Biomedical subjects

G Koren

Publications and source records attributed to G Koren.

At least 73 records · Page 4Linked to original sources

PubMed2001

Factors associated with elective termination of pregnancy among Canadian and American women with nausea and vomiting of pregnancy.

Case reports have associated severe nausea and vomiting of pregnancy (NVP) with elective termination of pregnancy. Therefore, our objective was to explore the determinants of consideration of termination and actual termination of pregnancy among women with NVP. From 1996 to 1997, callers to an advertised NVP Healthline underwent a semi-structured interview. From callers who retrospectively reported on NVP in a previous pregnancy, a nested unmatched case-control study was performed. Callers were divided into three groups: those who reported having electively terminated their pregnancy due to NVP, those who considered termination due to NVP and those who never considered termination. The severity of nausea and vomiting, and frequency of psychosocial morbidity, were compared between cases and controls, and multivariate logistic regression analysis was used to determine factors independently associated with termination and/or consideration of termination of pregnancy due to NVP. Of 3201 callers with NVP, 413 women reported having considered termination of pregnancy for NVP, 108 reported termination due to NVP and 2609 reported never having considered termination for NVP. The following factors were independently associated with a woman's consideration of termination of pregnancy due to NVP: unplanned pregnancy (p = 0.002), multiparity (p = 0.0001), more severe vomiting (p = 0.003), feelings of depression (p < 0.0001) and reported adverse effects of NVP on both her partner's daily life (p = 0.04) and her relationship with her partner (p = 0.0003). The following factors were independently associated with actual termination of pregnancy due to NVP: unplanned pregnancy (p < 0.0001), multiparity (p = 0.03) and feelings of depression (p = 0.001). There were no significant interactions between factors. Consideration of termination, or actual termination of pregnancy, due to NVP are associated with psychosocial circumstances, which should be taken into consideration when managing these women.

Abortion, Induced↗

PubMed2001

Cancer chemotherapy during pregnancy. Consortium of cancer in pregnancy evidence.

QUESTION: I have an 8-weeks' pregnant patient who was diagnosed with stage III Hodgkin's disease last week. The oncologist suggests delaying chemotherapy until the second trimester. What are the effects of chemotherapy on a fetus after the first trimester? Where can I find reliable information on the subject? ANSWER: Available data suggest that exposure to chemotherapy during the first trimester of pregnancy is associated with increased risk of major malformations. Exposure during the second and third trimesters does not result in major malformations, but could have nonteratogenic effects, such as low birth weight. The brain develops throughout pregnancy, and it could be affected later in pregnancy.

Abnormalities, Drug-Induced↗

PubMed2001

Abrupt discontinuation of psychotropic drugs during pregnancy: fear of teratogenic risk and impact of counselling.

OBJECTIVE: To assess the consequences to mother and baby of abruptly discontinuing antidepressant or benzodiazepine medication during pregnancy and to assess the impact of our counselling. PARTICIPANTS: All women who consulted the Motherisk Program between November 1996 and December 1997 and who stopped taking antidepressant or benzodiazepine medication when pregnancy was confirmed agreed to participate in the study. DESIGN AND INTERVENTIONS: Subjects were interviewed, received counselling, and completed a questionnaire 1 month after their initial call and after the birth of their baby. RESULTS: Of 36 women who completed the study, 34 discontinued their medication abruptly for fear of harming the fetus, 28 on the advice of their physician; 26 (70.3%) women reported physical and psychological adverse effects, 11 reported psychological effects only, and 11 reported suicidal ideation (4 were admitted to hospital). After counselling, 22 of 36 (61.1%) women resumed taking their medication, and 4 found that they no longer required it. One woman had a therapeutic abortion and 2 experienced spontaneous abortions; there were therefore 35 healthy babies (including 2 sets of twins) born to 33 women; 14 of 21 mothers breast-fed their babies while taking their psychotropic medication, with no adverse effects reported. CONCLUSIONS: When assessing the risks and benefits of taking psychotropic medication during pregnancy, women and their physicians should be aware that the abrupt discontinuation of psychotropic drugs can lead to serious adverse effects. Counselling is effective in reassuring women to adhere to therapy.

Adult↗

PubMed2001

Effects of prenatal exposure to marijuana.

