Pregnancy in patients with cystic fibrosis

Pulmonary disorders in pregnancy: Bronchiectasis, cystic fibrosis, sarcoidosis and interstitial diseases

This chapter aims to provide expert guidance to obstetricians, general practitioners, allied health staff and women with lung disease about the interactions between pregnancy and different lung diseases. This chapter will cover other airway diseases such as bronchiectasis and cystic fibrosis (CF) together with sarcoidosis and interstitial lung disease (ILD), noting that another chapter covers asthma. The physiological changes which occur in pregnancy, such as the changes in airway physiology, resting ventilation and sleep, are summarised in another chapter. This chapter extends the evidence-based approach and clinical expertise of the recent European Respiratory Society/Thoracic Society of Australia and New Zealand (ERS/TSANZ) taskforce. The papers selected were based on the population (pregnant women with lung disease other than asthma) and the effects of these diseases on risks of pregnancy-associated complications and miscarriages, breastfeeding, nutritional considerations, lung function, long-term maternal outcomes and management considerations during pregnancy. As there are very few randomised control trials in the area, the majority of the literature consists of observational studies (prospective or retrospective), cross-sectional surveys and case series. Other guidelines have also recently been published, which may be helpful to the reader.

ERS/TSANZ Task Force Statement on the management of reproduction and pregnancy in women with airways diseases

This European Respiratory Society/Thoracic Society of Australia and New Zealand statement outlines a review of the literature and expert opinion concerning the management of reproduction and pregnancy in women with airways diseases: asthma, cystic fibrosis (CF) and non-CF bronchiectasis. Many women with these diseases are now living into reproductive age, with some developing moderate-to-severe impairment of lung function in early adulthood. The statement covers aspects of fertility, management during pregnancy, effects of drugs, issues during delivery and the post-partum period, and patients' views about family planning, pregnancy and parenthood. The statement summarises current knowledge and proposes topics for future research, but does not make specific clinical recommendations.

Two successful pregnancies in a woman affected by cystic fibrosis: case report and review of the literature

BACKGROUND

Pregnancies in patients with cystic fibrosis (CF) are subject to an increased risk of complications.

METHODS

We have made a systematic review of the literature concerning pregnancies in women with CF to evaluate prognostic factors of pregnancy outcome such as lung function and nutritional status, also including and describing the case of a woman suffering from CF who had two pregnancies in her late thirties, both with a good outcome.

RESULTS

Thirteen case series and 22 case reports involving 523 pregnancies in 401 women were extracted. 83.1% of 516 pregnancies whose outcome was known resulted in the delivery of live births, with preterm birth rate of 24%. Miscarriage occurred in 6.3% and therapeutic abortion in 10% of pregnancies. Indirect mother's death occurred in seven cases. In our case report, the course of the second pregnancy proved to be much more difficult than the first, with preterm delivery probably related to a worsening of lung disease in the third trimester of pregnancy.

CONCLUSIONS

Pre-pregnant lung function as well as lung function deterioration, CF-related diabetes mellitus and weight gain in pregnancy, are parameters to consider in the counseling about the outcome of pregnancy.

Respiratory physiologic changes in pregnancy

In summary, the major physiologic changes that occur in pregnancy are the increased minute ventilation, which is caused by increased respiratory center sensitivity and drive; a compensated respiratory alkalosis; and a low expiratory reserve volume. The vital capacity and measures of forced expiration are well preserved. Patients who have many lung diseases tolerate pregnancy well, with the exception of those who have pulmonary hypertension or chronic respiratory insufficiency from parenchymal or neuromuscular disease.

[Cystic fibrosis and pregnancy: report of a twin pregnancy and review of the literature]

We report here the first published case of twin pregnancy in a woman with cystic fibrosis. This situation will become more and more common because the increased life expectancy of patients with cystic fibrosis and the development of medically assisted procreation. Conception of this twin pregnancy was medically assisted in a cystic fibrosis woman with moderate pulmonary disease. This observation is in accordance with several recent reports dealing with single pregnancies: morbidity, mortality and degradation of lung function have not been found to increase. The only effect of cystic fibrosis on pregnancy is an increased risk of preterm delivery. There is thus no systematic contraindication to pregnancy among women with cystic fibrosis provided that they are given attentive care by a multidisciplinary team. Genetic counselling and prenatal diagnosis also have an important role to play.

