Could a first-trimester blood phosphatidylethanol concentration ⩾4 nM be useful to identify women with moderate-to-heavy prenatal alcohol exposure who are at high risk of adverse pregnancy outcomes?

It is accepted that blood phosphatidylethanol (PEth) concentrations are reliable biomarkers of ethanol (alcohol) exposure. We therefore conducted a preliminary study to test the hypothesis that elevated blood PEth concentrations can help to identifying women with prenatal alcohol exposure who are at higher risk of adverse pregnancy outcomes. The study included 35 first-trimester pregnant women who self-reported alcohol ingestion and had PEth blood concentration ⩾4 nM at recruitment. As a control group, 233 first-trimester pregnant women who self-reported as being either abstainers or light alcohol drinkers and had blood PEth concentrations <4 nM, were also included. All participants were followed up until completion of their pregnancies. Women with prenatal alcohol exposure and PEth concentrations ⩾4 nM had a risk ratio of spontaneous abortions of 3.21 (95%CI 0.93-11.06; P=0.074). Because of the potential implications in the prenatal care of women reporting risky alcohol exposure, the preliminary results from the present study indicate the need for testing the hypothesis in a more definitive approach.

Linear Versus Non-Linear Dose-Response Relationship Between Prenatal Alcohol Exposure and Meconium Concentration of Nine Different Fatty Acid Ethyl Esters

Presence of individual fatty acid ethyl esters (FAEEs) in meconium is considered to be a reliable biomarker of prenatal alcohol exposure, and their concentration has been found to be linearly associated with poor postnatal development, supporting the widely extended idea that ethanol is a non-threshold teratogen. However, a growing number of epidemiological studies have consistently found a lack of adverse short- and long-term fetal outcomes at low exposure levels. We therefore aimed to investigate the relationship between the concentration of individual FAEEs and prenatal alcohol exposure in meconium samples collected within the first 6 to 12?h after birth from 182 babies born to abstainer mothers and from 54 babies born to women who self-reported either light or moderate alcohol ingestion in the second or third trimester of pregnancy. In most cases, the individual FAEE concentrations were negligible and not significantly different (P >0.05) between exposed and control babies. The concentrations appeared to increase linearly with the dose only in the few babies born to mothers who reported >3 drinks/week. These results provide evidence that the correlation between prenatal alcohol exposure and individual FAEE concentrations in meconium is non-linear shape, with a threshold probably at 3 drinks/week.

Simple high-throughput analytical method using ultra-performance liquid chromatography coupled with tandem mass spectrometry to quantify total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol in urine

BACKGROUND

Since the urinary concentration of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) is a reliable biomarker of exposure to tobacco smoke, we developed a relatively simple high-throughput chromatographic method to quantify total urinary NNAL concentrations in the general population.

METHODS

The high-throughput analytical method was developed using ultra-performance liquid chromatography coupled with tandem mass spectrometry (UPLC-MS/MS) to identify and quantify total urinary NNAL concentrations in 10 non-smokers and 15 otherwise healthy smokers.

RESULTS

Loss of nitric oxide at m/z 30 was found to be the predominant mass transitioned, and therefore was used as the SIM transition to quantify both NNAL and NNAL-methyl-d3 in urine. The analytical method did not require sample derivatization. Standard curves for total NNAL concentrations were linear between 20 and 1500 pg/mL, with coefficients of determination >0.95. Precision and accuracy ranged from 2.2% to 8.6% (CV) and from -5.6% to 10.9% (percent error), respectively. The lowest limit of quantification was 6.7 pg/mL, and 2.0 pg/mL the lowest limit of detection (LLOD). Total urinary NNAL concentrations in non-smoker subjects were <LLOD, whereas in smokers varied between <LLOD to 112.1 pg/mL.

CONCLUSIONS

An UPLC-MS/MS analytical method to quantify total urinary NNAL concentrations in smokers that does not require sample derivatization is presented herein. The method could be useful in clarifying the toxicities associated with human exposure to cigarette smoking. However, quantification might be adversely affected by co-eluting interfering compounds or selective ion suppression or enhancement as a result of having only one ion transition to monitor NNAL and NNAL-methyl-d3 in urine.

Assessment of fetal and neonatal outcomes in the offspring of women who had been treated with dried ginger (Zingiberis rhizoma siccus) for a variety of illnesses during pregnancy

The present study was designed to investigate if exposure to dried ginger during pregnancy would increase the risk of adverse fetal and neonatal outcomes. Participants consisted of 159 singleton pregnant women who received dried ginger as a herbal medication. We also included a control group of 306 pregnant women who had not been exposed to any herbal medication or any known teratogen. No increased risk of major malformations was detected in exposed women (OR = 4.9; 95% CI 0.9-25.5; p = 0.051). The incidence of stillbirths in the exposed group was marginally higher than in the controls (OR = 7.8; 95% CI 0.9-70.3; p = 0.05). The risk was more evident when the exposed group was compared with the general population in the Republic of Korea (OR = 7.9; 95% CI 2.9-21.4; p < 0.0001). Other fetal and neonatal study outcomes investigated in the exposed group were similar (p > 0.05) to the controls. In conclusion, dried ginger does not appear to be a major teratogen. However, due to the limitations of the study, e.g. the large variability in the dose of dried ginger in the exposed group, as well as the concomitant exposure to other herbal medications, the increased incidence of stillbirths requires confirmation in larger cohort studies.

Preventive effects of folic acid supplementation on adverse maternal and fetal outcomes

Although there is accumulating evidence regarding the additional protective effect of folic acid against adverse pregnancy outcomes other than neural tube defects, these effects have not been elucidated in detail. We evaluated whether folic acid supplementation is associated with favorable maternal and fetal outcomes. This was a secondary analysis of 215 pregnant women who were enrolled in our prior study. With additional data from telephone interviews regarding prenatal folic acid supplementation, existing demographic, maternal and fetal data were statistically analyzed. The concentration of folic acid in maternal blood was significantly higher following folic acid supplementation (24.6 ng/mL vs.11.8 ng/mL). In contrast, homocysteine level in maternal blood decreased with folic acid supplementation (5.5 µmol/mL vs. 6.8 µmol/mL). The rates of both preeclampsia (odds ratio [OR], 0.27; 95% confidence interval [CI], 0.09–0.76) and small for gestational age (SGA; 9.2% vs. 20.0%; OR, 0.42; 95% CI, 0.18–0.99) were lower in the folic acid supplementation group than those in the control group. Other pregnancy outcomes had no association with folic acid supplementation. The findings indicate that folic acid supplementation may help to prevent preeclampsia and SGA. Further studies are warranted to elucidate the favorable effects of folic acid supplementation on pregnancy outcomes.

