Prenatal Psychostimulant and Antidepressant Exposure and Risk of Hypertensive Disorders of Pregnancy

OBJECTIVE

To investigate the association, if any, of prenatal mental illness and psychotropic exposure with the risk of hypertensive disorders of pregnancy (HDP).

METHODS

A case-cohort analysis was conducted of 686 pregnant women participating in prospective, longitudinal observational studies in a tertiary referral center between January 1998 and May 2012. Risk estimates were produced using multivariate logistic regression modeling. Medication- and diagnosis-specific data were utilized to conduct post hoc confirmatory analyses of the risk estimates.

RESULTS

After adjustment for confounders, HDP were significantly associated with psychostimulant (odds ratio [OR] = 6.11; 95% CI, 1.79-20.9) and serotonin-norepinephrine reuptake inhibitor (SNRI) (OR = 2.57; 95%, 1.34-4.93) exposure following the 20th week of gestation and lifetime histories of cocaine dependence (OR = 2.99; 95% CI, 1.12-7.98) and panic disorder (OR = 1.78; 95% CI, 1.06-2.98) using DSM-IV diagnostic criteria. HDP risk was not associated with prenatal selective serotonin reuptake inhibitor exposure or other psychiatric disorders. Post hoc analyses demonstrated an increased risk for HDP with higher maternal daily doses of amphetamine psychostimulants and the SNRI venlafaxine.

CONCLUSIONS

These data indicate that psychostimulant and SNRI exposure following the 20th week of gestation conveys considerable risk for the emergence of HDP. Overall, the findings suggest that heightened vascular reactivity to noradrenergic, rather than serotonergic, stimulation may be pivotal to HDP risk among women with psychiatric illness.

The onset of postpartum depression: Implications for clinical screening in obstetrical and primary care

OBJECTIVE

Inconsistent diagnostic criteria fail to delineate guidelines for postpartum depression surveillance. This study evaluates the validity of commonly accepted postpartum onset criteria.

STUDY DESIGN

Consecutive referrals to the Emory Women's Mental Health Program for evaluation of postpartum depression fulfilling criteria for major depression and taking no psychotropic medication were included. Diagnostic interview, demographics, depression scales, and the time of illness onset were obtained. Descriptive analysis was conducted for 3 participant groups: pregnancy onset, early postpartum onset within 6 weeks of delivery, and late postpartum onset.

RESULTS

Among participants, 11.5% reported prenatal onset, 22.0% late postpartum onset, and 66.5% early postpartum symptom onset. Those reporting pregnancy onset were more likely to be unmarried, and those with a late postpartum onset were less likely to report a past history of postpartum depression.

CONCLUSION

The perinatal vulnerability to depression begins before delivery and extends beyond 6 weeks postpartum. Depression surveillance is therefore warranted during prenatal visits, at the postnatal check up, and at pediatric visits during the initial 6 months of the first postnatal year.

A novel system for the determination of antidepressant concentrations in human breast milk

The high incidence of psychiatric illness in the postpartum period and the increasing percentage of women who breastfeed has focused attention on the treatment of breastfeeding women with psychotropic medications and, additionally, the exposure of nursing infants to these medications. Consequently, there has been an increased effort to develop standardized methods for quantifying psychotropic medications in breast milk. This paper details a novel method for quantifying the concentrations of multiple selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) in breast milk. The method consists of a common liquid/liquid and solid-phase extraction followed by HPLC separation on a common column and UV detection. Assay system 1 measures fluoxetine, norfluoxetine, fluvoxamine, and paroxetine; assay 2 measures sertraline and desmethylsertraline; and assay 3 measures the TCAs including doxepin, nordoxepin, desipramine, imipramine, nortriptyline, and amitriptyline. The method is shown to be a highly accurate and precise technique for measuring 12 different antidepressants in human breast milk and to be free of the matrix effects often encountered in breast milk drug analyses.

The pharmacokinetics of sertraline excretion into human breast milk: determinants of infant serum concentrations

BACKGROUND

The purpose of this study was to attain a new landmark in the area of selective serotonin reuptake inhibitor therapy during lactation by establishing a basis for interpreting infant serum concentrations and for minimizing infant exposure in the absence of treatment-emergent side effects.

METHOD

Breast milk and paired maternal and infant sera were collected following maternal treatment with sertraline monotherapy (25-200 mg/day) administered once daily. Sertraline and its major metabolite were measured in breast milk and serum samples using high-performance liquid chromatography with UV detection (limit of detection = 2 ng/mL).

RESULTS

Twenty-six nursing women with DSM-IV major depressive disorder participated in the study; the mean (SD) daily sertraline dose was 123.9 (62.8) mg/day. Fifteen women submitted 182 breast milk samples for analysis of gradient (foremilk to hindmilk) and time course of medication excretion. The milk/plasma ratio was highly variable (range, 0.42-4.81). A significant gradient and time course of excretion for both sertraline (p <.001 for both) and desmethylsertraline (p <.001 for gradient and p <.046 for time course) were observed, with the highest concentrations observed in the hindmilk 8 to 9 hours after maternal ingestion. Mathematical modeling of sertraline and desmethylsertraline excretion revealed that discarding breast milk 9 hours after maternal dose decreased the infant daily dose of sertraline by a mean of 17.1% (1.8%). Twenty-two mother/infant sera pairs were obtained. Sertraline was detectable in 4 infants (18% of sample), and desmethylsertraline was found in 11 infants (50% of sample). The mean (SD) maximum calculated nursing infant dose of sertraline, 0.67 (0.61) mg/day, and desmethylsertraline, 1.44 (1.36) mg/day, represented 0.54% (0.49%) of the maternal daily dose. The maximum infant dose of desmethylsertraline (p <.002) significantly correlated with infant serum desmethylsertraline concentrations (ng/mL). In contrast, maternal daily dose, duration of medication exposure, and infant age and weight at sampling did not correlate with either detectability (< 2 ng/mL vs. > or = 2 ng/mL) or absolute concentrations (ng/mL) in infant serum. No adverse events were reported or documented in any infant.

