More Bad News for Valproate in Pregnancy

Use of valproic acid during pregnancy is associated with twice the risk for autism spectrum disorder (ASD) as well as a twofold increased risk for attention-deficit/hyperactivity disorder (ADHD) in offspring, the largest study of its kind to date has found.

Compared to previous research, this new study included a larger sample and longer follow-up and adjusted for important confounders other studies didn’t consider, including parental diagnosis, especially in fathers, and severity of maternal epilepsy.

After adjusting for these factors, the investigators found that among children of mothers who took lamotrigine, another antiseizure medication (ASM), during pregnancy, there was no significant increased risk of developing either autism or ADHD.



Kelsey Wiggs

Although the findings regarding valproate, a first-line treatment for generalized epilepsy, “may be disheartening,” it’s important to remember that lamotrigine “is considered to be almost as effective,” lead author Kelsey K. Wiggs, BS, a doctoral candidate in the Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana, told Medscape Medical News.

“If women are planning to become pregnant, it may be useful to consider lamotrigine as an alternative,” she said.

The study was published online October 28 in Neurology.

Registry Study

The study included 14,614 children born to women with epilepsy between January 1, 1996, and December 31, 2011, and who were followed to December 31, 2013.

About 23% of the women in the study used an ASM during the first trimester. Although use of such medications was determined on the basis of maternal reports, researchers cross-referenced this against filled prescriptions.

The most commonly used ASMs were carbamazepine (10%), lamotrigine (7%), and valproic acid (5%).

The researchers used linked Swedish national registries to investigate the association between use of ASM during early pregnancy and autism, diagnosed by a specialist, or ADHD, diagnosed by a specialist or through filled prescriptions for stimulant medication.

For both outcomes, the researchers only considered diagnoses made after 2 years of age.

Among other things, the researchers adjusted for maternal and paternal factors, such as psychiatric diagnoses, and maternal use of other medications during pregnancy, including antidepressants, anxiolytics, antipsychotics, mood stabilizers, and pain medication.

“I think this was an important part of our study,” said Wiggs. “We wanted to be sure to isolate the association with each specific antiseizure medication, independent of potential confounding or interactions with other medications.”

After adjustments, results showed that children whose mothers reported taking any ASM were at elevated risk for ASD and, to a lesser extent, ADHD, compared to those whose mothers did not take any antiseizure medications during pregnancy.

Restricting the analysis to children born to women who reported monotherapy, the hazard ratio (HR) for ASD was 1.52 (95% CI, 1.12 – 2.07); for ADHD, the HR was 1.27 (95% CI, 1.02 – 1.58).

Birth Defects, Complications

In the fully adjusted comparison that was restricted to monotherapy, children whose mothers reported use of valproic acid had a 2.3-fold elevated risk for ASD (HR, 2.30; 95% CI, 1.53 – 3.47) and a 1.7-fold elevated risk for ADHD (HR,

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‘Cardio-obstetrics’ Tied to Better Outcome in Pregnancy With CVD

A multidisciplinary cardio-obstetrics team-based care model may help improve cardiovascular care for pregnant women with cardiovascular disease (CVD), according to a recent study.

“We sought to describe clinical characteristics, maternal and fetal outcomes, and cardiovascular readmissions in a cohort of pregnant women with underlying CVD followed by a cardio-obstetrics team,” wrote Ella Magun, MD, of Columbia University, New York, and coauthors. Their report is in the Journal of the American College of Cardiology.

The researchers reported the outcomes of a retrospective cohort analysis involving 306 pregnant women with CVD, who were treated at a quaternary care hospital in New York City.

They defined cardio-obstetrics as a team-based collaborative approach to maternal care that includes maternal fetal medicine, cardiology, anesthesiology, neonatology, nursing, social work, and pharmacy.

More than half of the women in the cohort (53%) were Hispanic and Latino, and 74% were receiving Medicaid, suggesting low socioeconomic status. Key outcomes of interest were cardiovascular readmissions at 30 days, 90 days, and 1 year. Secondary endpoints included maternal death, need for a left ventricular assist device or heart transplantation, and fetal demise.

The most frequently observed forms of CVD were arrhythmias (29%), cardiomyopathy (24%), congenital heart disease (24%), valvular disease (16%), and coronary artery disease (4%). The median Cardiac Disease in Pregnancy (CARPREG II) score was 3, and 43% of women had a CARPREG II score of 4 or higher.

After a median follow-up of 2.6 years, the 30-day and 90-day cardiovascular readmission rates were 1.9% and 4.6%, which was lower than the national 30-day postpartum rate of readmission (3.6%). One maternal death (0.3%) occurred within a year of delivery (woman with Eisenmenger syndrome).