Dose-response and time-response analysis of total fatty acid ethyl esters in meconium as a biomarker of prenatal alcohol exposure

OBJECTIVES

Little is known on how the dose and timing of exposure co-influence the cumulative concentration of fatty acid ethyl esters (FAEEs) in meconium. The objective of the study was to assess the cumulative concentration of FAEEs in meconium as a biomarker of light, moderate, or heavy prenatal alcohol exposure occurring at either first, second, or third trimesters of pregnancy.

METHODS

History of prenatal alcohol exposure was obtained in the 34th week of gestation from 294 pregnant women. Meconium was collected from their babies within the first 6 to 12 h after birth and examined for the presence of nine FAEEs.

RESULTS

No significant differences were identified between the cumulative levels of FAEEs in the meconium from the babies born to abstainers and those born to mothers with history of light-to-moderate prenatal alcohol exposure during their pregnancy.

CONCLUSIONS

Light-to-moderate prenatal alcohol exposure cannot be reliably predicted by the cumulative FAEE concentrations in meconium of exposed babies. A cumulative FAEE level of >10 nmol/g would be required to consider that prenatal alcohol exposure during the second to third trimesters occurred at risky levels in the absence of reliable maternal history of ethanol exposure.

Fetal and neonatal outcomes in women reporting ingestion of licorice (Glycyrrhiza uralensis) during pregnancy

Maternal intake of licorice from dietary sources has been associated with adverse maternal and fetal outcomes. We prospectively studied the outcome of 185 singleton pregnancies who took over-the-counter or naturopathic formulations containing licorice during their pregnancy, and 370 age-matched singleton pregnant controls that were not exposed to any potential teratogen. The indication in 56.8% of the women taking licorice was for cough and cold control, with the maximum dose of 2104 mg/day and exposure occurring between the 4th day and 25th week of gestation. The rate of stillbirths was marginally higher among women who took licorice than those who did not (OR = 7.9; 95% CI 0.9-71.5; p = 0.048), and significantly higher when compared to the general population in the Republic of Korea (OR = 13.3; 95% CI 4.9-35.8; p < 0.001). Other fetal outcomes assessed in the study were similar between the two study groups, e.g., the OR of major malformations was 3.9 (95% CI 0.4-43.5; p = 0.27). In conclusion, the present study suggests that licorice is not a major teratogen. However, whether licorice may increase the risk of stillbirths requires careful consideration in further studies with a larger sample size.

Pregnancy outcomes and factors associated with voluntary pregnancy termination in women who had been treated for acne with isotretinoin

OBJECTIVE

We aimed to study the pregnancy outcomes of women exposed to isotretinoin and to identify the factors influencing their decision to request an abortion.

METHODS

The study prospectively identified 79 women who had been treated for acne with isotretinoin during the periconceptional period, and who were followed up until completion of their pregnancy. Characteristics of exposure and doses were self-reported by participants.

RESULTS

Of the 56 participants who decided to continue their pregnancy, there were 11 spontaneous abortions and 44 women who delivered healthy full-term babies of which 19 had been exposed to isotretinoin <1 month before conception or during pregnancy. In a nominal logistic regression analysis including 68 patients who provided adequate information for analysis, exposure to isotretinoin >2 weeks post-conception and pregnancy termination recommended by the first-contact physician were found to be significantly associated with patients' decision to undergo elective abortion: adjusted OR = 9.87 (95% CI 1.18-82.34) and 12.51 (95% CI 2.36-66.29), respectively.

CONCLUSIONS

Our study reports an elevated rate of babies born without evidence of gross malformation or neurofunctional abnormality even tough exposure occurred during the teratogenic risk period. However, caution is recommended since a substantial risk of congenital malformations has been reported with low doses of isotretinoin and at exposures limited to early pregnancy. We also found that primary-care physicians may influence patients' decision to request pregnancy termination independently of their timing of exposure to isotretinoin.

A prospective cohort study of pregnancy outcomes of women inadvertently exposed to methylephedrine in the 1st trimester of pregnancy

No information is currently available on the safety of methylephedrine, a component of various cold medications available in South Korea. With previous approval by an Institutional Review Board, 349 women inadvertently exposed to methylephedrine during the 1st trimester of pregnancy and an age- and gravidity-matched control group, were enrolled in a prospective cohort study. Study outcomes, for example gestational age at birth, birth weight and major and minor malformations were evaluated in 282 cases and 280 controls. Exposure to methylephedrine was at a gestational age of 4.0 weeks (median), at doses ranging from 52.5 to 1,575 mg/day, for a median duration of 3 (range: 1-30) days. No differences were observed between cases and controls in any of the pregnancy outcomes studied. There were 4/265 (1.5%) babies born with major malformations in the case group and 4/260 (1.5%) in the control group. In conclusion, inadvertent exposure to methylephedrine as a component of over-the counter oral cold remedies in early pregnancy was not associated with an increased rate of adverse pregnancy outcomes. Co-exposure with acetaminophen, cigarette smoking or alcohol did not appear to modify the outcomes.

Ondansetron dosing in pediatric gastroenteritis: a prospective cohort, dose-response study

BACKGROUND

Ondansetron is increasingly used to prevent emesis in children with acute gastroenteritis; however, the optimal dose is unknown.

OBJECTIVE

To determine if higher doses of oral ondansetron are associated with greater efficacy or side effects.

METHODS

We analyzed data from a prospective clinical trial performed between January 2004 and April 2005. Data were collected on 105 children with dehydration due to gastroenteritis who received an ondansetron oral disintegrating formulation. The following outcomes of efficacy were analyzed: number of vomiting episodes, volume of oral rehydration fluids consumed, percent weight gain, and the proportions of children who had ongoing vomiting, received intravenous rehydration, and were hospitalized. In addition, the number of episodes of diarrhea was evaluated to measure whether there were dose-dependent side effects.

