[HEAD INJURY DURING PREGNANCY].

No matter how severe is head injury during pregnancy, it can threaten both- the maternal and (or) the fetal life. The risk derives from systemic and cerebral consequences of high intracranial pressure, hypotension, anemia or expanding mass lessions in the cranial cavity. The specific hormonal background of the mother may contribute the better outcome after traumatic brain injury (TBI). Pregnancy and trauma push the doctors to create different and specific management than the usual case. Investigating literature data we figure out the initial assessment, management priorities for resuscitation of the head injured pregnant patient, concidering the specific anatomic and physiologic changes during pregnancy. We accept the principal: first save the mother, then the child, if possible, proposing algorithm for severe head injured pregnant patient management.

Head circumference and height abnormalities in autism revisited: the role of pre- and perinatal risk factors.

Pre/perinatal risk factors and body growth abnormalities have been studied frequently as early risk markers in autism spectrum disorder (ASD), yet their interrelatedness in ASD has received very little research attention. This is surprising, given that pre/perinatal risk factors can have a substantial impact on growth trajectories in the first years of life. We aimed to determine which pre/perinatal factors were more prevalent in ASD children and if these factors differentially influenced body growth in ASD and control children. A total of 96 ASD and 163 control children matched for gender participated. Data of growth of head size and body length during the first 13 months of life were collected. Data on pre/perinatal risk factors were retrospectively collected through standardized questionnaires. Results indicated that after matching for SES, prematurity/low birth weight and being first born were more prevalent in the ASD versus the control group. In addition, with increasing age children with ASD tended to have a proportionally smaller head circumference compared to their height. However, the effect of prematurity/low birth weight on head growth corrected for height was significantly different in ASD and control children: premature/low birth weight control children showed a disproportionate larger head circumference in relation to height during their first year of life, whereas this effect was absent in premature/low birth weight ASD children. This may suggest that the etiology of abnormal growth is potentially different in ASD and control children: where abnormal growth in control children is related to suboptimal conditions in the uterus, abnormal growth in ASD may be more strongly related to the causal factors that also increase the risk for ASD. However, prospective studies measuring growth and ASD characteristics in both premature/low birth weight and a terme children are necessary to support this conclusion.

Motor vehicle accidents during pregnancy: a population-based study.

This population-based cohort study of more than 600,000 Australian women describes the incidence of motor vehicle accidents (MVA) during pregnancy and the immediate and subsequent pregnancy outcomes. In this study, 3.5 women per 1000 maternities were admitted to hospital following an MVA. Immediate delivery was uncommon: 0.4% at <20 weeks of gestation and 3.5% at ≥ 20 weeks of gestation. Outcomes for those giving birth immediately were poor, with increased risk of antepartum haemorrhage, preterm birth, caesarean section and perinatal death. In contrast, women who remained undelivered following an MVA (96%) had similar pregnancy outcomes to women not involved in MVAs, and can be reassured.

Concentrations of organochlorine pesticides in placental tissue are not associated with risk for fetal orofacial clefts.

Previous epidemiological studies have shown that prenatal exposure to organochlorine pesticides (OCPs) entails a variety of adverse impacts on fetal health, but it is not yet known whether it is associated with risk for orofacial clefts (OFCs). This study of 103 fetuses or newborns with a diagnosis of OFCs (cases) and 103 healthy newborns without malformations (controls) examined whether prenatal exposure to OCPs, as indicated by their concentrations in placental tissue, is a risk factor for OFCs. No differences were found in the median concentrations of OCPs between cases and controls, with exception of o,p'-dichlorodiphenyldichloroethylene, o,p'-dichlorodiphenyldichloroethane, and total o,p'-dichlorodiphenyltrichloroethane (DDTs), whose concentrations were higher in controls than in cases (Ps < 0.05). Although higher concentrations of placental δhexachlorocyclohexane and isodrin were found to be associated with decreased risk for OFCs in logistic regression, no association was observed in the Bayesian kernel machine regression, a novel statistical model in analyzing exposure mixtures. Women who reported periconceptional folic acid supplementation had lower placental concentrations of DDTs than women who did not. In conclusion, no association between levels of OCPs in placental tissue and risk for OFCs was observed in this population. Supplementation with folic acid may help decrease the levels of DDTs in placental tissue, but further studies are needed to confirm this unexpected finding.

