Antiepileptic drugs and pregnancy. Population based pharmaco-epidemiological study on prescription patterns, pregnancy outcome and foetal health

Aims of the study: To assess the prevalence of Antiepileptic Drug (AED) exposure in pregnant women with or without epilepsy and the comparative risk of terminations of pregnancy (TOPs), spontaneous abortions, stillbirth, major congenital malformations (MCMs) and foetal growth retardation (FGR) following intrauterine AED exposure in the Emilia Romagna region (RER), Northern Italy (4 million inhabitants). Methods: Data were obtained from official regional registries: Certificate of Delivery Assistance, Hospital Discharge Card, reimbursed prescription databases and Registry of Congenital Malformations. We identified all the deliveries, hospitalized abortions and MCMs occurred between January 2009 and December 2011. Results: We identified 145,243 pregnancies: 111,284 deliveries (112,845 live births and 279 stillbirths), 16408 spontaneous abortions and 17551 TOPs. Six hundred and eleven pregnancies (0.42% 95% Cl: 0.39-0.46) were exposed to AEDs. Twenty-one per cent of pregnancies ended in TOP in the AED group vs 12% in the non-exposed (OR:2.24; CI 1.41-3.56). The rate of spontaneous abortions and stillbirth was comparable in the two groups. Three hundred fifty-three babies (0.31%, 95% CI: 0.28-0.35) were exposed to AEDs during the first trimester. The rate of MCMs was 2.3% in the AED group (2.2% in babies exposed to monotherapy and 3.1% in babies exposed to polytherapy) vs 2.0% in the non-exposed. The risk of FGR was 12.7 % in the exposed group compared to 10% in the non-exposed. Discussion and Conclusion: The prevalence of AED exposure in pregnancy in the RER was 0.42%. The rate of MCMs in children exposed to AEDs in utero was almost superimposable to the one of the non-exposed, however polytherapy carried a slightly increased risk . The rate of TOPs was significantly higher in the exposed women. Further studies are needed to clarify whether this high rate reflects a higher rate of MCMs detected prenatally or other more elusive reasons.

Congenital Nystagmus eye movements analysis and oculomotor system models evaluation

The term Congenital Nystagmus (Early Onset Nystagmus or Infantile Nystagmus Syndrome) refers to a pathology characterised by an involuntary movement of the eyes, which often seriously reduces a subject’s vision. Congenital Nystagmus (CN) is a specific kind of nystagmus within the wider classification of infantile nystagmus, which can be best recognized and classified by means of a combination of clinical investigations and motility analysis; in some cases, eye movement recording and analysis are indispensable for diagnosis. However, interpretation of eye movement recordings still lacks of complete reliability; hence new analysis techniques and precise identification of concise parameters directly related to visual acuity are necessary to further support physicians’ decisions. To this aim, an index computed from eye movement recordings and related to the visual acuity of a subject is proposed in this thesis. This estimator is based on two parameters: the time spent by a subject effectively viewing a target (foveation time - Tf) and the standard deviation of eye position (SDp). Moreover, since previous studies have shown that visual acuity largely depends on SDp, a data collection pilot study was also conducted with the purpose of specifically identifying eventual slow rhythmic component in the eye position and to characterise in more detail the SDp. The results are presented in this thesis. In addition, some oculomotor system models are reviewed and a new approach to those models, i.e. the recovery of periodic orbits of the oculomotor system in patients with CN, is tested on real patients data. In conclusion, the results obtained within this research consent to completely and reliably characterise the slow rhythmic component sometimes present in eye position recordings of CN subjects and to better classify the different kinds of CN waveforms. Those findings can successfully support the clinicians in therapy planning and treatment outcome evaluation.

Down Syndrome: Neuropsychological phenotype and mitochondrial DNA

Introduction. Down Syndrome (DS) is the most known autosomal trisomy, due to the presence in three copies of chromosome 21. Many studies were designed to identify phenotypic and clinical consequences related to the triple gene dosage. However, the general conclusion is a senescent phenotype; in particular, the most features of physiological aging, such as skin and hair changes, vision and hearing impairments, thyroid dysfunction, Alzheimer-like dementia, congenital heart defects, gastrointestinal malformations, immune system changes, appear in DS earlier than in normal age-matched subjects. The only established risk factor for the DS is advanced maternal age, responsible for changes in the meiosis of oocytes, in particular the meiotic nondisjunction of chromosome 21. In this process mitochondria play an important role since mitochondrial dysfunction, due to a variety of extrinsic and intrinsic influences, can profoundly influence the level of ATP generation in oocytes, required for a correct chromosomal segregation. Aim. The aim of this study is to investigate an integrated set of molecular genetic parameters (sequencing of complete mtDNA, heteroplasmy of the mtDNA control region, genotypes of APOE gene) in order to identify a possible association with the early neurocognitive decline observed in DS. Results. MtDNA point mutations do not accumulate with age in our study sample and do not correlate with early neurocognitive decline of DS subjects. It seems that D-loop heteroplasmy is largely not inherited and tends to accumulate somatically. Furthermore, in our study sample no association of cognitive impairment and ApoE genotype is found. Conclusions. Overall, our data cast some doubts on the involvement of these mutations in the decline of cognitive functions observed in DS.

Diagnosi prenatale delle malformazioni fetali: ecografia e risonanza magnetica a confronto in 11 anni di esperienza

Obiettivo: Valutare l’accuratezza reciproca dell’ecografia “esperta” e della risonanza magnetica nelle diagnosi prenatale delle anomalie congenite. Materiali e metodi: Sono stati retrospettivamente valutati tutti i casi di malformazioni fetali sottoposte a ecografia “esperta” e risonanza magnetica nel nostro Policlinico da Ottobre 2001 a Ottobre 2012. L’età gestazionale media all’ecografia e alla risonanza magnetica sono state rispettivamente di 28 e 30 settimane. La diagnosi ecografica è stata confrontata con la risonanza e quindi con la diagnosi postnatale. Risultati: sono stati selezionati 383 casi, con diagnosi ecografica o sospetta malformazione fetale “complessa” o anamnesi ostetrica positiva infezioni prenatali, valutati con ecografia “esperta”, risonanza magnetica e completi di follow up. La popolazione di studio include: 196 anomalie del sistema nervoso centrale (51,2%), 73 difetti toracici (19,1%), 20 anomalie dell’area viso-collo (5,2%), 29 malformazioni del tratto gastrointestinale (7,6%), 37 difetti genito-urinari (9,7%) e 28 casi con altra indicazione (7,3%). Una concordanza tra ecografia, risonanza e diagnosi postnatale è stata osservata in 289 casi (75,5%) ed è stata maggiore per le anomalie del sistema nervoso centrale 156/196 casi (79,6%) rispetto ai difetti congeniti degli altri distretti anatomici 133/187 (71,1%). La risonanza ha aggiunto importanti informazioni diagnostiche in 42 casi (11%): 21 anomalie del sistema nervoso centrale, 2 difetti dell’area viso collo, 7 malformazioni toraciche, 6 anomalie del tratto gastrointestinale, 5 dell’apparato genitourinario e 1 caso di sospetta emivertebra lombare. L’ecografia è stata più accurata della risonanza in 15 casi (3,9%). In 37 casi (9,7%) entrambe le tecniche hanno dato esito diverso rispetto agli accertamenti postnatali. Conclusioni: l’ecografia prenatale rimane a tutt’oggi la principale metodica di imaging fetale. In alcuni casi complessi e/o dubbi sia del sistema nervoso centrale sia degli altri distretti anatomici la risonanza può aggiungere informazioni rilevanti.