Pregnancy outcomes after laminaria placement and second-trimester removal

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.

Pregnancy outcomes after removal of osmotic dilators in patients who presented for second-trimester abortion

OBJECTIVE

The objective was to report pregnancy outcomes and potentially related complications among 13 patients who had osmotic dilators placed for second-trimester dilation and evacuation (D&E) followed by subsequent removal with the intention to continue their pregnancies.

STUDY DESIGN

We reviewed billing and scheduling data between 2005 and 2017 to identify the total number of women seen for D&E and to identify the individuals who had dilators placed without a subsequent scheduled dilation and evacuation. We then performed chart reviews to determine pregnancy outcomes.

RESULTS

Between 2005 and 2017, we treated 2532 patients who presented for second-trimester abortions by D&E and received osmotic dilators for cervical preparation. Twenty (0.8%) of these women had cervical dilators removed with the intention of continuing their pregnancies. We could obtain outcome data for 13 of these pregnancies; one of these women ultimately elected to have an abortion. Eight of the remaining 12 women (66%) experienced complications which included premature preterm rupture of membranes, preterm delivery, maternal infection and hemorrhage. Six (50%) pregnancies ended in spontaneous abortion or fetal or neonatal death.

CONCLUSION

Continuation of pregnancy after placement and removal of osmotic dilators may increase the risk of adverse pregnancy outcomes.

IMPLICATIONS

Of the women who had outcome data available, 50% who had cervical dilators removed experienced spontaneous abortion or fetal or neonatal death. Conservatively assuming that all women lost to follow-up had healthy pregnancies, 30% of women experienced fetal or neonatal death and 40% had an adverse pregnancy outcome.