Traumatic injuries to the pregnant patient: a critical literature review.

INTRODUCTION: Trauma during pregnancy is the leading non-obstetrical cause of maternal death and a significant public health burden. This study reviews the most common causes of trauma during pregnancy, morbidity, and mortality, and the impact upon perinatal outcomes associated with trauma, providing a management approach to pregnant trauma patients. MATERIALS AND METHODS: A systematic review of the current literature from January 2006 to July 2016 was performed. RESULTS: Fifty-one articles were identified, including a total of 95,949 patients. Motor vehicle crash was the most frequent cause of blunt trauma, followed by falls, assault both domestic and interpersonal violence, and penetrating injuries (gunshot and stab wounds). CONCLUSIONS: Trauma in pregnant women is associated with high rates of adverse maternal and neonatal outcomes. Knowledge of the mechanism of injury is important to identify the potential injuries and the complexity of the management of these patients. As in all traumatic events, prevention is of paramount importance.

Implications of Prenatal Exposure to the Spring 2011 Alabama and Missouri Tornadoes on Birth Outcomes.

OBJECTIVE: Despite emerging evidence of the detrimental effects of natural disasters on maternal and child health, little is known about exposure to tornadoes during the prenatal period and its impact on birth outcomes. We examined the relationship between prenatal exposure to the spring 2011 tornado outbreak in Alabama and Joplin (Missouri) and adverse birth outcomes. METHODS: We conducted a retrospective, cross-sectional cohort study using the 2010-2012 linked infant births and deaths data set from the National Center for Health Statistics for tornado-affected counties in Alabama (n=126,453) and Missouri (Joplin, n=6,897). Chi-square and logistic regression analyses were performed to estimate associations between prenatal exposure to tornadoes and birth outcomes. RESULTS: Prenatal exposure to the tornado incidents did not influence birth weight outcomes. Women exposed to Alabama tornadoes were less likely to have a preterm birth compared to unexposed mothers (OR: 0.93, 95% CI: 0.91, 0.96). Preterm births among Joplin-tornado exposed mothers were slightly higher (13%) compared with unexposed mothers (11.2%). Exposed mothers from Joplin were also more likely to have a cesarean section compared to their counterparts (OR: 1.14, 95% CI: 1.02, 1.26). CONCLUSIONS: We found no association between tornado exposure and adverse birth weight and infant mortality rates. Our findings suggest that prenatal exposure can amplify the odds for a cesarean section. (Disaster Med Public Health Preparedness. 2019;13:279-286).

Risks of 23 specific malformations associated with prenatal exposure to 10 antiepileptic drugs.

OBJECTIVE: To assess the association between exposure to monotherapy with 10 different antiepileptic drugs (AEDs) during the first 2 months of pregnancy and the risk of 23 major congenital malformations (MCMs). METHODS: This nationwide cohort study, based on the French health care databases, included all pregnancies ≥20 weeks and ending between January 2011 and March 2015. Women were considered to be exposed when an AED had been dispensed between 1 month before and 2 months after the beginning of pregnancy. The reference group included pregnant women with no reimbursement for AEDs. MCMs were detected up to 12 months after birth (24 months for microcephaly, hypospadias, and epispadias). Odds ratios (ORs) were adjusted for potential confounders for MCMs with at least 5 cases. Otherwise, we calculated crude ORs with exact confidence intervals (CIs). RESULTS: The cohort included 1,886,825 pregnancies, 2,997 of which were exposed to lamotrigine, 1,671 to pregabalin, 980 to clonazepam, 913 to valproic acid, 579 to levetiracetam, 517 to topiramate, 512 to carbamazepine, 365 to gabapentin, 139 to oxcarbazepine, and 80 to phenobarbital. Exposure to valproic acid was associated with 8 specific types of MCMs (e.g., spina bifida, OR 19.4, 95% CI 8.6-43.5), and exposure to topiramate was associated with an increased risk of cleft lip (6.8, 95% CI 1.4-20.0). We identified 3 other signals. We found no significant association for lamotrigine, levetiracetam, carbamazepine, oxcarbazepine, and gabapentin. CONCLUSIONS: These results confirm the teratogenicity of valproic acid and topiramate. Because of the small numbers of cases and possible confounding, the other 3 signals should be interpreted with appropriate caution.