QUESTION: I am treating a 27-year-old woman who is now in her 10th week of pregnancy. She smokes marijuana two to three times a week, but does not use other drugs. She also smokes 20 cigarettes a day. I am concerned about the effects of marijuana exposure on her baby. ANSWER: It is not always possible to isolate the effect of marijuana exposure from other possible confounders on pregnancy outcome. Although marijuana is not an established human teratogen, recent well conducted studies suggest it might have subtle negative effects on neurobehavioural outcomes, including sleep disturbances, impaired visual problem solving, hyperactivity, impassivity, inattention, and increased delinquency.

Adolescent↗

PubMed2001

Discontinuing antidepressants and benzodiazepines upon becoming pregnant. Beware of the risks of abrupt discontinuation.

QUESTION: Two of my patients are planning to become pregnant. One is taking paroxetine and the other lorazepam. We have discussed what to do when they become pregnant and have decided they should stop taking these drugs as soon as pregnancy is confirmed. Is this the right decision? ANSWER: The decision to discontinue these drugs during pregnancy should be based on scientific evidence rather than "hearsay" that women should not take psychotropic medications during pregnancy. Recent epidemiologic studies have documented the relative safety of these drugs, so women should not feel compelled to stop taking them when they become pregnant. If, after receiving appropriate evidence-based information, a woman decides to stop taking the drugs, they should be gradually tapered off to avoid abrupt discontinuation syndrome.

Anti-Anxiety Agents↗

PubMed2001

Leflunomide: new antirheumatic drug. Effect on pregnancy outcomes.

QUESTION: I am treating a 34-year-old woman with rheumatoid arthritis. She began taking the new drug leflunomide (Arava) 6 months ago and had good clinical response. She is now planning her first pregnancy. What should she do? ANSWER: Leflunomide is a new and effective disease-modifying antirheumatic drug. Animal studies have shown an increased rate of malformations and fetal death in various species, but there are no data on pregnancy outcomes in humans treated with leflunomide. Since the drug has a prolonged and unpredictable elimination half-life, it should be stopped during pregnancy. The manufacturer recommends that patients who wish to become pregnant be treated with cholestyramine, which enhances elimination.

Abnormalities, Drug-Induced↗

PubMed2001

Determinants of the need for hospital care among women with nausea and vomiting of pregnancy.

OBJECTIVES: To characterize a cohort of pregnant women who required hospital care owing to nausea and vomiting of pregnancy (NVP) and to identify variables that could serve as predictors of the need for hospital care. DESIGN: A retrospective, observational study. METHODS: Between 1996 and 1997, women who suffered from NVP were invited to call the NVP Healthline at The Motherisk Program in Toronto. After obtaining verbal consent, callers were interviewed by trained counsellors through a structured questionnaire about their NVP experience in previous pregnancies. Univariate and multivariate analyses were used to identify factors that could predict the need for hospital care. RESULTS: In total, 3,201 women were recruited;1,348 (43.8%) needed hospital care (treatment in the emergency room, day unit or hospital ward). The following characteristics were significantly associated with the need for hospital care: severity of vomiting (more than 5 times a day), use of more than one antiemetic medication, being primigravid, feeling depressed, having had an obstetrician as the primary health care provider and feeling that NVP had affected the partner's daily life. CONCLUSIONS: Several factors, including the severity of physical symptoms of NVP and psychosocial factors, are associated with the need for hospital care. In addition to treatment of physical symptoms, it is important to address other factors associated with NVP.

Analysis of Variance↗

PubMed2001

Taking drugs during pregnancy. How safe are the unsafe?

QUESTION: I prescribed misoprostol to one of my patients with a peptic ulcer. When she found out she was pregnant while on the drug, both she and, admittedly, I were very scared to learn that the drug is teratogenic in that it causes Möbius syndrome. How great is the risk? ANSWER: Very small. Although women who use misoprostol during the first trimester have a 30-fold higher risk of having babies with Möbius syndrome, the malformation is so rare that, even if you see 1000 women who took misoprostol during embryogenesis, you might not see a single child with the syndrome. It is crucial to explain the size of the risk; otherwise women tend to believe the risk is huge even when, in fact, it is hardly measurable.

Abnormalities, Drug-Induced↗

PubMed2001

Congenital cytomegalovirus infection. Is there a breakthrough?