Exacerbation of underlying pulmonary disease in pregnancy

OBJECTIVE

The presence of underlying pulmonary disease in women of childbearing potential can present a significant challenge during pregnancy and the postpartum period. Management of the underlying disease, recognizing and preventing disease progression, and, most important, managing and minimizing toxic side effects of various therapies require the expertise of an interdisciplinary team. This team must involve close collaboration between intensive care physicians, pulmonary physicians, and high-risk obstetricians familiar with these disease states in an effort to minimize fetal and maternal morbidity and mortality. We will review the impact of the pregnant state in lung transplant recipients, patients with pulmonary arterial hypertension, and patients with underlying cystic fibrosis.

DESIGN

Review of the literature in regards to pregnancy outcomes and issues for patients with cystic fibrosis, pulmonary hypertension, and lung transplants.

METHODS

A review of the epidemiology, pathophysiology, risk factors, classification, clinical features, and outcomes for pregnant patients with underlying pulmonary diseases.

CONCLUSIONS

Safety of pregnancy in the female lung transplant recipient concerns three outcomes: maternal outcome, fetal outcome, and transplanted graft outcome.

The metabolic effects of pregnancy in cystic fibrosis

OBJECTIVE

Our purpose was to determine glucose tolerance in pregnant women with cystic fibrosis (CF) and to relate glucose tolerance to insulin sensitivity, hepatic glucose production, and protein turnover.

METHODS

We studied 8 CF women during pregnancy (CFPreg). Results were compared with those from 9 pregnant controls (PregCont) and 8 nonpregnant CF women (CFCont). The following metabolic studies were conducted: oral glucose tolerance test (OGTT), hyperinsulinemic euglycemic clamp, stable isotope infusion of [1-13C]leucine and [6,6-2H2]glucose for measurement of whole body protein turnover and hepatic glucose production (HGP), respectively. Indirect calorimetry was used to measure resting energy expenditure (REE), and food intake was measured by 3-day food journals. Fat-free mass was measured by total body potassium 40K scan.

RESULTS

All but one CFPreg developed diabetes by the end of the second trimester and had significantly lower insulin secretion and more insulin resistance than PregCont. Hepatic glucose production was significantly higher and suppression by insulin was less in CF subjects, and protein breakdown was significantly higher. Insulin resistance and HGP increased during pregnancy similarly in CFPreg and PregCont groups.

CONCLUSION

Pregnancy in CF is associated with decreased insulin sensitivity and high HGP, in addition to inherent decreased insulin secretion. Pregnancy in CF is also associated with increased protein turnover and less response to insulin's anticatabolic effect. These changes appear to predispose the pregnant CF women to early development of diabetes and poor weight gain.

Successful pregnancy and delivery in a young woman with cystic fibrosis and gestational diabetes

We describe a 23-year-old Delta F508 homozygote cystic fibrosis primigravida. At the onset of gestation, she had mild to moderate pulmonary involvement, exocrine pancreatic insufficiency, focal biliary cirrhosis, satisfactory nutritional status and normal fasting and post-prandial glucose blood levels. At 29 weeks, she developed polyhydramnion and gestational diabetes. At 37 weeks, she was delivered of a live 2,980 g boy by caesarean section under epidural anaesthesia. Insulin was subsequently discontinued and her pulmonary function improved spontaneously. Neither maternal nor neonatal health problems were observed during the 3-month follow-up.