RESULTS

Participants were aged 0.5-8.2 years and the dose ranged between 0.13 and 0.26 mg/kg. There was no significant association between the dose of ondansetron and the outcomes of number of vomiting episodes, volume of fluids consumed, increase in bodyweight, or number of diarrhea episodes/hour. The mean dose of ondansetron (mg/kg) administered was not different amongst those who did and did not have ongoing vomiting, undergo hospitalization, and receive intravenous rehydration.

CONCLUSIONS

Within the dose range of 0.13-0.26 mg/kg, higher doses of ondansetron were not superior to lower doses, nor were they associated with increased side effects. Thus, ondansetron in this dose range was shown to result in a similar reduction in emesis in children with acute gastroenteritis.

Quantitation of fatty acid ethyl esters in human meconium by an improved liquid chromatography/tandem mass spectrometry

This paper reports the development and validation of an improved assay for quantitation of fatty acid ethyl esters (FAEEs) in human meconium using liquid chromatography/tandem mass spectrometry (LC-MS/MS). FAAEs (ethyl laurate, ethyl myristate, ethyl palmitate, ethyl palmitoleate, ethyl stearate, ethyl oleate, ethyl linoleate, ethyl linolenate, and ethyl arachidonate) and the internal standard (I.S.), ethyl heptadecanoate, were separated by reverse phase HPLC and quantified by MS/MS using electrospray ionization (ESI) and multiple reaction monitoring (MRM) in the positive ionization mode. The absolute recovery of FAEEs varied from 55+/-10% for 0.33 nmol/g (100 ng/g) of ethyl linoleate up to 86+/-8% for 1.55 nmol/g (500 ng/g) of ethyl miristate. The LODs and LOQs varied from 0.01 to 0.08 nmol/g and from 0.02 to 0.27 nmol/g, respectively. The assay has been successfully applied to examine the FAEE levels in 81 meconium samples from babies born to mothers reporting alcohol consumption, to varying degrees, during pregnancy.

Pregnancy outcome of women transfused during pregnancy with blood products inadvertently obtained from donors treated with acitretin

We assessed the pregnancy outcome of nine women inadvertently transfused with acitretin-contaminated blood products in South Korea. A total of 18 women matched to cases by age, gravidity, and singleton- or twin-pregnancy, and who were transfused with blood products not contaminated with acitretin, was also recruited. There were nine babies born in the case group. No differences (p > 0.05) were observed between cases and controls in the gestational age at delivery (38.3 +/- 1.6 weeks vs 37.8 +/- 2.2 weeks), birth weight (3,146 +/- 874 g vs 3,106 +/- 568 g), rate of pre-term deliveries (22.2% vs 11.1%) and rate of low birth weight (<2,500 g) (33.3% vs 16.7%). There was no case of malformation or neurological abnormalities born in either group. In conclusion, inadvertent exposure to acitretin-contaminated blood products was not associated with adverse pregnancy outcomes, probably because of the removal of acitretin and etretinate during the manufacturing process of blood products.

Obstetric and fetal outcomes in dystocic and eutocic sows to an injection of exogenous oxytocin during farrowing

Sixty hybrid Yorkshire-Landrace penned sows, 30 with eutocic farrowing and 30 experiencing a dystocic parturition, were studied to evaluate the obstetric and neonatal outcomes to low doses of oxytocin administered at advanced stages of parturition. Animals in each group were randomly subdivided into 2 subgroups: 15 eutocic and 15 dystocic sows received oxytocin 0.083 IU/kg (equivalent to 1 IU/12 kg body weight), administered intramuscularly after the delivery of the 5th piglet; the other 15 eutocic and 15 dystocic sows received saline solution intramuscularly at the same time. Oxytocin decreased the number of intrapartum deaths by approximately 50% (P = 0.002). No piglet was born dead from the saline- and oxytocin-treated eutocic sows. The highest viability score was observed among piglets born to eutocic sows treated with oxytocin. In summary, this dose schedule would help to decrease the number of stillbirths in both eutocic and dystocic farrowing sows.

A pilot study of nalbuphine versus tramadol administered through continuous intravenous infusion for postoperative pain control in children

Nalbuphine and tramadol are potent analgesic drugs. Our aim was to preliminarily assess and compare the efficacy and safety of nalbuphine and tramadol for postoperative analgesia in children. In a double-blind design, 24 ASA 1-3 children aged 1 to 10 years undergoing a scheduled surgical procedure were randomly allocated to receive either an intravenous bolus dose of nalbuphine 100 microg/kg immediately before the end of surgery followed by an infusion of 0.2 microg/kg/min for 72 hrs., or an intravenous bolus dose of tramadol 1000 microg/kg followed by an infusion of 2.0 microg/kg/min for 72 hrs. Postoperative pain control and drug-related adverse events were recorded. Three children who received nalbuphine required an extra bolus dose within the 12 hrs. of post-surgery versus one child in the tramadol group. A similar number of patients in both groups required an increment in the infusion rate within the 72 post-surgery hours. Sedation was observed in 2 children in the nalbuphine group and in 1 child in the tramadol group. Four children presented vomiting with tramadol and two with nalbuphine. Cardiovascular parameters remained within the normal ranges in both groups. In conclusion, the bolus/infusion regimen of tramadol evaluated in this study appears to have better postoperative analgesic efficacy than the bolus/infusion regimen of nalbuphine. These preliminary results require further confirmation by studies with a sample size enough to clearly identify differences in their efficacy as well as in the rate of adverse events secondary to the administration of each of them.

Fetal outcome following roxithromycin exposure in early pregnancy

OBJECTIVE

Because very little information exists on the fetal safety of roxithromycin, we aimed to extend the knowledge on fetal outcome in pregnant women who were exposed to roxithromycin in early pregnancy.

METHODS

Twenty pregnant women inadvertently exposed to roxithromycin during early pregnancy were identified and prospectively followed-up. For comparison, 170 pregnant women matched by age and gravidity, not being exposed to any potential teratogenic agent during pregnancy, were recruited as controls. All gestations were confirmed by ultrasound examination, and participants were followed-up until delivery. Newborns were examined by a neonatologist.

RESULTS

Of 20 pregnant women exposed to roxithromycin during early pregnancy, information was obtained from 17 cases. The median dose of roxithromycin to which pregnant women were exposed was 300 mg/day (range 300-450 mg/day) and exposure occurred at a mean of 4.0 (range 2.8-17.6) weeks. Mean gestational age at delivery was 39.2 weeks in the exposed group and 39.4 in the controls (p = 0.6). Birth weight of babies exposed in utero to roxithromycin was not different to controls. We did not observe any major malformation in the exposed group whereas three (1.8%) occurred in the control group.