Variations in prenatal sociodemographic factors associated with intellectual disability: a study of the 20-year interval between two birth cohorts in northern Finland.

The authors followed two cohorts of children born in northern Finland in 1966 (n = 12,058) and 1985-1986 (n = 9,432) to examine whether associations between maternal sociodemographic factors assessed during pregnancy and intellectual disability in the offspring changed over a 20-year interval. Both of the cohorts were followed up to the age of 11.5 years using similar methods and definitions of intellectual disability. Data on sociodemographic factors were based on comparable questionnaires returned by the mothers during the 25th week of gestation. Despite an interval of 20 years between the cohorts, the main indicators of socioeconomic disadvantage and maternal multiparity remained as having the largest impact on the incidence of intellectual disability, while single factors such as older maternal age at delivery, being single, and living in a remote area lost their association with intellectual disability. Over 20 years, prepregnancy maternal obesity (body mass index > or =30) became a newly associated factor (adjusted odds ratio = 2.8, 95% confidence interval: 1.5, 5.3). A future challenge is to explore the mediating mechanisms between intellectual disability and its associated preventable intergenerational environmental or lifestyle factors.

[Analysis of prenatal abuse in catalonia between the years 2011 and 2014]. / Análisis del maltrato prenatal en Cataluña entre los años 2011 y 2014.

INTRODUCTION: Foetal abuse is that intentional or negligent act that causes a harmful effect to the foetus. It is a type of abuse difficult to diagnose and handle. Some indicators of suspicion are the absence of gestational control, the maternal consumption of toxic substances, or the problematic maternal social environment. OBJECTIVE: To analyse the cases of foetal abuse registered in Catalonia between 2011 and 2014 to identify the risk profile. METHODS: A cross-sectional descriptive study was conducted on a sample of 222 cases of prenatal abuse registered in Catalonia between 2011 and 2014. RESULTS: The mean maternal age was 28.11 years, with 63% of Spanish nationality, 76% were unemployed, 60% had not followed correct gestational control, 76% had previous pregnancy interruptions, 20% reported to have been mistreated by the partner, had history of social problems (76% social intervention, 30.5% previous child retention, 13% custody of the mother by the administration, 7% deprivation of liberty), with high rates of mother-to-child transmission of infection (HIV 4.95%, HCV 9%, HIV+HCV co-infection 1.8%), and 73% reported toxic use (in order of frequency, cannabis, cocaine and heroin). In newborns, the rate of prematurity (26.3%) is highlighted, as well as the diagnosis of withdrawal syndrome in 34 cases. Just over half (51.6%) of the infants are currently with their mother. CONCLUSIONS: In our reference population with a diagnosis of prenatal abuse, there are high rates of maternal toxic consumption, HIV-HCV infection, unemployment, history of previous social intervention, and poor gestational control.

Treatment of Autoimmune Bullous Disorders in Pregnancy.

Autoimmune bullous diseases (AIBD), including pemphigus, bullous pemphigoid, epidermolysis bullosa acquisita, mucous membrane pemphigoid, and pemphigoid gestationis, pose significant therapeutic challenges, especially in pregnant and post-partum breastfeeding patients or those planning to conceive. Data on the safety and efficacy of therapeutic interventions during the perinatal period are lacking because randomized controlled trials are typically not performed in this setting. However, many of the treatments for AIBD are also used in other diseases, so data can be extrapolated from studies or case reports in these other patient populations. It appears that many of the treatments for AIBD can adversely affect the fetus or neonate, and alterations in immune status caused by pregnancy-associated hormonal changes can negatively impact disease control. This article summarizes and weighs the risks and benefits of the various agents used to treat AIBD during pregnancy. We also present the available information on lactation as well as effects on male fertility.