Abnormal fetal growth: intrauterine growth retardation, small for gestational age, large for gestational age

The two extremes of abnormal fetal growth are restricted growth and excessive growth, both of which originate from alterations in the uterine metabolic milieu. The fetus must adapt to these conditions to survive. In both instances, however, the inciting insult and the subsequent adaptation of the fetus carry long-term health consequences. In some instances, these changes may have generational implications. Counseling and care by pediatricians should be directed at the continuum of age ranges, including the expectant mother, the newborn, the child and adolescent, and future generations.

The Effect of Pregnancy on Survival in Women With Cystic Fibrosis

STUDY OBJECTIVES

Patients with cystic fibrosis (CF) are currently living to their fourth decade and are making reproductive decisions. Information concerning the reproductive health of women with CF has been limited to small or single-center studies.

DESIGN

We conducted a matched parallel-cohort study to assess the impact of pregnancy on the survival of women with CF.

PARTICIPANTS

A parallel-cohort study included all women > 12 years of age who were enrolled in the US Cystic Fibrosis Foundation National Patient Registry from 1985 to 1997.

MEASUREMENTS AND RESULTS

Six hundred eighty of the 8,136 women in the cohort became pregnant. These 680 women were matched on an index year to 3,327 control women with CF. At the inception of entry into the cohort, women who reported pregnancy were more likely to have had a higher percentage of predicted FEV(1) (67.5% predicted vs 61.7% predicted, respectively; p < 0.001) and a higher weight (52.9 vs 46.4 kg, respectively; p < 0.001). Using Kaplan-Meier survival curves, the 10-year survival rate in pregnant women (77%; 95% confidence interval [CI], 71 to 82%) was higher than in those women who did not become pregnant (58%; 95% CI, 55 to 62%). A separate analysis, matching pregnant patients on FEV(1) percent predicted, age, Pseudomonas aeruginosa colonization, and pancreatic function, obtained similar results. Using Cox proportional hazard modeling to adjust for baseline age, FEV(1) percent predicted, weight, height, and pulmonary exacerbation rate per year, pregnancy was not associated with an increase risk of death. Pregnancy was not harmful in any subgroup including patients with FEV(1) < 40% of predicted or diabetes mellitus.

CONCLUSIONS

Women with CF who became pregnant were initially healthier and had better 10-year survival rates than women with CF who did not become pregnant. After adjustment for the initial severity of illness, women who became pregnant did not have a significantly shortened survival.

Cystic fibrosis and pregnancy. Report from French data (1980-1999)

OBJECTIVE

To study the consequences of pregnancy on women affected by cystic fibrosis and to clarify the impact of the disease on maternal and newborn health.

DESIGN

Retrospective study.

SETTING

Pregnancy survey from the French Cystic Fibrosis Registry.

POPULATION

Women with cystic fibrosis having a pregnancy between 1980 and 1999.

METHODS

During the 1980-1999 period, 90 pregnancies in 80 French female patients were registered in the pregnancy survey of the French Cystic Fibrosis Registry. General and clinical data before pregnancy were noted. Outcome of the pregnancy was described. Variations of pulmonary function and body weight during pregnancy were evaluated. Comparison between a group of pregnant women and a group of non-pregnant cystic fibrotic women of same age and genotype, followed in the same care centre network, was made.

MAIN OUTCOME MEASURES

Spirometric and nutritional parameters, vital status and perinatal health indicators.

RESULTS

The outcome was identified for 75 cases: 64 delivered babies (45 at term and 10 prematurely, prematurity rate: 18%), 10 abortions (five spontaneous and five therapeutic or medical), and one maternal death during pregnancy. The proportion of newborns with low weight was 29.8%. Mean maternal weight gain during pregnancy was 5.5 kg. Four affected children were diagnosed after birth. A decline in the forced expiratory volume in one second (FEV1) and forced vital capacity was observed between the beginning of pregnancy and the year following the delivery. However, no significant difference was found when comparing the variation in the pulmonary function during pregnancy between cases and controls. Moreover, the pulmonary status before pregnancy was better than the status of non-pregnant women. Among 12 deaths recorded after pregnancy, only three happened in the year following the pregnancy. All three women had an FEV1 < 50% before pregnancy.