CONCLUSIONS

. Despite the limitations of the study due to the small sample size, roxithromycin appears not to be a major teratogen.

Fetal heart rate response to cordocentesis and pregnancy outcome: A prospective cohort

OBJECTIVE

To evaluate fetal cardiac response to cordocentesis and whether such changes may affect pregnancy outcome.

METHODS

117 singleton pregnant women requiring percutaneous trans-abdominal cordocentesis were prospectively included. Fetal heart rate was continuously evaluated by ultrasound for 1 min after completion of cordocentesis and intermittently for 20 min more. Fetal and pregnancy outcomes were analyzed by grouping fetal cardiac response to cordocentesis into bradycardia, normal heart rate and tachycardia groups.

RESULTS

Women included in the study were 30.5+/-4.0 years old and had a gestational age of 23.7+/-2.0 weeks. Fetal blood sample obtained by cordocentesis was 3.1+/-0.8 ml. Fetal heart rate before cordocentesis was 149+/-8 beats per minute (bpm), ranging from 130 to 169 bpm. Fetal heart rate post-cordocentesis was 145+/-30 bpm (from 32 to 175 bpm). The incidence of bradycardia and tachycardia was 10.3% (n=12) and 6.0% (n=7), respectively. Fetal heart rate returned to normal levels in all cases at <or=5 minutes post-cordocentesis. In the tachycardia group, 6 cases had normal pregnancy outcome and one patient was lost to follow-up. In the bradycardia group, we observed two pregnancy terminations, one patient was lost to follow-up and nine were normal outcomes. In the group with normal heart rate (n=98), we observed one intrauterine fetal death, nine adverse fetal outcomes, eight pregnancy terminations and nine patients were lost to follow-up.

CONCLUSIONS

Transient fetal tachycardia and bradycardia were uncommon and were not associated with adverse fetal or pregnancy outcomes.

Exposure to Amlodipine in the First Trimester of Pregnancy and During Breastfeeding

OBJECTIVE

To assess the fetal outcome of three hypertensive women exposed to amlodipine. 5 mg/day, in the first trimester of pregnancy. CASE 1: The patient was treated with amlodipine until 7 weeks of gestation. She was also exposed to levosulpiride, aluminum hydroxide gel, magnesium carbonate, and Ginkgo biloba. At 38(+3) weeks of pregnancy, she delivered a 3750 g healthy female baby, and restarted taking amlodipine, 5 mg/day, while exclusively breastfeeding her daughter. At three months of age, the infant was healthy. CASE 2: The patient was treated with amlodipine from 2(+2) to 3(+4) weeks of pregnancy. Her treatment was modified to atenolol until the week 6(+4 weeks), when she declined any antihypertensive treatment. At 39(+4) weeks of pregnancy, the patient delivered a 2600 g baby. At 20 months old, the baby presented with intellectual delay and weakness in the left arm and hand grasp. These neurological alterations were not attributed to her exposure to amlodipine early in utero. CASE 3: The patient was treated with amlodipine from 7(+6) to 12 weeks of pregnancy. She was also taking sucralfate and lorazepam. At 12 weeks of amenorrhea, ultrasound revealed a 15.3 mm, single fetal pole in the gestational sac without cardiac activity. She underwent dilatation and evacuation of a dead embryo.

CONCLUSION

As reported with other calcium-channel blockers, amlodipine does not appear to be teratogenic and it appears to be compatible with breastfeeding.

Angiotensin II Receptor Blockers in Pregnancy: A Case Report and Systematic Review of the Literature

OBJECTIVE

To describe the case of a woman exposed to angiotensin-II receptor blockers (ARBs) in the preconceptional period and to systematically review the literature on the safety of these drugs when used by pregnant women.

METHODS

The case was identified at the Korean Motherisk Program (Seoul). For the systematic review, we searched the PubMed for case reports, case series, and post-marketing surveys.

RESULTS

A hypertensive woman was exposed to irbesartan prior to conception. The embryo had delayed development of upper and lower extremities and decreased digital groove. A karyotype identified a 45,XO Turner syndrome. The patient had a spontaneous abortion. Including the case reported here, 64 published cases were identified in total; 57.8% had favorable and 42.2% had unfavorable outcomes. Duration of treatment during pregnancy among women who had adverse fetal outcomes was 26.3 +/- 10.5 weeks (mean +/- SD), compared with 17.3 +/- 11.6 weeks in those who had favorable outcomes (p = 0.04).

CONCLUSIONS

Exposure to ARBs for a period longer than the first trimester of pregnancy appears to be associated with a high risk for adverse fetal outcomes.

A systematic review of experimental and clinical studies of sildenafil citrate for intrauterine growth restriction and pre-term labour

Sildenafil could be an alternative in the treatment of intrauterine growth retardation (IUGR) and premature delivery. In order to systematically review the reproductive-related effects of sildenafil, a search was made on PubMed and the Science Citation Index for studies evaluating the effects of sildenafil on uterine vessels or myometrium either in vitro or in experimental animal models as well as for any clinical trial or case reporting the outcome of pregnant women treated with sildenafil. The information was obtained from: three in vitro studies, five studies performed in experimental animal models, four studies on women with fertility and sterility disorders receiving 100 mg/day of sildenafil intravaginally, and two case reports of pregnant women who received sildenafil for the treatment of pulmonary hypertension. Incubation with sildenafil of different in vitro preparations resulted in vasodilator and uterine relaxant effects. No evidence of teratogenicity was observed in the studies performed in mice, rats and dogs. Sildenafil increased fetal weight in rats. In women, contradictory results on uterine blood flow and endometrial development were reported after the intravaginal administration of sildenafil. No adverse fetal outcomes were reported in the two pregnant women with pulmonary hypertension receiving sildenafil late in their pregnancy. In conclusion, there is still limited information about the efficacy of sildenafil for the treatment of IUGR and premature delivery. However, studies in experimental animal models and two human case reports have reported no deleterious effects on the mother or offspring.

