Pregnancy outcome following in utero exposure to lithium: a prospective, comparative, observational study.

OBJECTIVE: The authors conducted a prospective, comparative observational study to evaluate the risk of major anomalies following exposure to lithium during pregnancy. METHOD: A total of 183 lithium-exposed pregnancies of women who contacted the Israeli Teratology Information Service were followed up (90.2% in the first trimester) and compared with 72 disease-matched and 748 nonteratogenic-exposed pregnancies. RESULTS: There were significantly more miscarriages (adjusted odds ratio=1.94, 95% CI=1.08-3.48) and elective terminations of pregnancy (17/183 [9.3%] compared with 15/748 [2.0%]) in the lithium-exposed group compared with the nonteratogenic exposure group. The rate of major congenital anomalies after exclusion of genetic or cytogenetic anomalies was not significantly different between the three groups (lithium-exposed in the first trimester: 8/123 [6.5%]; bipolar: 2/61 [3.3%]; nonteratogenic: 19/711 [2.7%]). Cardiovascular anomalies occurred more frequently in the lithium group exposed during the first trimester when compared with the nonteratogenic exposure group (5/123 [4.1%] compared with 4/711 [0.6%]) but not after excluding anomalies that spontaneously resolved (3/123 [2.4%] compared with 2/711 [0.3%]). Ebstein's anomaly was diagnosed in one lithium-exposed fetus and in two retrospective lithium cases that were not included because contact with the information service was made after the prenatal diagnosis by ultrasound. The rate of noncardiovascular anomalies was not significantly different between the groups. The rate of preterm deliveries was higher in the lithium group compared with the nonteratogenic exposure group (18/131 [13.7%] compared with 41/683 [6.0%]). CONCLUSIONS: Lithium treatment in pregnancy is associated with a higher rate of cardiovascular anomalies. Women who are treated with lithium during organogenesis should undergo fetal echocardiography and level-2 ultrasound.

Treating constipation during pregnancy.

QUESTION: Many of my patients experience constipation during pregnancy, even after increasing dietary fibre and fluids. Are there any safe treatments I can recommend to them? ANSWER: Although the recommended first-line therapy for constipation includes increasing fibre, fluids, and exercise, these are sometimes ineffective. Therefore, laxatives such as bulk-forming agents, lubricant laxatives, stool softeners, osmotic laxatives, and stimulant laxatives might be considered. Although few of the various types of laxatives have been assessed for safety in pregnancy, they have minimal systemic absorption. Therefore, they are not expected to be associated with an increased risk of congenital anomalies. However, it is recommended that osmotic and stimulant laxatives be used only in the short term or occasionally to avoid dehydration or electrolyte imbalances in pregnant women.

Outcome following high-dose methotrexate in pregnancies misdiagnosed as ectopic.

OBJECTIVE: The objective of this study was to report the outcomes of intrauterine pregnancies misdiagnosed as ectopic and exposed to methotrexate, a major teratogen. STUDY DESIGN: We report the outcomes of all subjects who sought consultation after exposure to high-dose methotrexate to induce abortion in presumed ectopic pregnancies, which were later identified as viable intrauterine pregnancies by 3 North American Teratology Information Services between 2002 and 2010. RESULTS: Eight women with normal, desired pregnancies were administered high-dose methotrexate in the first trimester because of presumed, misdiagnosed ectopic pregnancies. All pregnancies resulted in catastrophic outcomes. Two pregnancies resulted in severely malformed newborns with methotrexate embryopathy; 3 women miscarried shortly after exposure, and in 3 the erroneous diagnosis led the physicians to advise and perform surgical termination. CONCLUSION: Erroneous diagnosis of intrauterine pregnancies as ectopic with subsequent first-trimester exposure to methotrexate may result in the birth of severely malformed babies or fetal demise.

Food-borne illnesses during pregnancy: prevention and treatment.

QUESTION: After hearing about outbreaks of illness resulting from Listeria and Salmonella, many of my patients are wondering about the risks of food-borne illnesses during pregnancy and what they can do to reduce their chances of contracting them. ANSWER: Although heating or cooking food is the best way to inactivate food-borne pathogens, improved standards and surveillance have reduced the prevalence of contaminated foods at grocery stores. Therefore, it is no longer necessary for pregnant women to avoid foods like deli meats and soft cheeses (associated with Listeria); soft-cooked eggs (associated with Salmonella); or sushi and sashimi. Regardless of whether seafood is raw or cooked, pregnant women should choose low mercury seafood (eg, salmon and shrimp) over higher mercury varieties (eg, fresh tuna). Pregnant women should ensure that their food is obtained from reputable establishments; stored, handled, and cooked properly; and consumed within a couple of days of purchasing.

Treating the common cold during pregnancy.

QUESTION: Many of my pregnant patients inquire as to what medication they can use when they experience symptoms of the common cold, such as cough, congestion, sneezing, and fever. I am hesitant to recommend over-the-counter cold remedies because I have heard conflicting information regarding the safety of these products. What is known about the safety of cold medications during pregnancy? ANSWER: Although there are many over-the-counter brands of cold medications, most products are quite similar, with some containing up to 5 medicinal ingredients. The evidence-based information for all these ingredients suggests no increased risk with short-term use. However, pregnant women should read labels carefully and, when necessary, consult with pharmacists to ensure they are not taking medicine they do not require.