CONCLUSION

Pregnancy only has a slight adverse effect on maternal health if the women are in good general condition before starting pregnancy. Women with a better health status are more inclined to initiate and successfully complete a pregnancy. Complete collaboration between cystic fibrosis practitioners and obstetricians should be observed to allow women to deliver children in the best conditions.

The outcome of 72 pregnancies in 55 women with cystic fibrosis in the United Kingdom 1977-1996

OBJECTIVE

To identify pregnancies in women with cystic fibrosis and describe obstetric, infant and maternal medical outcomes in relation to the severity of maternal disease.

DESIGN

Retrospective study, based on casenotes.

SETTING

Eleven cystic fibrosis centres in the United Kingdom.

POPULATION

Pregnant women with cystic fibrosis.

METHODS

Single observer medical and obstetric casenote review categorising maternal cystic fibrosis (e.g. genotype, pancreatic, hepatic and diabetic status) and pre-pregnant severity (e.g. weight and lung function) and noting fetal outcome and maternal morbidity.

MAIN OUTCOME MEASURES

Completed pregnancies and pregnancy losses, fetal outcome and complications, maternal morbidity, such as changes in weight, lung function, pulmonary infections during and after pregnancy. Relation of outcomes to severity of maternal cystic fibrosis.

RESULTS

From 72 pregnancies identified, the outcomes were known for 69; there were 48 live births (70%) of which 22 were premature (46%); 14 therapeutic abortions (20%); and 7 miscarriages (10%). There were no stillbirths, neonatal or early maternal deaths. Three major fetal anomalies were seen, but no infant had cystic fibrosis. At the conclusion of our study three pregnancies were still continuing. Prematurity with increased fetal complications and maternal morbidity with infection, declining lung function and poor weight gain were associated with poor pre-partum lung function.

CONCLUSION

Pregnancy occurs in women with cystic fibrosis of all degrees of severity. Outcomes for the infant are generally good but are variable for the mother. Predicting outcome on the basis of maternal severity is difficult but lung function appears to be the most significant determining factor. Pregnancy may be normal in women with normal lung function (forced expiratory volume > 80%). However, it may adversely affect mild and moderate lung disease due to cystic fibrosis and should be avoided in pulmonary hypertension, cor pulmonale and when forced expiratory volume < 50% predicted. Ideally, all pregnancies should be planned with prior counselling and monitored by dedicated cystic fibrosis teams, including obstetricians who are experienced in managing high risk pregnancies.

Reproductive health in women with cystic fibrosis

The life expectancy of women with cystic fibrosis has doubled in the last 20 years. A major implication of this is the advent of previously unseen reproductive health problems. We review the management problems presented by these women throughout their reproductive lives, including pregnancy.

Cystic fibrosis and pregnancy

The case records of 11 patients with cystic fibrosis (CF) who had 13 completed pregnancies between 1975 and 1995 were retrospectively reviewed to assess: (1) the changes in spirometry and body mass index (BMI) during pregnancy; and (2) maternal and neonatal complications and outcomes. Prepregnancy the mean age of the group was 24 (range 17-27) years. Two patients were exsmokers, 7 had pancreatic insufficiency and 7 had chest X-ray evidence of bronchiectasis. None of the patients had diabetes mellitus but 3 developed gestational diabetes. The mean +/- SEM (% predicted) forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) prepregnancy were 2.3 +/- 1.0 (83%) litres and 3.0 +/- 0.9 (85%) litres respectively. Five patients had normal spirometry (FEV1 and FVC >80% predicted) prior to 6 pregnancies. The mean body mass index (kg/height(m)2) for the group was 20.5 +/- 2.0. There was a significant decline in spirometry during pregnancy (FEV1 15.5 +/- 6.6% p<0.01; FVC 14.0 +/- 8.3% p<0.5). However, FVC but not FEV1 recovered to prepregnancy values by 12 months postpartum. There was a significant increase in both weight (7.1 kg) and BMI (2.6 kg/height(m)2) at the time of delivery compared with prepregnancy (p=0.0004). However, postpregnancy both weight and BMI had returned to their prepregnancy values (p<0.2). Mothers with an FEV1>80% had less decline in FEV1 related to pregnancy, better outcomes, fewer operative and instrumental deliveries, fewer preterm infants and fewer neonatal complications. Suggestions for the planning and management of pregnancy in women with CF are discussed.