Teratogen risk counselling by internet: A prospective cohort study

Although the internet may play a role in providing proper teratogen-risk counselling for pregnant women, the experience with this type of service has not been reported. We aimed to compare the pregnancy outcome of women counselled by the internet to women that received typically in-clinic teratogen risk counselling in the clinic. In a prospective cohort design, 1,011 patients were counselled in the clinic and 235 patients were counselled via the internet. Teratogen risk counselling was provided according with the information obtained from medical literature and specialised software. Information about pregnancy outcome (delivery, spontaneous abortion, or termination of pregnancy and major malformations) was obtained from 903 (89.3%) patients from the clinic group and 141 (60%) from the internet group. The amount of alcohol, cigarettes smoked, and millirads of X-ray were greater ( p < 0.05) in patients counselled by internet than in clinic. The rate of deliveries, ongoing pregnancies, pregnancy terminations, and spontaneous abortions were similar between clinic and internet (chi2 = 1.32; p = 0.7). Of 498 babies born to mothers counselled in the clinic, major malformations were identified in 3.6%. Of 67 babies born to mothers counselled by internet, major malformations were present in 1.5% ( p = 0.6). Teratogen-risk counselling by internet and clinic seems to have a similar efficacy in pregnancy outcome.

Prenatal multivitamins containing folic acid do not decrease prevalence of depression among pregnant women

Several studies have reported an association between depression and folic acid deficiency. We investigated whether intake of prenatal multivitamins containing folic acid (MVandFA) was associated with decreased rates of depression among pregnant women. A questionnaire was given to 1,314 low-risk pregnant women. Of them, 1,277 (97.2%) women completed the questionnaire. The overall prevalence of depression was 8.1%. Of 652 participants who did not take MVandFA, 9.4% had depression, whereas 6.9% of 624 women who had MVandFA had depression (p = 0.11). In a multivariate logistic regression analysis, family history of depression (adjusted OR 3.7; 95% CI 1.9-7.3) and premenstrual syndrome (adjusted OR 3.0, 95% CI 1.8-4.8) were identified as risk factors for depression during pregnancy. In conclusion, intake of MVandFA was not associated with lower rates of depression during pregnancy whereas family history of depression and personal history of premenstrual syndrome were significant risk factors.

Pregnancy outcome after exposure to oral contraceptives during the periconceptional period

To evaluate whether periconceptional exposure to oral contraceptives (OCs) increased adverse pregnancy outcomes, 136 pregnant women taking OCs within the periconceptional period were identified at the Korean Motherisk Program. Of them, 120 pregnant women accepted to participate in their study and were followed up until completion of the pregnancy. A control group of 240 age- and gravidity-matched pregnant women exposed to non-teratogen drugs for at least 1 month before pregnancy was also included. The median gestational age at delivery was 39.1 (27.0-41.0) weeks in the exposed group and 39.3 (27.4-42.0) weeks in the control group (P = 0.19). In the exposed group, 7.1% of babies were born with low birth weight versus 2.6% in the control group (P = 0.068). The number of preterm deliveries or babies born large for gestational age did not differ between the two groups. In the exposed group, the rate of birth defects was 3.2% (n = 3/99) versus 3.6% (n = 7/193) in the control group (P = 1.0). There were 15 women who took high doses of progesterone (emergency contraception) and no adverse fetal outcomes were observed. In conclusion, periconceptional exposure to OCs does not appear to increase the risk for adverse pregnancy outcomes.

Cefepime/clindamycin vs. ceftriaxone/clindamycin for the empiric treatment of poisoned patients with aspiration pneumonia

Different antimicrobial treatments have proved to be effective in patients with aspiration pneumonia. However, resistant bacterial strains are commonly observed in hospital settings challenging the empirical treatment of these patients. In this study, we aimed to compare the efficacy of cefepime/clindamycin and ceftriaxone/clindamycin for empiric therapy of poisoned patients with aspiration pneumonia. In an open, randomized, prospective design, 140 consecutive patients aged more than 13 years, with radiographic signs of infiltration in chest radiography and dullness on percussion or pulmonary rales or ronchi in combination with at least two of the following clinical criteria were considered as eligible: fever > or = 37 degrees C (axillary), or hypothermia < 35 degrees C (axillary) and leukocytosis (> 10 cells/mm3), or leukopenia (< 3,000 cells/mm3), a left-shift of > 10%, or purulent sputum or secretion from trachea or bronchi. Participants received intravenously either ceftriaxone 1 g q12 h and clindamycin 900 mg q8 h (group 1) or cefepime 1 g q12 h and clindamycin 900 mg q8 h (group 2). On day 5 of treatment, the number of improved/cured patients was not different between groups (OR 0.86; 95% CI 0.24 to 2.90) nor at 14 days of the study (OR 0.66; 95% CI 0.12 to 3.29). Six patients died in group 1 and 5 in group 2 (RR 0.83; 95% CI 0.28 to 2.46). In conclusion, efficacy of empiric treatment of poisoned patients with aspiration pneumonia with ceftriaxone/clindamycin was comparable to treatment with cefepime/clindamycin.

Accidental poisoning with "Chinese chalk"

We present a 1.5-year old, 11 kg, female infant with a history of bronchial hyper-responsiveness who accidentally ingested half of a "Chinese chalk". A day later, the infant showed vomiting, cough, fever, drowsiness, and irritability and her clinical conditions progressively worsened. She was admitted to the emergency department with cough, respiratory distress, and hepatomegaly. It has been reported that the chalk may contain deltamethrin and cypermethrin. The patient was successfully treated with supportive therapy. This report identifies "Chinese chalk" as a potential source of accidental poisoning in children and should be considered as part of the differential diagnoses in the emergency rooms since poisoning with these compounds may be misdiagnosed as organophosphate poisoning due to the presentation of similar symptoms.

Is prenatal childbirth preparation effective in decreasing adverse maternal and neonatal response to labor? A nested case-control study

Sophrology, based on a combination of Western relaxation therapy and Eastern yoga and meditation might decrease maternal stress during labor. This study aimed to evaluate whether prenatal sophrologic childbirth preparation may decrease maternal and neonatal adverse response associated with delivery. In a nested case-control study, 69 nulliparous, singleton pregnant women who underwent an educational course of sophrologic childbirth preparation were compared to 69 nulliparous, singleton, age- and gestational age-matched pregnant women who did not receive any childbirth preparation. All babies were vaginally delivered. Groups were not different (P > 0.05) in the number of neonates born with meconium-stained amniotic fluid as well as in the number of babies with Apgar score < or = 7 at 1 and 5 minutes after birth. Duration of labor was not different between groups. The number of women requiring oxytocin and delivering babies with low pH blood levels tended to be lower in the group undergoing sophrologic childbirth preparation, i.e. 58.0% vs 72.5% (P = 0.07) and 1.4% vs 10.9% (P = 0.06), respectively. In conclusion, we were unable to confirm that prenatal sophrologic childbirth preparation has a definitive role in decreasing adverse maternal and fetal response to pain or in shortening labor. Prospective cohort studies with a larger sample size or randomized trials may help to clarify this gap.