Pregnant women in vehicles: Driving habits, position and risk of injury.

This study proposed to broadly examine vehicle use by pregnant women in order to improve realism of accident simulations involving these particular occupants. Three research pathways were developed: the first consisted in a questionnaire survey examining the driving habits of 135 pregnant women, the second obtained measurements of 15 pregnant women driving position in their own vehicle from the 6th to the 9th month of pregnancy by measuring distances between body parts and vehicle parts, and the third examined car accidents involving pregnant occupants. Results obtained indicate that between 90% and 100% of pregnant women wore their seat belts whatever their stage of pregnancy, although nearly one third of subjects considered the seat belt was dangerous for their unborn child. The measurements obtained also showed that the position of the pregnant woman in her vehicle, in relation to the various elements of the passenger compartment, changed significantly during pregnancy. In the studied accidents, no correlation was found between the conditions of the accident and the resulting fetal injury. Results reveal that pregnant women do not modify significantly the seat setting as a function of pregnancy stage. Only the distance between maternal abdomen and steering wheel change significantly, from 16 cm to 12 cm at 6 and 9 month respectively. Pregnant women are mainly drivers before 8 months of pregnancy, passengers after that. Car use frequency falls down rapidly from 6 to 9 months of pregnancy. Real crashes investigations indicate a low rate of casualties, i.e. 342 car accidents involving pregnant women for a period of 9 years in an approximately 1.7 million inhabitants area. No specific injury was found as a function of stage of pregnancy.

Obstetric and neonatal outcomes after antipsychotic medication exposure in pregnancy.

OBJECTIVE: Antipsychotic medications are used by increasing numbers of women of reproductive age. The safety of these medications during pregnancy has not been well described. We undertook a systematic review and meta-analysis of the adverse obstetric and neonatal outcomes associated with exposure to antipsychotics during pregnancy. DATA SOURCES: PubMed, Reprotox, and ClinicalTrials.gov were searched to identify potential studies for inclusion. METHODS OF STUDY SELECTION: Case-control or cohort studies estimating adverse birth outcomes associated with antipsychotic exposure during pregnancy were included. Pooled odds ratios (ORs) were used for dichotomous outcomes and weighted mean differences were used for neonatal birth weight and gestational age. Thirteen cohort studies, including 6,289 antipsychotic-exposed and 1,618,039 unexposed pregnancies, were included. TABULATION, INTEGRATION, AND RESULTS: Antipsychotic exposure was associated with an increased risk of major malformations (absolute risk difference [ARD] 0.03, 95% confidence interval [CI] 0.00-0.05, P=.04, Z=2.06), heart defects (ARD 0.01, 95% CI 0.00-0.01, P<.001, Z=3.44), preterm delivery (ARD 0.05, 95% CI 0.03-0.08, P<.001, Z=4.10), small-for-gestational-age births (ARD 0.05, 95% CI 0.02-0.09, P=.006, Z=2.74), elective termination (ARD 0.09, 95% CI 0.05-0.13, P<.001, Z=4.69), and decreased birth weight (weighted mean difference -57.89 g, 95% CI -103.69 to -12.10 g, P=.01). There was no significant difference in the risk of major malformations (test for subgroup differences: χ²=0.07, degrees of freedom=1, P=.79) between typical (OR 1.55, 95% CI 1.21-1.99, P=.006) and atypical (OR 1.39, 95% CI 0.66-2.93, P=.38) antipsychotic medications. Antipsychotic exposure was not associated with risk of large-for-gestational-age births, stillbirth, and spontaneous abortion. Although antipsychotic exposure during pregnancy was associated with increased risk of adverse obstetric and neonatal outcomes, this association does not necessarily imply causation. This analysis was limited by the small number of included studies and limited adjustment in studies for possible confounders. CONCLUSION: Women requiring antipsychotic treatment during pregnancy appear at higher risk of adverse birth outcomes, regardless of causation, and may benefit from close monitoring and minimization of other potential risk factors during pregnancy.