Epidural analgesia for vaginal delivery in a patient with cystic fibrosis following double lung transplantation

The anaesthetic management is described of a patient with cystic fibrosis who had had a double lung transplantation for intractable respiratory failure. An epidural block provided analgesia/anaesthesia for vaginal birth and bilateral tubal ligation.

Cystic fibrosis in pregnancy

Advances in the diagnosis and treatment of cystic fibrosis have resulted in increased survival for those afflicted with this disease. As a result, more women are reaching their reproductive years and will subsequently conceive. Multiple organ systems are affected during the course of cystic fibrosis and may impact on pregnancy; however, pulmonary complications play a major role in morbidity and mortality. Therefore, this article primarily focuses on the pulmonary aspects of cystic fibrosis as they relate to pregnancy. The current literature suggests a favorable outcome for the pregnancy when there is limited pulmonary dysfunction. Chronic severely impaired pulmonary function is associated with poorer pregnancy outcome; however, it is the acute deterioration of pulmonary function that may in fact be associated with the highest morbidity and mortality for both mother and infant. Aggressive management of pulmonary infection and function is essential, and pulmonary status should be evaluated on a monthly basis. The forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) can be used to monitor pulmonary status. Close surveillance, aggressive management, and a team approach can and has resulted in successful pregnancy outcome in those women with cystic fibrosis.

Pregnancy and cystic fibrosis: a case-controlled study

STUDY OBJECTIVES

Changes in cardiorespiratory and pulmonary function that occur with normal pregnancy along with increased maternal and fetal demands related to cystic fibrosis (CF) may augment morbidity for the woman with CF. Status prior to pregnancy is implicated in pregnancy outcome and maternal life expectancy postpartum. The purpose of this study was to investigate the effect of pregnancy on these patients' course during pregnancy and document prepregnancy status and 2-year postpregnancy survival.

DESIGN

Patients with documented pregnancies were matched to nonpregnant CF patients of similar age (+/-2 years), severity of airflow obstruction (percent predicted forced expiratory volume in 1 min [+/-15%]), weight (+/-10 kg), height (+/-5 cm), and pancreatic sufficiency status at 1 year preconception.

PATIENTS

Using their 1-year preconception data, seven women with CF and with documented pregnancies were matched to nonpregnant control subjects. All patients were pancreatic insufficient.

INTERVENTIONS

Weight, forced expiratory volume in 1 min (% FEV1), FVC, Schwachman-Kulczycki (S-K) and Brasfield scores, sputum cultures, pregnancy outcome, and pulmonary exacerbations were followed from 1 year preconception, during pregnancy, and 2 years postpregnancy.

MEASUREMENTS AND RESULTS

Mean weight gain during pregnancy was 5.2 kg. There were no differences between the groups in the rate of decline for pulmonary function or S-K scores over time. Greater rate of decline was noted in the pregnancy group, however, for body weight and Brasfield scores in the postpartum interval. One patient in the pregnancy group died 6 months postpartum.

CONCLUSIONS

Pregnancy has little adverse effect on patients with stable CF, but poor outcomes can occur in individuals with more advanced disease.

Pregnancy in patients with cystic fibrosis

With increasing life span of patients with CF, more women with CF are becoming pregnant and others are seeking information about the risks involved during pregnancy and delivery. A striking limitation of the available information is the lack of large prospective studies of pregnant patients with CF matched for age and disease severity compared with their non-pregnant cohorts. A study investigating the effect of pregnancy on morbidity and mortality is being completed by the Cystic Fibrosis Foundation. We recommend that all women with CF be offered contraceptive measures and counseling on the maternal and fetal risks of pregnancy, including the genetic risks for the child. The issue of who will raise the child in the event of subsequent morbidity or maternal mortality should ideally be prospectively discussed.

