The PREGVAXGRIP study: a cohort study to assess foetal and neonatal consequences of in utero exposure to vaccination against A(H1N1)v2009 influenza

BACKGROUND

In October 2009, in the context of an A(H1N1)v2009 influenza pandemic, a vaccination campaign was launched in France, in which one of the priority groups was pregnant women, on account of the high risk of developing complications following infection by this virus.

OBJECTIVE

The aim of this multicentric, prospective, observational study was to assess safety and pregnancy outcomes in a cohort of pregnant women when receiving the A(H1N1)v2009 influenza pandemic vaccine.

METHODS

This was a prospective study that followed up pregnant women recruited mainly in vaccination centres and maternity departments. Following the expected delivery date, follow-up data were collected concerning the delivery, the infant, and, if appropriate, the reasons why the pregnancy did not reach its term.

RESULTS

Between 1 November 2009 and 31 March 2010, 2,415 pregnant women were included at the time of vaccination; 97.6 % of women received a vaccine without adjuvant and 2.4 % received an adjuvanted vaccine. Ninety-two (3.9 %) women were vaccinated during the first trimester of pregnancy, 1,090 (46.5 %) during the second trimester, and 1,162 (49.6 %) during the third trimester. One hundred and thirty-three adverse events (5.5 % of women) were reported, of which 12 were unexpected or serious. There were 2,246 (93.0 %) known pregnancy outcomes with 12 spontaneous abortions (0.5 %), 6 stillbirths (0.3 %), and 4 therapeutic abortions (0.2 %). There were 65 neonates with congenital anomalies, among which 31 were major. But only one congenital malformation (1.4 %) was reported for the 92 women vaccinated in their first trimester. Of the women, 93.3 % were delivered full term and 6.7 % preterm. For 96 (4.2 %) neonates, a disorder was reported in the neonatal period and 130 (5.6 %) were transferred to the neonatology department.

CONCLUSIONS

This study suggests that exposure to the A(H1N1)v2009 pandemic influenza vaccine during pregnancy does not increase the risk of adverse pregnancy outcomes. However, because of the relatively small number of women exposed during the first trimester, other studies are needed to exclude an increased risk of malformation.

Antipsychotics: a real or confounding risk factor for venous thromboembolism?

In a meta-analysis of case-control studies, Zhang et al. (2011) found an increased risk of venous thromboembolic events (VTE) in patients exposed to antipsychotics (OR=2.39 [1.71-3.35]). Our updated meta-analysis including the 2 available cohort studies, recognized as a more relevant type of observational study, showed a weaker, but still strong association (OR=1.84 [1.39; 2.44]). In view of the lack of data on the confirmed risk factors for VTE in existing studies, prospective studies including adjustment for these risk factors are warranted to confirm this association and to assess the benefit/risk ratio of antipsychotics in high-risk patients.

[Dextropropoxyphene hepatotoxicity: four cases and literature review]

We report 4 cases of hepatic injury in patients treated with a dextropropoxyphene-paracetamol combination in which the causal relationship with dextropropoxyphene can be suspected. These four cases show similarities with the 29 cases found in international publications. Hepatotoxicity occurs more frequently among old patients and women. Clinically, this condition can mimic a biliary tract disease with sometimes few or no symptoms. Biochemical criteria can show cholestatic, mixed or cytolytic hepatitis. Intrahepatic cholestasis may be found in liver biopsies sometimes suggesting cholangitis. Outcome is favourable on withdrawal of the drug. The mechanism of action of dextropropoxyphene is discussed.

[Drug-induced taste disorders: analysis of the French Pharmacovigilance Database and literature review]

Taste disorders, generally poorly studied, have various causes. From 1985 to 1997, 305 observations of taste disorders imputed to drugs were notified to Regional Pharmacovigilance Centres. Patients were on average 54.4 years old and 58 per cent were women. Quantitative as well as qualitative disorders have been observed. Drugs mainly found were: angiotensin converting enzyme inhibitors, terbinafine, zopiclone, D-penicillamine, imidazole derivatives, quinolones, macrolides, carbimazole and calcium channel blockers. The outcome was favourable for 60.3 per cent of patients. The possible efficacy of zinc is discussed. It is generally considered that taste disorders are not a serious side-effect, but they can reduce the quality of life and lead to poor compliance with treatment.