CONCLUSION

These results extend previous studies by demonstrating the utility of breast milk analysis in interpreting infant serum concentrations and minimizing infant exposure.

Screening for dyslipidemia. Practice parameter

Screening for serum lipid disorders is recommended by numerous specialty societies to identify patients at risk for coronary heart disease (CHD). The best screening tests will identify patients at highest risk for CHD who would benefit from intervention. This report discusses an appropriate test panel to use as the initial screen on a healthy outpatient population, and the required accuracy and precision of the tests from the Laboratory Medicine perspective. Controversy exists regarding which methods to use and at what age testing should begin. The following parameters will be modified as studies continue and new tests are developed. The recommendations are as follows: (1) Total serum cholesterol (TC) and high density lipoprotein-cholesterol (HDL-C) are presently the recommended screening tests for dyslipidemia in the general population; (2) The National Cholesterol Education Program (NCEP) recommends measuring TC and HDL-C in adults with a single sample at 5-year intervals beginning at age 20; (3) The NCEP recommends measuring TC in children with at least one parent having TC > or = 6.24 mmol/L (> or = 240 mg/dL); (4) The NCEP recommends a lipoprotein analysis consisting of a 12-hour fasting TC, HDL-C, triglyceride, and estimated low density lipoprotein-cholesterol (LDL-C) in adults with the following results: (a) TC > or = 6.24 mmol/L (> or = 240 mg/dL); (b) borderline TC of 5.20-6.23 mmol/L (200-239 mg/dL) and HDL-C < 0.91 mmol/L (< 35 mg/dL) or two or more risk factors; (c) desirable TC of < 5.20 mmol/L (< 200 mg/dL), but HDL-C < 0.91 mmol/L (< 35 mg/dL); (5) The NCEP recommends a lipoprotein analysis in children with documented CHD in a parent or grandparent, or in children that have a TC of > or = 5.20 mmol/L (> or = 200 mg/dL); (6) Two or three separate lipoprotein analyses should be done to confirm the LDL-C result before therapeutic intervention. Specimens should be tested from 1 to 8 weeks apart and the results averaged to account for physiologic variability; (7) Enzymatic methods are preferred for TC determination, and should be standardized and traceable to the reference method and materials at the Centers for Disease Control and Prevention (CDC); (8) The analytic method for TC should have a bias against the reference method of < 3% and a within laboratory reproducibility of < 3% coefficient of variation; (9) Chemical precipitation methods are preferred for HDL-C determination.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis and localization of prostate carcinoma by fine-needle aspiration cytology and correlation with histologic whole-organ sections after radical prostatectomy

Twenty-nine patients with clinical stage T1-2, NO, MO prostate carcinoma were treated by retropubic radical prostatectomy. Diagnosis was made by fine-needle aspiration biopsy from six to eight separate sectors of the prostate. At the time of biopsy, diagrams of the palpated organ were drawn, depicting the location of the lesion and the site of each biopsy. Without the examiners' knowledge of cytologic data, extirpated prostate glands were examined with whole organ histologic sections, and carcinomas were scored according to the method of Gleason. The location and extent of all typical and malignant foci were mapped on a standard diagram. The results of preoperative cytologic examination were compared with postoperative histopathologic findings, showing a tendency toward underestimation of both the extent and degree of differentiation of the carcinomas during cytologic examination. In no case were these parameters overestimated during cytologic examination. The Gleason score correlated well with the presence of capsular and seminal vesicle invasion.

A comparative study of DNA cytometry methods for benign and malignant thyroid tissue

DNA measurements of 46 thyroid specimens were performed by use of fresh tissue for flow cytometry and formalin-fixed paraffin-embedded tissue for flow and static cytometry. The tissue included four histopathologic subgroups, i.e., 19 colloid goiters, 7 papillary carcinomas, 10 follicular adenomas, and 10 follicular carcinomas. The methods measured DNA index and the percentage of cells in S-phase for each subgroup. There was a strong correlation between the methods for DNA-index measurements. In three cases, tissue interpreted as diploid by one method was aneuploid by another method. The S-phase measurements were not reproducible between the methods because of the low percentage of cells in S-phase (mean: 2.6%; range: 0.0-7.5% overall). Aneuploid cells were rare in nodular goiter (2 of 19 cases, 10.5%) but were increasingly present in subsequent subgroups, i.e., 2 of 7 papillary carcinomas (28%), 3 of 10 follicular adenomas (30%), and 6 of 10 follicular carcinomas (60%).

Chronic glomerular microangiopathy complicating metastatic carcinoma

Six cases of metastatic carcinoma associated with chronic glomerular microangiopathy and renal failure are reported. All had prominent subendothelial lucent zones and double-contoured glomerular basement membranes. There was no immunohistologic or ultrastructural evidence for immune complex entrapment in glomeruli. By immunohistology, material antigenically related to fibrin or fibrinogen was identified in glomerular basement membranes despite a paucity of typical fibrillar fibrin. Four patients received mitomycin C before the onset of renal disease, and one patient received chemotherapy other than mitomycin C before development of renal failure. One patient had no chemotherapy but was given radiotherapy, which did not include the kidneys in the irradiated field. These six cases emphasize the diverse pathophysiologic mechanisms by which glomerular microangiopathy may arise in metastatic carcinoma.