Anaesthesia and cystic fibrosis

Cystic fibrosis occurs in 1 in 2000 children and the majority now reach adulthood. The disease is a complex multisystem disorder which is likely to challenge anaesthetists with increasing frequency. In this review the presentation and genetics of the disease are briefly described, followed by a detailed account of the pathophysiology relevant to anaesthesia. The pre-operative assessment and conduct of anaesthesia are discussed and some suggestions made regarding management.

Impact of lactation on women with cystic fibrosis and their infants: a review of five cases

OBJECTIVE

To evaluate the impact of lactation on the health status of women with cystic fibrosis and their infants.

DESIGN

Data were acquired through a retrospective review of pulmonary, obstetric, and pediatric medical records.

SETTING

A medical school-based Pediatric Cystic Fibrosis Center in Philadelphia, Pa.

SUBJECTS

Five women with cystic fibrosis and their respective infants.

MAIN OUTCOME MEASURES

For the women, measures of pregravid, gravid, and postpartum height, weight, pulmonary function test results, and energy intake were determined. For the infants, birth Apgar scores were obtained, as were measures of growth and development.

STATISTICAL ANALYSES PERFORMED

Means and standard deviations were calculated. Data were compared with published standardized references.

RESULTS

Mean maternal age at conception was 25.4 +/- 4.1 years. Mean pregravid weight was 60.0 +/- 10.7 kg of standard body weight for height (range = 50.8 to 76.7 kg; median = 58 kg). Two women consumed up to two enteric-coated supplemental enzyme capsules per meal, three women consumed none. Pulmonary disease was mild in four of the five women. Mean weight gain during pregnancy was 10.2 +/- 7.4 kg. Mean gestation was 37.4 +/- 1.5 weeks; mean birth weight was 3.0 +/- 0.5 kg. Sweat tests performed on all infants were negative. Duration of breast-feeding was 3 to 30 weeks. Four of the five infants maintained appropriate growth velocity during breast-feeding. Mean maternal energy intake during lactation was above the Recommended Dietary Allowance for lactating women. Four of the five women were at or above their standard body weight during lactation.

CONCLUSIONS/APPLICATIONS

We conclude that women with the clinical diagnosis of mild cystic fibrosis disease can maintain a normal pregnancy with appropriate weight gain and can deliver infants of normal weight for gestational age. During lactation, women with mild cystic fibrosis disease can maintain their own weight and support growth in healthy infants. The dietitian needs to be an integral member of the health care team in assessing, monitoring, and managing women with cystic fibrosis during their child-bearing years.

Anaesthesia for the parturient with cystic fibrosis

Cystic fibrosis is an inherited disorder that primarily affects the exocrine glands of the gastrointestinal and respiratory systems. It is commonly diagnosed at birth or shortly thereafter, and until recently few of these patients lived to reproductive age. However, as a result of improved medical care, there are now an increasing number of pregnancies in women with cystic fibrosis. We present the histories of two parturients with cystic fibrosis and discuss the anaesthetic and perinatal implications of this complex disease to their management.

Pneumonia during pregnancy: has modern technology improved maternal and fetal outcome?

The maternal death rate and rate of preterm delivery associated with pneumonia during pregnancy have not decreased since the introduction of antibiotics four decades ago. We retrospectively reviewed 25 cases of pneumonia during pregnancy; these cases occurred among 32,179 deliveries. Medical complications included: bacteremia, 16%; empyema, 8%; atrial fibrillation, 4%; respiratory failure necessitating mechanical ventilation, 20%. Obstetric complications occurring during the pneumonia episode included: preterm labor, 44%; preterm delivery, 36%. A patient with cystic fibrosis died; one stillbirth and two neonatal deaths occurred. Underlying maternal disease was significantly associated with maternal medical complications (p = 0.023) and preterm delivery (p = 0.012). Significant medical and obstetric complications continue to occur frequently despite modern antimicrobial, tocolytic, and supportive therapy. Underlying maternal disease, including acquired immunodeficiency syndrome and cystic fibrosis, was associated with preterm delivery and neonatal and maternal death.