“Despite high CARPREG II scores in this patient population, we found low rates of maternal and fetal complications with a low rate of 30- and 90-day readmissions following delivery,” the researchers wrote.

Experts Weigh In

“We’re seeing widely increasing interest in the implementation of cardio-obstetrics models for multidisciplinary collaborative care and initial studies suggest these team-based models improve pregnancy and postpartum outcomes for women with cardiac disease,” said Lisa M. Hollier, MD, past president of the American College of Obstetricians and Gynecologists and professor at Baylor College of Medicine in Houston.

Magun and colleagues acknowledged that a key limitation of the present study was the retrospective, single-center design.

“With program expansions over the next 2-3 years, I expect to see an increasing number of prospective studies with larger sample sizes evaluating the impact of cardio-obstetrics teams on maternal morbidity and mortality,” Hollier said.

“These findings suggest that our cardio-obstetrics program may help provide improved cardiovascular care to an otherwise underserved population,” the authors concluded.

In an editorial accompanying the reports, Pamela Ouyang, MBBS, and Garima Sharma, MD, wrote that, although this study wasn’t designed to assess the benefit of cardio-obstetric teams relative to standard of care, its implementation of a multidisciplinary team-based care model showed excellent long-term outcomes.

The importance of coordinated postpartum follow-up with both cardiologists and obstetricians is becoming increasingly recognized, especially for women with

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Epilepsy Meds During Pregnancy May Raise Autism Risk in Child | Health News

By Serena Gordon HealthDay Reporter

(HealthDay)

FRIDAY, Oct. 30, 2020 (HealthDay News) — Women who take the epilepsy medication valproic acid during pregnancy have more than twice the risk of having a child with autism, new research suggests.

The study also found that taking the drug during pregnancy almost doubled the odds that a child would have attention-deficit/hyperactivity disorder (ADHD), compared to children who weren’t exposed to the drug during pregnancy.

“These women are in a bind. Valproic acid is a first-line drug for epilepsy, and having uncontrolled epilepsy is also a risk to mom and baby. We’re not trying to point a finger at valproic acid, but we did see these associations,” said study author Kelsey Wiggs. She’s a doctoral candidate in the department of psychological and brain sciences at Indiana University in Bloomington.

Wiggs noted that the study wasn’t designed to prove cause-and-effect relationships, only associations.

She added that the study is important because of the associations it didn’t find, as well.

“We didn’t find an association with the antiseizure medications lamotrigine and carbamazepine,” Wiggs said.

Between three and seven women out of every 1,000 pregnant women have epilepsy — a seizure disorder. The main treatment for epilepsy is antiseizure medications, according to background information in the study. But valproic acid has been linked to a higher risk of birth defects and lower cognitive test scores (IQ and other tests), according to the U.S. Food and Drug Administration.

The drug has also been associated with a higher risk of ADHD and autism in smaller studies, the researchers noted.

The latest study included nearly 15,000 children who were born to women with epilepsy between 1996 and 2011. Nearly one in four of the mothers took antiseizure medication during their first trimester of pregnancy.

About 10% of the women took carbamazepine and 7% took the medication lamotrigine. Five percent of the women took valproic acid (699 children).

Of those who were exposed to valproic acid in pregnancy, 36 developed autism by the age of 10. There were just over 11,000 kids who weren’t exposed to any antiseizure medication. Just 154 of them were diagnosed with autism.

Fifty-four of the kids exposed to valproic acid developed ADHD by 10. In those with no exposure to the drugs, 251 out of 11,000 were diagnosed with ADHD, the study authors said.

Wiggs said it’s not clear how valproic acid exposure might trigger autism or ADHD. She said that the medication is associated with the increased metabolism of the nutrient folate. Folate is important in the development of nervous system cells, so it’s possible that may play a role.

Dr. Steven Pacia, vice chair of neurology at North Shore University Hospital in Manhasset, N.Y., said that folate might be one factor, but he suspects there are likely multiple reasons why this medication is associated with higher rates of autism and ADHD.

Pacia said this study is the largest to link valproic acid to autism and ADHD, but that the drug was already known to

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Aussie fitness influencer Steph Claire Smith announces pregnancy

Lifestyle

The couple tied the knot in December last year. Photo / Instagram

Melbourne model and fitness entrepreneur Steph Claire Smith has taken to Instagram to reveal she is expecting her first child with hubby Josh Miller.

The 25-year-old shared an adorable snap of herself in a fitted white dress as Josh could be seen kissing her exposed belly.