QUESTION: My 26-year-old patient is planning her first pregnancy in the coming month. She works in a day-care centre. Recently, two cases of cytomegalovirus (CMV) infection were diagnosed in her class. What tests should she have before and during the pregnancy, and how should I care for her? ANSWER: Cytomegalovirus infection, the most common congenital viral infection in humans, carries high risk of long-term morbidity and mortality. Seronegative mothers of children in day-care centres are at as high risk of acquiring the infection as day-care workers themselves. The immune status of at-risk patients should be evaluated as pregnancy progresses. Evidence of fetal infection does not necessarily mean fetal disease or damage. With a primary-infected fetus, termination of pregnancy might be discussed with the parents.

Abortion, Induced↗

PubMed2001

Neurodevelopment of adopted children exposed in utero to cocaine: the Toronto Adoption Study.

BACKGROUND: Published studies of children's neurodevelopment after in utero exposure to cocaine have not separated intrauterine from postnatal environmental effects as cocaine-using mothers cluster in low socioeconomic classes and have other risk factors. METHODS: To overcome this limitation, a study was done to assess physical and neurodevelopmental characteristics of 52 children: 26 were adopted by parents who sought counselling in the Motherisk Program at the University of Toronto for prenatal cocaine exposure, and 26 were controls matched for maternal intelligence quotient (IQ), socioeconomic status and gestational age. MAIN OUTCOME MEASURES: Head circumference, McCarthy General Cognitive Index (GCI) score, language performance and temperament tests. RESULTS: The children in the study group had smaller head circumferences (34th versus 54th percentiles p = 0.009), lower McCarthy GCI scores (102.8 versus 114.2, p = 0.02), poorer receptive and expressive language performance on the Reynell test, and higher activity levels, less persistence and increased distractibility on temperament tests. On multivariate analysis, cocaine exposure was significantly (p = 0.001) associated with lower IQ and poorer language development independent of intrauterine growth retardation and other potential confounders. INTERPRETATION: By controlling for postnatal environmental factors, this adoption study documents intrauterine developmental risks associated with cocaine exposure. Follow-up into school years is warranted to evaluate the extent of these effects.

Adoption↗

PubMed2001

Motherisk alert: Folic acid fortification of flour--three years later.

Fortification of flour with folic acid aims to prevent neural tube defects. In Canada, flour fortification began in 1997. The objective of this study was to quantify the changes in women's erythrocyte folic acid levels. Comparing these levels among normocytic women revealed an almost twofold increase (from 517+/-215 nmol/L in 1995 to 901+/-318 nmol/L in 1998) (P<0.00001). While the mean value increased substantially, even now, women at the low range of measured values (367 nmol/L) confer a relative risk of 3.2 for neural tube defects. For these women, higher intake of nutritional folic acid and perinatal supplementation of folic acid tablets continue to be crucial.

Adolescent↗

PubMed2001

Is chronic poisoning with acetaminophen in children a frequent occurrence in Toronto?

BACKGROUND: Acetaminophen is a common cause of poisoning in children. Recent American studies suggest that acetaminophen poisonings pose serious risks in children, particularly in the case of chronic poisoning caused by therapeutic error. OBJECTIVE: To evaluate whether chronic acetaminophen poisoning in children is a frequent occurrence in a large, Canadian, urban population. PATIENTS AND METHODS: Retrospective study. Charts of all patients admitted to The Hospital for Sick Children, Toronto, Ontario from January 1, 1990 to June 31, 1996 with an acetaminophen overdose were reviewed. RESULTS: A total of 110 patients were admitted within the study period; only four of whom were preschool children (younger than five years of age). Among the preschool children, three had an acute overdose and one had possible chronic poisoning by therapeutic error. All preschool children were treated with N-acetylcysteine; one developed hepatotoxicity (aspartate aminotransferase or alanine aminotransferase greater than 1000 U/L) after presenting 24 h after acute ingestion. Of the remaining patients, all were adolescents; 102 had acute intentional overdose and four had staggered intentional overdoses. Fifty-three adolescents were treated with N-acetyl cysteine. Hepatotoxicity was present in 13 of 63 adolescents (21%). No patients required liver transplantation or died. CONCLUSIONS: Contrary to American experience, chronic acetaminophen poisoning, including therapeutic error in children in Toronto, is a rare occurrence--most cases of acetaminophen poisonings are acute intentional ingestion in adolescents.