Hemorrhoids in pregnancy

QUESTION

One of my patients is in the third trimester of her first pregnancy. She has recently experienced spotting during her bowel movements. She has hemorrhoids. What medications are safe?

ANSWER

The treatment is mainly symptomatic for most patients. Most forms of the condition can be treated by increasing fibre content in the diet, administering stool softeners, increasing liquid intake, and training in toilet habits. Although none of the topical antihemorrhoidal agents commonly used have been assessed for safety in pregnancy, it is unlikely that the constituent parts (anesthetic, corticosteroids, and anti-inflammatory agents) will harm the third-trimester infant. In most women, most symptoms of the condition will resolve spontaneously soon after giving birth.

Effects of sildenafil on the fetal growth of guinea pigs and their ability to survive induced intrapartum asphyxia

OBJECTIVE

Our goal was to determine whether sildenafil increased fetal weight and favored fetal tolerance to induced asphyxia at birth in guinea pigs.

STUDY DESIGN

Twenty guinea pigs were randomly allocated to placebo (n = 10) or sildenafil 50 microg/kg (n = 5) or 500 microg/kg (n = 5), starting from day 35 of gestation to delivery. Fetuses were delivered by cesarean section. Fetal asphyxia was induced by clamping the umbilical cord at birth for 5 minutes.

RESULTS

Sildenafil protected the pups against induced asphyxia at birth in a dose-dependent manner (eg, partial pressure (tension) of carbon dioxide levels were 75.9 +/- 19.3, 66.9 +/- 18.8, and 54.8 +/- 13.0 in the control and low- and high-dose sildenafil groups, respectively). The high-dose sildenafil group of piglets gained 1.5 times more body weight.

CONCLUSION

In guinea pigs, low doses of sildenafil administered from day 35 to the end of gestation favored fetal tolerability to induced intrapartum asphyxia. High doses of sildenafil increased fetal weight.

Hypereosinophilia, hyper-IgE syndrome, and atopic dermatitis in a toddler with food hypersensitivity

We describe a 20-month-old girl with hypereosinophilia, hyper-immunoglobulin (Ig) E syndrome, and atopic dermatitis. Her peripheral eosinophil count and IgE plasma levels were 2.65 x 10(9)/L and 6702 IU/mL, respectively. Specific IgE levels for a variety of foods and inhalants were high and single-blind food challenges were positive for cow's milk, hen's egg, oat, wheat, and soy. When the patient received an extensively hydrolyzed milk formula, an exclusion diet, and 2 mg/kg of prednisone daily, the atopic dermatitis partially improved. Further improvement was observed with 1 mg/kg of azathioprine daily. Long-term clinical response was satisfactory. We suggest that food hypersensitivity should be ruled out in patients with hypereosinophilia, hyper-IgE syndrome, and atopic dermatitis. Azathioprine may be a good therapeutic alternative for treatment in such cases.

Pregnancy outcomes in women using inhaled fluticasone during pregnancy: a case series

BACKGROUND

The aim of the study was to report the maternal and fetal outcomes of women with respiratory illnesses who were treated with inhaled fluticasone during pregnancy.

MATERIAL AND METHODS

We identified 12 cases treated with inhaled fluticasone during pregnancy out of women who received obstetric and teratogen-risk evaluation at the Korean Motherisk Program. A detailed medical and obstetric history was obtained and cases were followed-up until either spontaneous or voluntary pregnancy termination or delivery occurred.

RESULTS

None of the participants had any obstetric complication. However, in addition to fluticasone, most of the 12 cases were simultaneously exposed to a variety of medications. There were 3 abortions (one spontaneous and 2 requested by the patients arguing personal reasons). Live born babies without any evidence of major congenital malformations included 8 singleton babies and 2 twins. Of them, 3 babies were born prematurely.

CONCLUSIONS

Our results are in agreement with previous large studies where no increased rate of adverse outcomes was reported with the use of inhaled corticosteroids during pregnancy.

Influence of time at which oxytocin is administered during labor on uterine activity and perinatal death in pigs

Oxytocin is extensively used to induce or augment uterine contractions, especially to facilitate the third stage of labor in humans. Administration of oxytocin to parturient sows reduces duration of labor whereas mortality of the offspring may remain unchanged. This study aimed to evaluate whether time of administration of oxytocin during parturition may alter the uterine response and fetal outcomes. Two hundred parturient sows were randomly assigned to intramuscularly receive either saline solution (control group) or oxytocin 0.083 IU/kg immediately after the delivery of the 1st, 4th or 8th piglet (groups O-1, 0-4 and 0-8, respectively). Uterine effects and fetal outcomes were registered in all groups. The duration of labor was 20-40 min shorter (P < 0.0001) and time interval between babies was reduced by 3-5 min (P < 0.0001) in the three groups receiving oxytocin. The duration and intensity of contractions, meconium-stained piglets and intrapartum deaths decreased as time at which oxytocin administered during labor was increased. In group 0-8, we observed approximately 70% less meconium-stained piglets and intrapartum deaths than in the control group. In conclusion, oxytocin administered at early phases of parturition to sows may increase duration and intensity of uterine contractions as well as adverse fetal outcomes.

A case-control study of food hyper-sensitivity, timing of weaning and family history of allergies in young children with atopic dermatitis

BACKGROUND

The aim of this study was to investigate the relationship between food hypersensitivity and atopic dermatitis (AD) in young children.

MATERIAL AND METHODS

In a case-control design, 28 patients < 3 years old, with AD and 28 age-matched healthy children were included in the study. A detailed medical history of allergies and timing of weaning was obtained. Children underwent skin tests (prick and patch) to evaluate food hypersensitivity. The status of DA and food allergies in the study participants was investigated 4 years later.

