NSIDRC Journal Article Alert — November
23, 2007
Prepared by the National Sudden Infant Death Resource Center
at Georgetown University.
This journal article alert provides selected items added to
the National Library of Medicine’s PubMed database in
the last week.
Past issues of NSIDRC journal alerts are available at http://www.sidscenter.org.
Availability of full-text journal articles is usually limited
to subscribers or through inter-library loan. Please
see your local library for copies of these articles.
1: Frazier LM.
Reproductive disorders associated with pesticide exposure.
J Agromedicine. 2007;12(1):27-37
1010 N Kansas Ave, Wichita, KS, 67214.
Exposure of men or women to certain pesticides at sufficient
doses may increase the risk for sperm abnormalities, decreased
fertility, a deficit of male children, spontaneous abortion,
birth defects or fetal growth retardation. Pesticides from
workplace or environmental exposures enter breast milk. Certain
pesticides have been linked to developmental neurobehavioral
problems, altered function of immune cells and possibly childhood
leukemia. In well-designed epidemiologic studies, adverse reproductive
or developmental effects have been associated with mixed pesticide
exposure in occupational settings, particularly when personal
protective equipment is not used. Every class of pesticides
has at least one agent capable of affecting a reproductive
or developmental endpoint in laboratory animals or people,
including organophosphates, carbamates, pyrethroids, herbicides,
fungicides, fumigants and especially organochlorines. Many
of the most toxic pesticides have been banned or restricted
in developed nations, but high exposures to these agents are
still occurring in the most impoverished countries around the
globe. Protective clothing, masks and gloves are more difficult
to tolerate in hot, humid weather, or may be unavailable or
unaffordable. Counseling patients who are concerned about reproductive
and developmental effects of pesticides often involves helping
them assess their exposure levels, weigh risks and benefits,
and adopt practices to reduce or eliminate their absorbed dose.
Patients may not realize that by the first prenatal care visit,
most disruptions of organogenesis have already occurred. Planning
ahead provides the best chance of lowering risk from pesticides
and remediating other risk factors before conception.
2: Isaacs H Jr.
Fetal and neonatal hepatic tumors.
J Pediatr Surg. 2007 Nov;42(11):1797-803.
Department of Pathology, Rady Children's Hospital San Diego,
San Diego, CA, USA; Department of Pathology, University of
California San Diego School of Medicine, La Jolla, CA, USA.
BACKGROUND/PURPOSE: Although hepatic tumors are uncommon in
the perinatal period they are associated with significant morbidity
and mortality in affected patients. The purpose of this review
is to focus on the fetus and neonate in an attempt to determine
the various ways liver tumors differ clinically and pathologically
from those found in the older child and adult and to show that
certain types of tumors have a better prognosis than others.
METHODS: The author conducted a retrospective review of perinatal
hepatic tumors reported in the literature and of patients treated
and followed up at Children's Hospital San Diego and Children's
Hospital Los Angeles. Only fetuses and infants younger than
2 months with adequate clinical and pathologic data ere accepted
for review. The period of patient accrual was from 1970 to
2005. Length of follow-up varied from 1 week to more than 5
years. Elevated alpha-fetoprotein level was defined as one
significantly higher than that of the reporting institution's
normal level for age group; laboratory values for this protein
vary from one institution to the next and therefore it was
not possible to assign one figure as a standard reference number.
Discussion of the differential diagnosis and pathologic findings
of hepatic tumors in the fetus and neonate are described elsewhere
and will not be discussed here in detail (Perspect Pediatr
Pathol 1978;4:217; Weinberg AG, Finegold MJ. Primary hepatic
tumors in childhood. In: Finegold M, editor. Pathology of neoplasia
in children and adolescents. Philadelphia, PA: WB Saunders,
1986; Am J Surg Pathol 1982;6:693; Pediatr Pathol 1983;1:245;
Arch Surg 1990;125:598; Semin Neonatol 2003;8:403; Pediatr
Pathol 1985;3:165; Isaacs H Jr. Liver tumors. In: Isaacs H
Jr, editor. Tumors of the fetus and newborn. Philadelphia,
PA: WB Saunders, 1997; Isaacs H Jr. Liver tumors. In: Isaacs
H Jr, editor. Tumors of the fetus and infant: an atlas. Philadelphia,
PA: WB Saunders, 2002). RESULTS: One hundred ninety-four fetuses
and neonates presented with hepatic tumors diagnosed prenatally
(n = 56) and in the neonatal period (n = 138). The study consisted
of 3 main tumors: hemangioma (117 cases, 60.3%), mesenchymal
hamartoma (45 cases, 23.2%), and hepatoblastoma (32 cases,
16.5%). The most common initial finding was a mass found either
by antenatal sonography or by physical examination during the
neonatal period. Overall, hydramnios was next followed by fetal
hydrops, respiratory distress, and congestive heart failure,
which were often related to the cause of death. Half of the
fetuses and neonates with hepatoblastoma had abnormally elevated
serum alpha-fetoprotein levels compared with 16 (14%) of 117
of those with hemangioma and 1 neonate with mesenchymal hamartoma.