“Mini Miller due April 2021,” she captioned with post, alongside a baby and love-heart emoji.

“We are absolutely overjoyed, grateful and love the journey so far.”

The mega influencer, who has an Instagram following of 1.5 million, runs the health and wellness business Keep It Cleaner (KIC) with best friend and fellow model Laura Henshaw.

The duo have a reinvented the online fitness space with their at-home workouts, tips, advice and nutritional programs.

Since posting the exciting news on Wednesday evening, Steph’s post has already amassed nearly 100,000 likes and more than 4,000 comments.

A clearly excited Laura left several “crying” emojis, indicating tears of happiness for her long-time friend and business partner.

Others have bombarded her post leaving messages of congratulations and well wishes.

“BEYOND EXCITED FOR YOU BOTH.. YOU’RE GOING TO MAKE THE BEST PARENTS,” wellness influencer and “meal prep queen” Lady Lolas wrote.

“OH MY GOODNESS. Congratulations Steph and Josh,” another follower added.

“Omfg guys!!!! GUYS!!! I am so excited for you! Congratulations to you both!” wrote a third.

Steph began to gain fame online in 2013 when workout content she posted on Instagram started getting reported by “fitness inspo” Tumblrs and blogs around the world.

Her burgeoning online fanbase is now creeping towards the 2 million follower mark following the success of KIC.

In December last year, the fitness guru tied the knot to childhood sweetheart Josh and wasted no time changing her surname to match his on her Instagram

She shared photos of her stunning wedding with her 1.5 million followers who were in awe of her bridal gown.

She donned a crop top with a full skirt, completely shunning a traditional bridal look to put her killer abs on full display.

Steph’s “dream” dress was designed by One Day Bridal before she changed into a more casual number, teamed with white sneakers.

Both Steph and Josh are overjoyed to be welcoming their first child together early next year.

“Our little family is getting a little bigger soon. We are so excited to meet you little one!” Josh wrote on Instagram, alongside a snap of himself, Steph and their little pup.

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First Response Pregnancy Test Survey Reveals Women Are Putting Off Having Children Due to Increased Uncertainty During COVID-19

OB/GYN Mary Jane Minkin, M.D. offers advice to address pregnancy anxieties

According to a new First Response survey about the current family planning goals of 3,000 US women aged 18-35, nearly 20% say they’re uncertain of their trying to conceive (TTC) plans while 38% are intentionally putting off conceiving during the pandemic due to anxiety and stress. Mary Jane Minkin, Clinical Professor of Obstetrics & Gynecology at Yale Medical School tells women to follow simple safety measures when considering getting pregnant during this unprecedented time.

“Women are understandably facing a lot of anxiety when considering their family planning journey and many are waiting for a vaccine before starting or growing their family,” says Minkin. “However, if the time is right to have a baby, go ahead and book an appointment with a medical provider, take extra precautions, utilize telehealth appointments, and implement precautions based on the advice from healthcare providers.”

Dr. Minkin offers the following advice to address pregnancy related anxieties:

  1. Book a preconception appointment. OB-GYN’s, doctors, and nurse practitioners are available via phone and in person to answer all questions and health concerns. If you need help finding a healthcare provider, contact your nearest hospital clinic, community health center external icon, or health department. Medical visits can also be handled virtually by scheduling a telehealth appointment, which can be helpful to address any questions you may have.

  2. When unsure, take a pregnancy test. Stress and anxiety can trigger symptoms that mimic those of pregnancy, like morning sickness, food cravings, mood swings, and fatigue – so the best way to know if pregnant is to use a reliable pregnancy test like First Response Early Result so you don’t need to leave the house until COVID-19 settles down. A test can be revealing up to six days before a missed period. Be sure to call your doctor right away if the test is positive to put a proper plan of action in place.

  3. Be wary of listening to friends or relying on Dr. Google. While the experiences of others or the internet can hold insights, when it comes to making important personal health decisions make sure to consult a medical professional to confirm whether what you’ve been told or read is really true. Other reliable online sources include ACOG.org, CDC.gov, and WHO.int.

  4. Stay current on all vaccines. Pregnancy can alter the immune system and lead to an increased risk of respiratory infections. A flu shot can help mom and baby by causing the body to create protective antibodies (proteins produced by the body to fight off diseases.) The whooping cough (Tdap) vaccine will help protect your baby against whooping cough, which can mimic symptoms of COVID-19.