Trauma in pregnancy and its consequences in Kermanshah, Iran from 2007 to 2010.

OBJECTIVE: Nowadays, with decreased mortality of pregnant women by obstetrical causes, trauma has become a leading cause of morbidity and mortality in pregnant women. This study was carried out to determine the frequency of trauma in pregnancy and related causes and selected consequences in pregnant women of Kermanshah, Iran from 2007 to 2010. METHODS: In this descriptive-analytical study, all pregnant women who suffered trauma and were admitted to Imam Reza, Taleghani, and Motazedi hospitals located in Kermanshah from 2007-2010 were studied. Sampling was done by census method and medical records of all eligible patients were studied. Data analysis was done by the SPSS software for Windows 9ver. 16.0). RESULTS: There were 102 cases of trauma in pregnancy registered in this time period. Mean age of the cases was 26 years. Most cases (43%) were in their third trimester of pregnancy upon admission. Most trauma cases were of blunt traumas (68%). In 68 cases (66.67%), trauma resulted in maternal injury (independent of pregnancy) and 13 cases (12.75%) resulted in obstetrical or fetal injuries. Maternal injuries showed significant difference (P= 0.02) in different years. Motor vehicle accidents with a frequency of 47% were the most common cause of trauma. CONCLUSION: Trauma in pregnancy can be a leading cause of injury and fatality in mother and fetus. The most common type of injury was motor vehicle accidents. Therefore, any strategy that can decrease the rate of motor vehicle accident in a community can decrease mortalities of women (even pregnant or non-pregnant).

Prediction of the hazard of foetal malformation in pregnant women with epilepsy.

The data collected in the Australian Register of antiepileptic drugs in pregnancy have been studied in the hope of defining simple items of information that could be recorded at initial interview of pregnant women with epilepsy, and which might allow estimation of the risk of the pregnancy resulting in a malformed foetus. Analysis of the data showed that dose of valproate, but not intake of other commonly used antiepileptic drugs, in the current pregnancy, and a past history of a pregnancy involving a malformed foetus, statistically significantly increased the malformation hazard in the current pregnancy, and that continuing alcohol intake might decrease it. Plotting the hazard against valproate dose in monotherapy, with or without histories of (i) previous pregnancies with foetal malformations (FMs), and (ii) continuing alcohol intake, provided quantitative information concerning the degree of increased risk. It is hoped that this information may help in advising about the risk of foetal malformation (FM) in individual pregnancies.

Prenatal mercury exposure in a multicenter cohort study in Spain.

BACKGROUND: Mercury is a ubiquitous heavy metal that may negatively affect human health. It is desirable to investigate mercury exposure in vulnerable populations. OBJECTIVE: To determine the concentrations of total mercury (T-Hg) in cord blood and to evaluate the role of maternal fish consumption in a Spanish mother and child cohort. METHODS: A total of 1883 mother and child pairs from a population-based cohort were included between 2004 and 2008. T-Hg concentrations were measured in whole cord blood and maternal seafood consumption was ascertained by means of a food-frequency questionnaire. Linear regression was used in stratified analyses, while a joint model was adjusted using a mixed-effects linear model. RESULTS: Maternal daily seafood consumption was 78g/d and the geometric mean for T-Hg was 8.2µg/L. Maternal fish intake during pregnancy, mother's age, country of origin, educational level, employment status and parity, as well as area of study and season of delivery, were associated with cord blood T-Hg levels. A doubling in consumption of large oily fish was associated with an increase of 11.4% (95%CI: 3.8 to 19.6%) in cord blood T-Hg levels, followed by an increase of 8.4% (95%CI: 5.7 to 11.2%) in the case of canned tuna and 8.3% (95%CI: 5.5 to 11.1%) in that of lean fish. CONCLUSION: A high proportion of newborns had elevated concentrations of cord blood T-Hg according to the current US-EPA reference dose (5.8µg/L for methylmercury). Mercury concentrations were related to maternal fish consumption, with large oily fish being the main contributor.

Birth before arrival at a hospital in eastern Tokyo, Japan.