Acetaminophen↗

PubMed2001

Maternal obesity and risk of neural tube defects.

QUESTION: One of my patients is taking olanzapine for schizophrenia. She has gained a lot of weight, which, I understand, often happens with some of the new atypical antipsychotics. Due to her weight gain, she failed to notice she had become pregnant. Is she at risk? ANSWER: Experience with olanzapine is relatively slight, but available prospective data do not show increased teratogenic risk. Adiposity, on the other hand, is associated with increased risk of neural tube defects. Only some of this risk can be reduced by folate supplementation.

Antipsychotic Agents↗

PubMed2001

Managing hypothyroidism during pregnancy.

QUESTION: One of my pregnant patients is taking levothyroxine for hypothyroidism. I prescribed her iron because she was anemic, but she continues to be weak and to have high levels of thyroid-stimulating hormone (TSH). Increasing her dose of levothyroxine did not seem to affect her TSH levels. ANSWER: Many women need higher doses of levothyroxine during pregnancy. You should continue to monitor her TSH levels carefully and be aware that iron given during pregnancy might form an insoluble complex with thyroxine in the gestational tract.

Drug Interactions↗

PubMed2001

Can herbal products be used safely during pregnancy? Focus on echinacea.

QUESTION: Many of my patients are now using herbal medicines; some even use them during pregnancy. As we enter the "cold and flu" season, many are inquiring about use of the herb echinacea to prevent these ailments. Is there any evidence to suggest that use of echinacea during pregnancy is safe? ANSWER: Although herbal products have been used in the past during pregnancy and delivery, there is little evidence showing they are safe. Many authoritative reviews of echinacea report that its safety for use during pregnancy has not been established. A recent Motherisk study showed that use of echinacea during the first trimester of pregnancy was not associated with increased risk of major malformations.

Adult↗

PubMed2001

Nicotine replacement therapy during pregnancy.

QUESTION: Several years ago you argued in favour of trying nicotine replacement therapy during pregnancy. The Ontario Medical Association recommended the same. Are there any studies now to show that the patch works? ANSWER: A large randomized, blinded study from Denmark has recently shown that the rate of quitting smoking during pregnancy using the nicotine patch is very low and not different from the rate among those given placebo. Preliminary data suggest that women who cannot quit smoking after the first trimester metabolize nicotine rapidly and that this could be a mechanism for their failure to quit.

Administration, Cutaneous↗

PubMed2001

The role of the placenta in variability of fetal exposure to cocaine and cannabinoids: a twin study.

There is wide variability in the reported adverse fetal effects of cocaine and cannabinoids. The causes of this variability are largely unknown. We hypothesized that variability in placental handling of drugs affect fetal exposure. We used twin pregnancies as a paradigm to address the role of the placenta in this variability. We analyzed hair or meconium samples taken from dizygotic and monozygotic twins exposed in utero to illicit drugs. Out of 12 pairs, 5 had negative levels in both twins, and seven pairs of twins had chemical evidence of fetal exposure to cocaine (n = 5) or cannabinoids (n = 2). The one known monozygotic pair of twins had almost identical levels of cocaine. In contrast, the six dizygotic pairs had large disparities in either cocaine or cannabinoid concentrations. In three of these six dizygotic pairs, levels of cocaine (n = 2) or canabinoids (n = 1) were undetectable in one twin while positive in the other. Given that twins are theoretically exposed to similar maternal drug levels, our findings suggest that the placenta may have a major role in modulating the amounts of drug reaching the fetus.

Cannabinoids↗

PubMed2001

Update on perinatal HIV.

QUESTION: Many patients in my practice come from countries where HIV is endemic. Are there current figures on their risk of being infected during pregnancy? ANSWER: In Ottawa and Toronto, Ont, about half the pregnant women identified as HIV-positive were born in countries where HIV is endemic. If you suspect a woman has HIV or have other questions, call the Motherisk HIV-Healthline at 1-888-246-5840. Human immunovirus infection among pregnant women continues to be a serious public health concern. Most fetuses can be protected from contracting HIV if appropriate antiretroviral (ARV) therapy is instituted.

Anti-HIV Agents↗