  5. Maintain overall health. Make sure to have at least a 30-day supply of the medicines you need on hand, stop smoking, eat healthy foods and supplement with folic acid. Try an easy to take pre-natal vitamin like the vitafusion gummy vitamin. It is also important to avoid alcohol and limit caffeine intake

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New guidelines address rise in opioid use during pregnancy

Opioid use in pregnancy has prompted new guidance from the American Academy of Pediatrics, aimed at improving care for women and newborns affected by their mothers’ drug use.

The number of affected women and infants has increased in recent years but they often don’t get effective treatment, and the pandemic may be worsening that problem, said Dr. Stephen Patrick, lead author of the academy report released Monday.

“While we have been talking about the opioid crisis for years, pregnant women and their newborns seldom make it to the top of the heap. Infants are receiving variable care and not getting connected to services,” said Patrick, a Vanderbilt University pediatrician.


The academy’s report says pregnant women should have access to opioid medication to treat opioid misuse. Two opioids, buprenorphine and methadone, are effective treatments but pregnant women often face stigma in using them and doctors who prescribe them are scarce.

The academy says hospitals should written protocols for assessing and treating opioid-affected newborns. Many don’t and practices vary widely.

Breastfeeding and other practices that promote bonding should be encouraged, and parent education and referral to services for affected newborns should be provided, the academy says. Its recommendations echo guidance from other medical groups and the U.S. government.

“This is a substantial public health problem that is still lacking solutions,” Patrick said.

According to the federal Centers for Disease Control and Prevention, 7% of U.S. women reported in 2019 that they had used prescription opioids during pregnancy. One in 5 of those women reported misusing the drugs while pregnant.

Some infants born to these women develop symptoms of opioid withdrawal, including tremors, fussiness and diarrhea.

By some U.S. estimates, nearly 80 affected infants are diagnosed every day on and the numbers have tripled in recent years.

Patrick has done research suggesting that these infants may be at risk for developmental delays, but says it’s possible those findings reflect use of alcohol or other drugs during pregnancy, poor prenatal care or stress.

“Getting into treatment may be getting even harder” because of the pandemic, he said. “There’s so much going on in the world that that issues involving opioid use are flying under the radar.”

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Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

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Heart Conditions Could Raise Risk of Torn Aorta During Pregnancy | Health News

By Robert Preidt, HealthDay Reporter

(HealthDay)

THURSDAY, Oct. 22, 2020 (HealthDay News) — Pregnancy can increase the risk of a rare, dangerous heart condition called aortic dissection, researchers report.

This is especially true for women with underlying heart conditions that can go undetected.

Aortic dissections — which affect 3 in 100,000 people per year — cause the layers of the aorta to tear, and blood to pool or leak instead of flow normally. Patients require lifesaving care.

Researchers analyzed data from 29 women who were unexpectedly hospitalized for aortic dissection while pregnant. Most already had a heart condition that hadn’t been diagnosed in many cases.

Aortic diseases and conditions such as Marfan syndrome or Loeys-Dietz syndrome are often found in women who have an aortic dissection while pregnant, the researchers said. But they added that high blood pressure, the most common risk factor in the general population, may also be a factor.

The researchers found that 19% of aortic dissections in women younger than 35 were associated with pregnancy. That means a woman already predisposed to have a dissection is more likely to have one during pregnancy, possibly due to hormones and changes to the body during pregnancy and postpartum.

Women in the study had aortic dissections in all three trimesters of pregnancy, as well as within three months after giving birth, but most cases occurred in the latter part of pregnancy and immediately after.

Pre-pregnancy care for a woman with known aortic disease would include evaluation of maternal and fetal risk, counseling and possible genetic testing, followed by ongoing monitoring and testing, study co-author Dr. Melinda Davis, a cardio-obstetrics expert at University of Michigan Medicine, said in a university news release.

Aortic dissection is most often seen in older men, but this study shows the importance of careful monitoring of heart conditions during pregnancy, according to Davis and her colleagues.

The study was published online Oct. 14 in the journal JAMA Cardiology.

Copyright © 2020 HealthDay. All rights reserved.

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Depression in Pregnancy May Raise Risk of Childhood Asthma

A mother’s psychological distress during pregnancy may increase the risk for asthma in her child, a new study suggests.

Researchers had the parents of 4,231 children fill out well-validated questionnaires on psychological stress in the second trimester of pregnancy, and again three years later. The mothers also completed questionnaires at two and six months after giving birth. The study, in the journal Thorax, found that 362 of the mothers and 167 of the fathers had clinically significant psychological distress during the mothers’ pregnancies.

When the children were 10 years old, parents reported whether their child had ever been diagnosed with asthma. As an extra measure, the researchers tested the children using forced expiratory volume, or FEV, a standard clinical test of lung function.