There were 76 (65%) examples of solitary (unifocal) hemangiomas
and 41 (35%) of multifocal (which included the entity diffuse
hemangiomatosis) with 86% and 71% survival rates, respectively.
Of 45 patients with mesenchymal hamartoma, of the 29 (64%)
who had surgical resections, 23 (79%) survived. Patients with
hepatoblastoma had the worst outcome of the group, for only
8 (25%) of 32 were alive. Half of patients with either stage
1 or 3 hepatoblastoma died; no patient with stage 4 survived.
There was some relationship between histologic type and prognosis.
For example, half of the patients with the pure fetal hepatoblastoma
histology survived compared with those with fetal and embryonal
histology where 30% survived. Fifteen of 32 hepatoblastoma
patients received surgical resection with or without chemotherapy,
resulting in 7 (47%) of 15 cures. The 56 fetuses and 138 neonates
with hepatic tumors (hemangioma, mesenchymal hamartoma, and
hepatoblastoma) had survival rates of 75%, 64%, and 25%, respectively.
The overall survival of the entire group consisting of 194
tumors was 125 or 64%. CONCLUSIONS: The study shows that clinical
findings in fetuses and neonates with hepatic tumors are less
well defined than in older children. Survival rates are much
lower as well. When the clinical course is complicated by associated
conditions such as stillbirth, fetal hydrops, congestive heart
failure, severe anemia, or thrombocytopenia, the mortality
rate is much greater. If the patient is mature enough and in
a clinical condition where he or she can be operated on, survival
figures approach those of the older child. Some hepatic tumors
have a better prognosis than others. Neonates with focal (solitary)
hepatic hemangiomas have the best outcome and fetuses with
hepatoblastoma the worst. Although infantile hemangioma undergoes
spontaneous regression, it may be life threatening when congestive
heart failure and/or consumptive coagulopathy occur. Mesenchymal
hamartoma is a benign lesion best treated by surgical resection,
which usually results in cure. However, there are fatal complications
associated with this tumor, ie, fetal hydrops, respiratory
distress, and circulatory problems owing to a large space occupying
abdominal lesion and sometimes stillbirth, all contributing
to the death rate. Hepatoblastoma, the major malignancy of
the fetus and neonate, is treated primarily by surgical resection.
Pre- or postoperative chemotherapy is reserved for those patients
with unresectable tumors or metastatic disease. The survival
rate is much lower than that reported by multigroup prospective
trials. Patients die from the mass effect caused by the tumor,
which lead to abdominal distension, vascular compromise, anemia,
hydrops, respiratory distress, and stillbirth. Metastases to
the abdominal cavity, lungs, and placenta are other causes
of death. Because of the danger of labor-induced rupture of
the tumor and potentially fatal intraabdominal hemorrhage,
cesarean delivery is recommended when a hepatic tumor is found
on prenatal ultrasound.
3: Smith GC, Fretts RC.
Stillbirth.
Lancet. 2007 Nov 17;370(9600):1715-25.
Department of Obstetrics and Gynaecology, Cambridge University,
Cambridge, UK. gcss2@cam.ac.uk
In the UK, about one in 200 infants is stillborn, and rates
of stillbirth have recently slightly increased. This recent
rise might reflect increasing frequency of some important maternal
risk factors for stillbirth, including nulliparity, advanced
age, and obesity. Most stillbirths are related to placental
dysfunction, which in many women is evident from the first
half of pregnancy and is associated with fetal growth restriction.