The primary care physician and the patient with cystic fibrosis

Although CF has increasingly become a "subspecialty disease," the decisions and practice style of the patient's pediatrician or family physician are extremely important. The primary physician's handling of everything from the timing of infant immunizations to teenage advice about sex and drug abuse have far-reaching medical and psychosocial implications and must be carefully considered.

Clinical management of patients with cystic fibrosis and pulmonary insufficiency

Management of a patient with cystic fibrosis who started her pregnancy in a state of pulmonary insufficiency, as defined by arterial blood gas values and a chest x-ray film, is described. A systematic approach to evaluation of patients with cystic fibrosis, including serial assessments of pulmonary functions, screening for diabetes, maintenance of adequate nutrition (including hyperalimentation), and cardiac function evaluation is described.

Clinical features, survival rate, and prognostic factors in young adults with cystic fibrosis

The medical records of 142 patients with cystic fibrosis were reviewed. The patient group included 78 males and 64 females; three patients were black. Periods of observation ranged from two to 25 years (mean, 14.5 years). The analysis focused on clinical evaluation at age 18 years and included information gained at an earlier age. Evaluation at age 18 years was based on Shwachman and Kulczycki's (S-K) scoring system, Brasfield chest roentgenographic scoring system, pulmonary function measurements, height-adjusted weight percentile, sputum bacteriologic results, number of hospitalizations for treatment of pulmonary infections prior to the age of 18 years, time of onset of clubbing, and frequency of complications. There were no significant differences between the sexes in clinical features. Median survival from the time of diagnosis to the conclusion of the study period (1955 to 1984) was 22 years for females and 25 years for males (NS). Median length of survival beyond the age of 18 years was eight years for females and 12 years for males (NS). Stepwise logistic regression and Cox regression analysis applied to 11 variables identified the S-K clinical score at 18 years of age as the best predictor of survival to the age of 23 years. The median durations of survival after the age of 18 years for patients with clinical scores of 30 to 49, 50 to 64, and 65 to 75 at age 18 were five, seven and a half, and 12 years, respectively (p less than 0.0001). Low clinical score, low weight percentile, and Pseudomonas cepacia colonization of the lower respiratory tract at the age of 18 years indicated a poor prognosis. On the other hand, high clinical score, good weight percentile, and colonization with Staphylococcus aureus alone were likely to be found in patients with mild disease and an increased likelihood of long-term survival with preserved pancreatic function.

Parenteral nutrition in a pregnant cystic fibrosis patient

This case report describes a 30-year-old pregnant woman with cystsic fibrosis who had marasmus as evidenced by clinical examination. The patient was maintained on central venous hyperalimentation for 18 days in her last trimester. The patient delivered a full-term infant via cesarian section with Apgar of 8 and 9, at 1 and 5 minutes, respectively, and adverse affects.

Amenorrhoea in cystic fibrosis

Menstrual history in relation to nutritional status and lung function was assessed in 45 adolescent and adult patients with cystic fibrosis (CF). Twenty patients had regular menstrual cycles (of whom six had been pregnant), 12 had primary or secondary amenorrhoea, 11 had irregular cycles and two were premenarcheal. Patients with regular menstruation had a significantly higher body mass index and percentage body fat (estimated from skinfold thickness measurements) than those with amenorrhoea (P less than 0.001), and also better lung function (P less than 0.01). A linear discriminant analysis indicated that of the four indices studied percentage body fat was the most important predictor of menstrual function. Ovarian and uterine morphology were studied by ultrasonography in 28 patients and 17 healthy controls. In 10 patients multicystic ovaries were noted. Even in patients with regular cycles uterine size was reduced (P less than 0.01) and in those with amenorrhoea appeared to be related to thinness. Amenorrhoea in CF is an appropriate adaptive response in preventing pregnancy, but the resultant oestrogen deficiency and psychological effects must be considered.