After controlling for age, smoking during pregnancy, body mass index, a history of asthma and other factors, they found that maternal depression and anxiety during pregnancy was significantly associated with both diagnoses of asthma and poorer lung function in their children. There was no association between childhood asthma and parents’ psychological distress in the years after pregnancy, and no association with paternal psychological stress at any time.

“Of course, this could be only one of many causes of asthma,” said the lead author, Dr. Evelien R. van Meel of Erasmus University in Rotterdam, “but we corrected for many confounders, and we saw the effect only in mothers. This seems to suggest that there’s something going on in the uterus. But this is an observational study, and we can’t say that it’s a causal effect.”

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Pregnancy care is dangerously distant for women in maternity care ‘deserts’ | Health care/Hospitals

Each week, Ashley Landreneau, a mom of two with another little one on the way, jumps in her car and heads to her doctor’s office in Lafayette.

The 33-year-old salon owner gets a regular weekly ultrasound because a history of seven previous miscarriages means her pregnancy is considered high risk.

And while everything has gone smoothly 19 weeks into her the current pregnancy, what makes it more dangerous is how far she has to trek. From her home in Bayou Chicot, the trip to her doctor’s office is an hour away.

“With my experience and everything I’ve been through, I can’t see just anyone,” said Landreneau. “The closest hospital to me is 45 minutes away. There’s not a specialist there that can deliver. There’s no NICU.”

When Elizabeth O’Brien Brown found out she was pregnant, she knew it would be expensive. So she chose a hospital in her insurance network and …

Louisiana has among the highest rate of death for pregnant women in the U.S. One of the reasons, according to new research, is the lack of maternal care in many areas of the state, which forces women to travel long distances for routine checkups, emergency visits and deliveries.

Twenty-two parishes in the state are without a hospital offering obstetric care, a birth center or any OB/GYNs or certified nurse-midwives, according to an analysis of 2018 federal workforce data released last month by the March of Dimes, a national nonprofit focused on improving health care for mothers and their babies.

In Evangeline Parish, where Landreneau lives, there is just a single OB/GYN in a population of over 33,000 people. That puts the parish among the 35 out of Louisiana’s 64 parishes that have little to no access to maternal care, according to the report.

Due to that scarcity, researchers estimate that one in four pregnant women in Louisiana may need to travel outside of their parish for the many appointments necessary to monitor a pregnancy: ultrasounds, blood tests, glucose screenings, specialist appointments and delivery.

Dr. Rahul Gupta, the nonprofit’s chief medical officer, said that the inconveniences of distance can make it hard for expectant mothers to get the care needed to keep them healthy.

“Transportation becomes an issue,” said Dr. Gupta. “Time becomes an issue, it becomes a money issue. You have to take a day off, go and wait in a practitioner’s office. A lot of times pregnant people have other kids they need to take care of. They have to then find child care. These things accumulate in maternity care deserts.”

According to a study published in the journal Women’s Health Issues last week, a lack of nearby providers is impacting the state’s maternal mortality rate, which was the worst in the country in 2019.



Pregnancy during pandemic: How providers are rewriting birthing care standards amid coronavirus

At this point, the medical procedure that Lacy Smith has scheduled for Friday at Ochsner Medical Center in New Orleans could hardly be put off…

Study author and Tulane University epidemiologist Maeve Wallace compared the geographic data from the March

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Let’s Talk About Constipation During Pregnancy

Constipation may be two to three times more common during and after pregnancy, Finnish researchers report.

The scientists studied 877 women having babies, comparing them with 201 nonpregnant controls of the same age. They rated the women on the Rome IV criteria for diagnosing constipation, which considers five symptoms, including the amount of straining at stool, sensations of incomplete defecation, the necessity of manual maneuvering required to defecate, the firmness of stool and the frequency of bowel movements. The study is in BJOG.

Based on these criteria, 21 percent of the controls had constipation, compared with 40 percent of pregnant women and 52 percent of postpartum women. About 44 percent of women had constipation in the second trimester, and 36 percent in the third trimester. Fifty-seven percent of women who gave birth by C-section and 47 percent of those who gave birth vaginally were constipated at least for a few days afterward, but at one month postpartum, rates differed little from controls.

“For pregnant women, I would suggest that they talk about this symptom frankly,” said the senior author, Dr. Merja Kokki, an anesthesiologist at the University of Eastern Finland. “It’s more common in pregnancy than nausea and vomiting, which are always openly discussed. It’s a big problem that can cause difficult symptoms later in life — pelvic floor problems, uterine prolapse, urinary problems. These are things that can impair the quality of life.”

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