[Delayed drug-induced hepatic injury. Evoking the role of amoxicillin-clavulinic acid combination]

Although infrequent, hepatitis associated with amoxicillin and clavulanic acid combination is probably underestimated. Except for cases with few symptoms, a time interval between stopping treatment and the first manifestations (jaundice in most cases), sometimes of several weeks, may hinder diagnosis. We report 9 patients who exhibited this characteristic. The delay between stopping treatment and the onset of hepatitis varied from 13 days to 6 weeks after stopping the drug. Other causes of jaundice were excluded. Male sex, advancing age, or prolonged treatment (more than 10 days) may increase the risk. Complete recovery occurs within 1 to 4 months after discontinuation of treatment. The mechanism is unclear. Clinical and biological signs of hypersensitivity may suggest an immunoallergic reaction.

[Drug prescription for pregnant women in the department of the Loire]

A prospective drug prescription and descriptive study was undertaken in a sample of 214 pregnant women in the department of the Loire. This population was randomized using pregnancy declaration files from the French Health Care Centre. Data recording was retrospective. A total of 2064 drugs have been prescribed; 90 per cent of women received at least one drug during the course of pregnancy with an average of 11.5 drugs per woman. Antispasmodics are mainly prescribed in the first trimester while vitamins, mineral supplements, antianemics and vasoactive agents are found in the third trimester. Prescriptions do not rise with age but increase in urban areas. Use of PDD/DDD (Prescribed Daily Dose/Defined Daily Dose) is an estimation of prescription customs. For ketoprofen, it is 1.6 in the last trimester, although this drug is contra-indicated.

[Hemorrhagic syndromes related to selective serotonin reuptake inhibitor (SSRI) antidepressants. Seven case reports and review of the literature]

PURPOSE

Selective serotonin reuptake inhibitors (SSRIs) are widely prescribed. Since their release unexpected adverse effects such as bleeding disorders have been described.

METHODS

Thirty patients with either hematoma or muco-cutaneous bleeding have been selected from case reports of the Saint-Etienne Pharmacovigilance center and from a literature review.

RESULTS

The female/male sex-ratio was 3:4 and the mean age 42 years. Two newborns who had been exposed in utero to SSRIs were also included in the study. Eleven patients presented an underlying disease or were at risk. Various adverse effects such as bruising, hematoma, petechiae or purpura, epistaxis, and more rarely intestinal hemorrhage, ocular bleeding or cerebral hemorrhage were encountered. Symptoms were sometimes associated with prolonged bleeding time and platelet aggregation disorders and usually resolved within two days to four months after treatment discontinuation.

CONCLUSION

Hematoma and muco-cutaneous bleeding would therefore be related to treatment, including selective serotonin reuptake inhibitors. However, these adverse effects are still poorly known and rarely reported. The main mechanism suggested would be a decrease in serotonin platelet leading to a defect in platelet aggregation. However, an increase in capillary fragility or susceptibility related to the patient's condition might be involved. Study of hemostasis history in patients requiring treatment with SSRIs might be of value.

[Adverse effects of quinine in the treatment of leg cramps]

In France, three over-the-counter products containing quinine exist to treat cramps. This study aims to analyse data on spontaneous reports to the French System of Pharmacovigilance of adverse reactions to quinine drug products. From 1985 to 1996, we reviewed 58 adverse reaction reports. Most involved hypersensitivity reactions: rash, pruritus, generalized anaphylaxis, thrombopenia and hepatitis. Cinchonism is rarely observed at the usually low dose of quinine in this indication. No fatal outcome has been notified as described in the USA and Australia. The Food and Drug Administration (FDA) decided that prescription of quinine drug products should not be used any longer in the treatment of muscle cramps. Immuno-allergic reactions are potentially serious and must be avoided by giving clear information to patients and prescribers, and looking into the history of such reactions in patients in respect of the quinine drug and also tonic water.