RESULTS

There were more children with positive skin tests for food hypersensitivity among cases than controls, OR 4.2 (95%CI 1.3 to 13.4). In contrast, there were no differences in the number of children with positive family history of allergic diseases or weaned at < or = 6 months of age between groups. Four years later, out of the 28 original cases, the state of AD was investigated in 13 (46.4%) infants. Of them, 11 followed an exclusion diet; 6 (46.1%) remained with AD. Of 28 original controls, 15 (51.7%) infants were investigated 4 years later; only one case developed AD.

CONCLUSIONS

Young children who had hypersensitivity to cow's milk, hen egg, wheat, fish, soy, or legumes were found to have a higher risk of AD. Positive family history of allergies and early weaning were not found to be relevant risk factors.

Hemodynamic and oxidative stress profile after exercise in type 2 diabetes

This study investigated the effect of an acute bout of exercise (>85% VO2Max) on biochemical, hemodynamic and oxidative stress variables in sedentary and physically active subjects with type 2 diabetes (T2D). Blood measurements were taken before and after a treadmill test on 12 sedentary non-diabetes subjects (ND), 12 sedentary type 2 diabetes (T2S) and 9 physically active T2D subjects (T2DA). T2DS subjects before and after the treadmill test showed a higher plasma glucose (123.2 +/- 19.0 mg/dL versus 108.9 +/- 16.8 mg/dL, p < 0.001), HbA1C (8.7 +/- 2.4% versus 7.3 +/- 1.2%, p < 0.001) and body fat% (21.3 +/- 5.7% versus 34.6 +/- 4.5%, p < 0.001) than T2DA subjects. T2DA had higher VO2Max (37.7 +/- 3.5 versus 29.5 +/- 3.2, p < 0.05), time on treadmill (22.3 +/- 2.1 min versus 16.1 +/- 2.1 min, p < 0.05), hemoglobin (17.9 +/- 0.9 g/dL, p < 0.05) and lower blood pressure levels in comparison to ND and T2DS subjects. Thiobarbituric acid substances (TBARS) in T2DS were higher than in T2DA subjects (0.27 +/- 0.1 nmol/mL versus 0.21 +/- 0.1 nmol/mL, p < 0.05). Glutathione (GSH) levels were similar among the groups. Physically active type 2 diabetes subjects had a more favorable biochemical, hemodynamic and oxidative stress profile than sedentary subjects. The coexistence of a poor cardiopulmonary performance and high oxidative stress environment can determine a profile of high risk for serious cardiovascular events in patients with diabetes.

Human Teratogens and Evidence-based Teratogen Risk Counseling: The Motherisk Approach

There are only a limited number of drugs proven to be human teratogens including thalidomide, isotretinoin, coumarin derivates, valproic acid, and folate antagonists. In some cases, the combination of 2 drugs may increase the teratogenic risk. The risk of birth defects may also vary with the time at which the drug is administered during pregnancy and the dose. There are some examples of drugs in which the dose has proven to be a major determinant of their teratogenicity in humans. There is more safety information for older than for newer drugs. Proactive teratogen risk counseling should include a critical appraisal of all available data including the consequences of the untreated maternal condition.

A study of piglets born by spontaneous parturition under uncontrolled conditions: could this be a naturalistic model for the study of intrapartum asphyxia?

In order to evaluate how spontaneously born piglets could be a suitable model for the study of intrapartum hypoxia, 230 newborn piglets were studied. Out them, 8.3% (n = 19) died intrapartum, 21.7% (n = 50) were born with moderate-to-severe intrapartum hypoxia, and 70% (n = 161) were born with mild or no evidence of intrapartum distress. Piglets born without any evidence of intrapartum asphyxia weighed approximately 240 g lower than those born with intrapartum hypoxia and intrapartum-dead piglets (P<0.0001). The viability score was approximately 3 units lower and the latency to contact the udder was two times longer in the piglets surviving intrapartum hypoxia than in controls (P <0.0001). In comparison with the control group, metabolic acidosis was most severe among intrapartum-dead piglets followed by piglets surviving intrapartum asphyxia (P =0.002). According to a multiple linear regression analysis, pCO2 and lactate blood levels, and birth weight were identified as explanatory variables of viability score (r: 0.78; P <0.001). Viability score, K+ and lactate blood levels, and birth weight were identified as explanatory variables of latency to contact the udder (r: 0.80; P <0.001). In conclusion, the spontaneously-born asphyxiated piglet could be considered as a naturalistic model for the study of intrapartum asphyxia. Histopathologic and more rigorous functional and behavioral evaluations are still required to further characterize the model. (www.actabiomedica.it)

The incidence of nausea and vomiting of pregnancy (NVP): a comparison between depressed women treated with antidepressants and non-depressed women

BACKGROUND

Nausea and vomiting of pregnancy (NVP) affects up to 80% of pregnant women. In many cases NVP causes changes i n family, social, o roccupational functioning. Several studies have linked NVP with depression; however, whether depression preceded or resulted from NVP, has not been established.

OBJECTIVE

To examine whether pregnant women, diagnosed with depression pre-conceptionally, treated with an antidepressant, reported a higher incidence of NVP when compared with pregnant women without depression.

METHOD

In this pilot study, two groups of pregnant women who called the Motherisk Program in Toronto, Canada, were compared. Group 1 was comprised of 179 pregnant women who reported taking an antidepressant for the treatment of depression prior to pregnancy and in the first trimester. Group 2 was comprised of 179 pregnant women with no history of depression. The incidence of NVP in both groupswas recorded and compared.

RESULTS

In the depressed group 109/179 (61%) women reported suffering from NVP vs.121/179 (68%) in the non-depressed group (P = 0.1). The logistic regression analysis did not identify any independent variable as significantly explaining NVP.

CONCLUSION

Depression and treatment with antidepressants prior to and in early pregnancy, does not appear to affect the incidence of NVP.

A new endoscopic procedure for membranectomy of fenestrated duodenal membranes

AIM OF THE STUDY

We describe a new endoscopic procedure for membranectomy of fenestrated duodenal membranes.

METHODS

With the patients under general anesthesia and tracheally intubated, a flexible video-panendoscope was introduced into the second portion of the duodenum. The fenestrated membrane was visualized and a triple-lumen stone extraction balloon of 15 mm was inserted through the fenestration. After the balloon was insufflated, gentle traction was performed in order to expose the fenestrated membrane and differentiate it from the normal duodenal wall. The orifice was dilated in order to introduce the endoscope and localize the Vater's ampulla. A sphincterotome was used to carry out one or two incisions of 1.5 to 2 cm in the membrane in the opposite direction to the ampulla.