Pharmacokinetics of contraceptive steroids in patients with cystic fibrosis

The pharmacokinetics of the commonly used contraceptive steroids ethinyloestradiol and levonorgestrel were investigated after oral and intravenous administration in six women with cystic fibrosis. The results were compared with data obtained from healthy women of similar age. The total body clearance of ethinyloestradiol was significantly higher in the patients with cystic fibrosis (0.61 (SD 0.19) l/h/kg) than in control women (0.32 (0.16) l/h/kg; p less than 0.02). In addition, the oral bioavailability of ethinyloestradiol was greater in women with cystic fibrosis than in controls (76.9% (11.7%) compared with 47.3% (7.5%); p less than 0.001). As a result of these two changes, the area under the plasma concentration--time curve after an oral dose of ethinyloestradiol was similar in patients and controls. The pharmacokinetics of levonorgestrel did not differ significantly between patients with cystic fibrosis and healthy women. The data suggest that women with cystic fibrosis will receive similar contraceptive protection from these steroids as do healthy women.

Intrauterine insemination for infertility due to cystic fibrosis

Mild CF is not associated with increased obstetric risk to patients or offspring. These patients can be identified on the basis of Shwachman-Kulczycki scores, nutritional status, normal chest x-ray and pulmonary function tests, normal lung volumes, and mild to moderate airway obstruction. Spontaneous pregnancy has been achieved in women with CF, but they appear to have a decreased fertility. One possible cause in mild disease is a cervical factor due to abnormal viscous mucus. This mucus has been shown to fail to hydrate, and at midcycle contains less than 80% water, whereas 93% to 96% hydration appears to be necessary for sperm migration. Cyclic electrolyte changes in cervical mucus are not noted in CF patients, and sodium concentration in dry residue at midcycle is 10% of normal. Intrauterine insemination with a washed sperm fraction offers a theoretically safe method of bypassing this barrier. Preliminary data have revealed that this may be a useful therapy in other cases of infertility in which the abnormality is an unexplained, negative postcoital test. CF patients should be carefully evaluated and advised of risks before becoming pregnant. In cases of mild CF in which no factor for infertility exists other than consistently abnormal cervical mucus, intrauterine insemination with washed motile sperm may be beneficial. We believe this to be the first case of a CF patient successfully treated in this manner.

Diagnosis of cystic fibrosis during adolescence

The manifestations of cystic fibrosis (CF) may be minimal, absent, or overlooked during childhood, thus 8-10% of cases are diagnosed during adolescence. Between 1970 and 1982, 14/157 (8.9%) patients were diagnosed as having CF as teenagers, based on clinical findings and elevated sweat electrolyte levels. Of these 14 patients (means = 15 years, range = 12-20 years), 50% had pulmonary and gastrointestinal symptoms dating from childhood; 50% became symptomatic during adolescence (primarily with pulmonary manifestations). None had a family history of CF. Four had false-negative sweat tests resulting in a mean diagnostic delay of 7.3 years. Because of the potential long-term complications of CF on physical maturation, completion of the psychosocial tasks of adolescence, adaptation to a chronic illness, and issues of sexuality and fertility, consideration of this diagnosis is crucial.

Cystic fibrosis. A disorder of adults too!

Cystic fibrosis is the most frequently occurring lethal hereditary disorder among whites. Many persons with cystic fibrosis now live into their adult years, and some cases are not diagnosed until adulthood. As a result, the disorder is no longer rare in adults. Respiratory symptoms and findings usually predominate, but a host of other complications that arise in adults also present therapeutic challenges to physicians. While no cure is yet available for cystic fibrosis, genetic counseling can help couples determine their relative risk for parenting a child with the disorder.