There is no effective screening test that has clearly shown
a reduction in stillbirth rates in the general population.
However, assessments of novel screening methods have generally
failed to distinguish between effective identification of high-risk
women and successful intervention for such women. Future research
into stillbirth will probably focus on understanding the pathophysiology
of impaired placentation to establish screening tests for stillbirth,
and assessment of interventions to prevent stillbirth in women
who screen positive.
4: Zolghadri J, Tavana Z, Kazerooni T, Soveid M, Taghieh M.
Relationship between abnormal glucose tolerance test and history
of previous recurrent miscarriages, and beneficial effect
of metformin in these patients: a prospective clinical study.
Fertil Steril. 2007 Nov 12; [Epub ahead of print]
OBJECTIVE: To determine the incidence of an abnormal glucose
tolerance test in patients with recurrent spontaneous abortion
and whether metformin would safely reduce the rate of first
trimester spontaneous abortions in patients without polycystic
ovary syndrome (PCOS) as well as with PCOS and an abnormal
glucose tolerance test. DESIGN: Prospective control clinical
trial. SETTING: Shiraz University-affiliated hospital. PATIENT
(S): Patients with a history of recurrent spontaneous abortion
and women with a history of normal full term pregnancy. INTERVENTION(S):
The incidence of abnormal carbohydrate metabolism was determined.
Metformin and placebo were given to women with an abnormal
glucose tolerance test and who had recurrent spontaneous abortions.
MAIN OUTCOME MEASURE(S): Continuation of pregnancy beyond the
first trimester in all groups and presence or absence of teratogenicity
in the delivered baby after metformin therapy. RESULT(S): Twenty-nine
of the patients in the group with recurrent spontaneous abortion
were found to have an abnormal glucose tolerance test result
compared with just four (5.4%) patients in the normal pregnancy
group. The abortion rate was significantly reduced after metformin
therapy in patients without PCOS in comparison to the placebo
group (15% vs. 55%). CONCLUSION(S): This study indicates an
important link between an abnormal glucose tolerance test and
a history of recurrent abortion. It was also found that metformin
therapy improves the chances of a successful pregnancy in patients
with an abnormal glucose tolerance test.
5: Kapoor N, Sankaran S, Hyer S, Shehata H.
Diabetes in pregnancy: a review of current evidence.
Curr Opin Obstet Gynecol. 2007 Dec;19(6):586-590.
Maternal Medicine Unit, Epsom & St Helier University Hospitals
NHS Trust, Surrey, UK Department of Medicine & Endocrinology,
Epsom & St Helier University Hospitals NHS Trust, Surrey,
UK St George?s Hospital Medical School, London, UK.
PURPOSE OF REVIEW: There is controversy about the best approach
to screening and management for gestational diabetes. In the
recent Confidential Enquiry in Maternal and Child Health (CEMACH)
the outcome of women with diabetes compared with women without
diabetes. The results were exceptionally poor, suggesting the
need for a new management approach. The aim of this review
is to address these findings and our suggested care pathways.
RECENT FINDINGS: The CEMACH report showed the congenital malformation
rate was four to 10-fold higher, the perinatal mortality rate
was four to seven-fold higher, stillbirth was five times more
common, and babies were three times more likely to die in the
first 3 months of life. Only 39% of women with established
diabetes took folic acid and only 37% had some documentation
of glycaemic control before pregnancy. Overall, less than a
fifth of NHS trusts in the UK had any kind of multidisciplinary
preconception services. The results for women with type 2 diabetes
were as bad as those for type 1. Caesarean delivery rates were
very high (67%). SUMMARY: Prepregnancy counselling and multidisciplinary
team management is the key in achieving good pregnancy outcomes.
There is emerging evidence about the safety and efficacy of
oral hypoglycaemics like metformin in pregnancy.
Prepared by the
National Sudden Infant Death Resource Center
Georgetown University
2115 Wisconsin Avenue, N.W., Suite 601
Washington, DC 20007
(866) 866-7437 toll free
(202) 687-7466 local
(202) 784-9777 fax
info@sidscenter.org
http://www.sidscenter.org
(Back to the Top)
|