RESULTS

The procedure was successfully performed in five patients with a mean surgical time of 50 minutes. None of the patients complained of postoperative pain. Peristalsis was not affected, and patients started intake of oral fluids at approximately 24 hours. On discharge patients were completely asymptomatic, and four patients were followed up for one year following the procedure and remained asymptomatic. One patient who was also asymptomatic did not continue follow-up longer than two weeks after the procedure.

CONCLUSION

Endoscopic membranectomy of duodenal membranes is a safe and effective procedure that reduces surgical times, postoperative fasting times and the length of hospitalization, and probably has no postoperative complications.

Antimicrobial therapy and local toxicity of intraventricular administration of vancomycin in a neonate with ventriculitis

Infection is the most common complication and cause of failure of cerebrospinal fluid (CSF) shunt devices used to control hydrocephalus. A male newborn was admitted for treatment of congenital occlusive hydrocephalus by means of a ventriculo-peritoneal shunt. A day later, the skin area around the site of insertion of ventriculo-peritoneal catheter was red and edematous. Intravenous ceftazidime and vancomycin were initiated. The shunt was removed but the external ventricular drain was preserved. Blood and CSF cultures showed Enterococcus faecalis sensitive to vancomycin, ciprofloxacin and gentamicin, but resistant to ampicillin. Intraventricular administration of vancomycin 10 mg/24 h was initiated through the external ventricular drain. Before the first dose of vancomycin intraventricularly, CSF levels were 19 mg/dL as a result of administration. On the third day of intraventricular dosing, vancomycin levels in CSF reached 388 mg/dL and protein levels were 1160 mg/dL. On the fifth day of intraventricular treatment the patient had clinically improved and was bacteriologically cured. However, in CSF, protein levels were 3300 mg/dL and vancomycin levels 201 mg/dL. In an attempt to prevent high and potentially toxic levels in CSF, the intraventricular dose of vancomycin should be individualized according to clinical response, bacteriological cultures, vancomycin levels in CSF, and surrogate markers of neurotoxicity, that is, eosinophilia and high protein levels in CSF.

A randomized trial comparing laryngeal mask airway to endotracheal tube in children undergoing upper gastrointestinal endoscopy

Although the efficacy of laryngeal mask airway (LMA) has been demonstrated for securing patency of the airway in children, it has not yet been compared to endotracheal tube (ET) in this population. This study aimed to compare the safety and efficacy of LMA vs. ET in children undergoing elective diagnostic upper gastrointestinal endoscopies. Sixty ASA I-III patients were randomly allocated to ET (Group I) or LMA (Group II). A set of cardiovascular and respiratory parameters were obtained before, during and after the endoscopic procedure. The recovery time and the time to discharge were also registered. The cardiovascular and respiratory parameters evaluated in the study varied across the different evaluation periods. However, they remained within physiological ranges and were not different between groups. The median (range) recovery time was 4 (2-10) min and the time to discharge was 58 (36-88) min in the ET group and 3 (1-7) min and 50 (35-67) min in the LMA group (P > 0.10), respectively. In a 16 month-old, 80 cm and 10 kg girl, we failed to secure the patency of the airway with LMA. In conclusion, the LMA was as effective and safe as ET for securing the airway of children undergoing diagnostic upper endoscopies. However, the 3% failure rate occurred with LMA.

Individual and family household smoking habits as risk factors for wheezing among adolescents

BACKGROUND

The study aimed to evaluate the household smoking habits as risk factors for wheezing in adolescents.

METHODS

During a 2-month period, the study was performed by applying the standardized ISAAC phase 1 questionnaire to 3474 adolescents attending a random sample of secondary public schools located at the southeast of Mexico City. Adolescents were grouped as "cases" if they had at least one episode of wheezing in the year prior to the study, or as "controls" if they did not. Positive individual and family (father, mother or other persons living in the home) smoking habits at home were evaluated as potential risk factors.

RESULTS

More than 98% of respondents in the two groups reported that the father smoked in the house. More mothers who smoked were reported among cases than controls (OR 2.42; 95% CI 1.60-3.68). More adolescents in the group of cases had history of ever having rhinitis, rash or wheezing. Fifty-four percent of adolescents in the group of cases had ever smoked versus 38.8% of controls (OR 1.89; 95% CI 1.33-2.67). Sex-adjusted logistic regression analysis identified a "protective" role for wheezing when the number of smokers at home was < or =2 (OR 0.44; 95% CI 0.27-0.71).

CONCLUSION

Individual, maternal and other family members' indoor smoking habits may increase the risk of wheezing among adolescents.

Use of proton pump inhibitors during pregnancy and breastfeeding

QUESTION

A 36-year-old pregnant patient has symptoms of peptic disease. Treatment with diet and lifestyle modifications and also antacids has given her little relief. If she were not pregnant, I would prescribe a proton pump inhibitor (PPI) for her. She is now 4 weeks pregnant, and I need to determine whether PPIs are safe during pregnancy.

ANSWER

Data currently available suggest that omeprazole is not teratogenic in humans. While information on other PPIs is limited, a systematic review of the evidence suggests that they are also not teratogenic.

Obstetric and neonatal outcomes to recombinant porcine somatotropin administered in the last third of pregnancy to primiparous sows

This study aimed to investigate whether the administration of recombinant porcine somatotropin (rpST) late in gestation is associated with increased rates of obstetric and neonatal complications in primiparous sows. From days 80 to 114 of gestational age, 20 primiparous sows were randomly assigned to receive an intramuscular injection of either saline or 6 mg rpST/day. Throughout pregnancy, sows were fed 2.5 to 3 kg/day of a corn-soybean diet (14 MJ ME/kg). Of 111 piglets born to control sows and 109 piglets born to treated sows, 8.1% and 17.4% piglets respectively died intrapartum (P=0.04). Glucose blood levels in sows and live-born piglets in the rpST-treated group were significantly higher than in their corresponding controls. Birth weight of live-born piglets in the treated group was 1.4 +/- 0.1 kg versus 1.3 +/- 0.1 kg in the control group (P<0.0001). Birth weight of piglets born dead was also higher in the former than in the latter group (P<0.0001). No evidence of teratogenicity was observed in either of the groups. In conclusion, rpST administration in late pregnancy to primparous sows increased the rate of neonatal deaths and was associated with higher blood glucose levels in both sows and piglets.