results, except two, used non-asthmatic women as reference group, making it difficult to differentiate between the effect of the disease from the one of the beta2-agonists. Non-significant results should be interpreted with caution due to the low statistical power of several studies.

CONCLUSION

Methodological limitations and lack of power of several studies prevent us to conclude on the perinatal safety of beta2-agonists. Until further evidence is available, physicians should continue prescribing them as recommended in the guidelines whenever needed to attain asthma control.

Safety of bronchodilators and corticosteroids for asthma during pregnancy: what we know and what we need to do better

Asthma is a common medical condition complicating pregnancy with potentially serious effects on pregnancy outcome. The aim of this review is to provide an update on efficacy and safety of asthma medications, primarily bronchodilators and corticosteroids, used during pregnancy with focus on pregnancy outcome, and, furthermore, to discuss limitations of available studies and point to possible improvements in future studies. A planned series of systematic searches was conducted using the PubMed database. Use of short-acting β2-agonists has generally been established as safe, and the few studies stating otherwise appear to have, perhaps critical, methodological limitations. The safety of long-acting β2-agonists remains to be further investigated, and the few available studies have methodological limitations and, therefore, provide no definite answers, although a very recent study supports the safety of add-on long-acting β2-agonists to inhaled corticosteroids. Inhaled corticosteroids are generally found to be safe, although further research is needed to investigate both the efficacy and safety of high dose therapy with inhaled corticosteroids. Studies have reported associations between the use of systemic corticosteroids and adverse perinatal outcomes, such as preterm birth, low birth weight, and pre-eclampsia. This must, however, be weighed against the potential serious impact of severe, uncontrolled asthma itself on pregnancy outcome. The main obstacle to a valid interpretation of several of the available studies is the inadequate stratification for asthma severity and control. Overall, asthma in itself and not just poor asthma control poses a greater risk to pregnancy outcomes than asthma medication. Nonetheless, more studies focusing on disentangling the effects of asthma alone and asthma medications are needed. Increased use of stratified risk assessments, taking the concept of asthma severity into greater consideration, is much warranted in future studies.

Coexistence of aplasia cutis congenita, faun tail nevus and fetus papyraceus

BACKGROUND

Aplasia cutis congenita is a disorder of the skin embryonic development characterized by a defect of localized or widespread areas of skin at birth. The lesions are mostly oval, 1-3 cm in diameter, with localization on the parietal part of scalp (60%) and rarely on the face and extremities.

MAIN OBSERVATIONS

Herein, we reported a case of aplasia cutis congenita termly born at 39 weeks of gestation to a 30-year-old mother with bronchial asthma attacks. She was referred for 3 punched-out punctate depressed defective lesions in 0.4 cm's diameter on the vertex covered with necrotic and hemorrhagic crusts. There was a hypertrichotic area consisting of tufts of terminal hair on the lumbosacral area over a sinus tract. Maternal perinatal drugs included aerosol salbutamol sulfate, ipratropium bromide and oral montelukast sodium for bronchial asthma. The pregnancy was firstly started as a di-chorionic, di-amniotic twin gestation, but deteriorated after the fetal resorption of the co-twin in the 20th gestational week resulting in fetus papyraceus.

CONCLUSION

In multi-gestational pregnancies, the presence of the fetus papyraceus or the death of the co-twins should make the neonatologists and dermatologists be aware of the possible cutaneous defects like aplasia cutis congenita. We emphasize that the possibility of this rare entity should be kept in mind in the presence of fetus papyraceus, perinatal drug use, maternal cigarette smoke, or maternal diseases like bronchial asthma in multiple gestations.