Delivery before arrival at a hospital did not cause major perinatal complications; however, it may reflect a serious problem of perinatal medicine in eastern Tokyo, Japan.

Pesticides and health risks.

Pesticides are a category of chemicals formulated to kill or repel a pest or halt its reproduction. In this article we review the toxicological and epidemiological literature; describe common potential pesticide exposures; and focus on the associated health risks to fetal development. Clinical implications are reviewed, and recommendations are made regarding the integration of this environmental health concern into nursing education, practice, research, and policy/advocacy work. Recommendations for pesticide elimination and reduction in health care settings are included.

Tocotraumatismo materno e fetal. Experiência de um hospital universitário nível III / Maternal and fetal birth injury: Experience in a tertiary referral university hospital

Introdução: Os tocotraumatismos maternos e fetais, por estarem diretamente vinculados à morbiletalidade, constituem tema importante na área perinatológica. Conhecer a real incidência desse evento torna-se importante para eventuais correções de condutas. O objetivo deste estudo foi identificar a prevalência e os tipos de tocotraumatismos materno e fetal na população usuária de um hospital universitário nível III. Métodos: Estudo de corte transversal, que envolveu gestantes no período de julho/2004 a dezembro/2005. Foram avaliadas variáveis maternas e neonatais. Utilizou-se o programa estatístico SPSS 16.0 para analisar as médias, desvios padrões e percentuais. Resultados: Em 2.137 nascimentos foram identificados 25 casos (1,2%) de tocotraumatismo fetal e 34 (1,6%) de tocotraumatismo materno. Dentre os tocotraumatismos fetais, a via de parto predominante foi a vaginal (88%) e a média da idade materna foi de 25,1±5,8 anos. O peso fetal médio foi de 3.366,4g±696,3g. As lesões leves foram as mais observadas (n=16; 64%). A fratura de clavícula foi o tocotraumatismo mais prevalente, seguido do céfalo-hematoma. Dentre os tocotraumatismos maternos, 33 nascimentos ocorreram via vaginal (97,1%) e a média da idade materna foi de 26,6±7,1 anos. O peso fetal médio foi de 3.152,9g ± 507,8g. As lesões mais observadas foram as de fúrcula vaginal (n=19; 55,9%). Conclusão: Dentre os casos de tocotraumatismo fetal (1,2%), as lesões do tipo leve e superficial foram as mais observadas, prevalecendo a fratura de clavícula. Dentre os casos de tocotraumatismos maternos (1,6%), as lacerações do 1.o e 2.o graus foram as mais prevalentes

Introduction: Because the maternal and fetal birth injuries are directly linked to morbidity/mortality, they are a major theme in the perinatal field. To get to know the real incidence of such events becomes important in order to correct any misconducts. The aim of this study was to determine the prevalence and the types of maternal and fetal birth injuries in the population cared for at a tertiary referral university hospital. Methods: A cross-sectional study involving pregnant women in the Jul/2004-Dec/2005 period. Maternal and neonatal variables were evaluated. Statistical software SPSS 16.0 was used in the analysis of means, standard deviations, and percentages. Results: Of 2.137 births, 25 cases (1.2%) of fetal and 34 (1.6%) cases of maternal birth injuries were reported. Among the fetal birth injuries, vaginal childbirth was the prevailing route of delivery (88%) and the mean maternal age was 25.1±5.8 years. The mean birth weight was 3.366.4g±696.3g. Minor lesions were the most prevalent ones (n=16; 64%). Fracture of the clavicle was the commonest injury, followed by cephalhematoma. Among the maternal birth injuries, 33 were through vaginal childbirth (97.1%) and the mean maternal age was 26.6±7.1 years. The mean birth weight was 3.152.9g±507.8g. The commonest injuries were those to the vaginal furcula (n=19; 55.9%). Conclusion: Among the cases of fetal birth injury (1.2%), minor, superficial lesions were the most frequent ones, with fracture of the clavicle prevailing. Among the maternal birth injuries (1.6%), 1st and 2nd degree lacerations were the most prevalent