Physician, University of Yaounde 1
Fetal anencephaly in maternal toxoplasma and HIV co-infection in Cameroon
Fetal anomalies like neural tube defects are a significant source of morbidity and mortality, and are responsible for a high psychological and economic cost worldwide. However, the impact of these diseases remain largely under-ascertained in middle income and low income settings.
This case report presents a fetal anencephaly in a terrain of maternal toxoplasma and HIV co-infection in a resource limited setting, and the impact of the disease to the client and the healthcare professional.
A 39 year old Cameroonian female with a positive Toxoplasma and HIV serologic test consulted at a district hospital in the suburb of Cameroon. This lady could not benefit from a fetal ultrasound partly because there was no trained personnel to perform the examination in the hospital in which she was followed up, and also due to accessibility constraints to the nearest referral center with a radiologist. Twenty weeks later, she returned to the hospital in labor pains after being reported to have lost a huge quantity of turbid liquor at home. Delivery was conducted, but unfortunately, a neonate with anencephaly was born. The frustrated parents of the baby were counseled and given psychological support.
More attention has to be paid to ameliorate the healthcare in middle income and low income settings.
Abstract: Aim: When parents-to-be are faced with a terminal prenatal diagnosis, they are confronted with the decision either to continue the pregnancy or to terminate it at an advanced stage. This difficult decision is intimately affected by the experience of the inevitability of loss, and ethical dilemmas posed in this usually completely unexpected situation. Studies indicate that perinatal child loss due to lethal foetal anomalies is a major life event and a source of serious psychological issues, which can last for many years after the experience. Moreover, it has been shown that care for bereaved parents, if guided by their needs, can ease their burden, regardless of whether they choose to end or continue the pregnancy. The aim of this study is to inspect current practices of counselling and support of affected families and develop practical guidelines for health and social professionals involved. Methods: A sample of 32 parents in the German-speaking part of Switzerland was investigated between December 2012 and March 2014. Semi-structured problem-centred interviews were conducted, transcribed verbatim and thematically analysed. Results: 4 main time periods and 6 themes were identified by participants ranging from diagnosis until birth: "shock", "choices and dilemmas", "taking responsibility", "still being pregnant", "saying goodbye/letting go" and "planning the future". However, findings reflect critical points of care and showed gaps not only between emphasising time periods but also between affected parents' and involved professionals' views. This article reports the findings from the parents. Conclusion: This study provided new insights into parental responses when they are confronted with a fatal prenatal diagnosis. The results contribute towards rethinking current practices in midwifery and other healthcare during pregnancy, birth and puerperium as well as the palliative care of the child.
Pub.: 28 Jan '17, Pinned: 30 Jun '17
Abstract: The disclosure of a diagnosis during pregnancy of a fetal malformation, which is incompatible with life, normally comes completely unexpectedly to the parents. Although a body of international literature has considered the topic, most of it comes from the United States and little has been generated from Europe. This study aims to illuminate the contemporary treatment associated with such diagnoses, regardless of whether parents decide to terminate or continue the pregnancy.a qualitative design was used with data collected by semi-structured interviews and subjected to a thematic analysis.the research was conducted in the German speaking areas of Switzerland with data collected from participants in places of their choice.61 interviews were conducted with 32 parents and 29 health professionals.the theme of 'temporality' identified four main time points from the professionals: diagnosis, decision, birth/death, and afterwards. However, in contrast to these, six major themes in this study, primarily generated from parents and extended from receiving the diagnosis until the interview, were identified: shock, choices and dilemmas, taking responsibility, still being pregnant, forming a relationship with the baby, letting go. Although there was concurrence on many aspects of care at the point of contact, parents expressed major issues as gaps between the points of contact.care varied regionally but was as sensitive as possible, attempting to give parents the space to accept their loss but fulfil legal requirements. A gap exists between diagnosis and decision with parents feeling pressured to make decisions regarding continuing or terminating their pregnancies although health professionals' testimonies indicated otherwise. A major gap manifested following the decision with no palliative care packages offered. During the birth/death of the baby, care was sensitive but another gap manifested following discharge from hospital.
Pub.: 15 Mar '16, Pinned: 30 Jun '17
Abstract: To investigate the relationship between antiepileptic drug (AED) polytherapy in pregnant women and the risk of fetal malformations as prescribing practice changed, with valproate being used less often and at lower doses. Specifically, the risks associated with two of the most common AEDs included in polytherapy over recent years, levetiracetam and topiramate, were examined.An observational cohort study in which malformation rates were analyzed in 1,461 pregnancies exposed to AED monotherapy, and in 484 exposed to antiepileptic drug combinations, from the Australian Register of Antiepileptic Drugs in Pregnancy over a 15‐year period (1999–2014).Fetal malformation rates had fallen over time in monotherapy pregnancies, but increased in polytherapy pregnancies, despite decreasing use and lower dosages of valproate. The rise in polytherapy malformation rates began around 2005 when levetiracetam and topiramate use began to increase. Excluding pregnancies involving valproate exposure, malformation rates were higher in the remaining polytherapy pregnancies as compared with the monotherapy ones (6.90% vs. 3.64%; odds ratio [OR] 1.96, 95% confidence interval [CI] 1.14–3.39). Malformation rates were similar in polytherapy pregnancies whether or not levetiracetam was included (7.14% vs. 8.38%), but were higher in polytherapy pregnancies involving topiramate (14.94% vs. 6.55%: OR 2.507, 95% CI 1.23–5.10). Logistic regression showed that topiramate in polytherapy had a positive dose relationship with teratogenicity risk (p = 0.025).The malformation risk associated with AED polytherapy depends on the specific drugs involved. Topiramate, when used as part of AED polytherapy that did not include valproate, was associated with a dose‐related increased risk of fetal malformations.
Pub.: 01 May '16, Pinned: 30 Jun '17
Abstract: The prevalence of the use of herbal medicines is on the rise across the world, especially amongst pregnant women. A fact that draws attention is that many species commonly used by pregnant women, including the Tropaeolum majus L. (Tropaeolaceae), also present inhibitory activity on the angiotensin-converting enzyme (ACE). Herein, we have investigated the effects of T. majus extract (HETM) on fetal development, evaluating its relationship with possible ACE inhibitory activity. Pregnant Wistar rats were treated with different HETM doses (3, 30 and 300 mg/kg/day) from gestational days 8-20. Rats were sacrificed on the day 20 of pregnancy and the following parameters were evaluated: clinical symptoms of maternal toxicity; maternal body weight; feed and water intake; maternal liver, kidney, and ovary weights, maternal ACE activity and aldosterone levels, live fetuses mean; dead fetuses percentage, fetus weight, and fetal malformation. All pregnant rats treated with high HETM doses showed significant reduction in plasma ACE activity accompanied by a decrease in serum aldosterone levels. Moreover, significant changes in fetal development were observed, including growth retardation and renal damage after 20 days of gestation. Thus, data presented demonstrate the significant effects of the use of HETM on fetal development during pregnancy.
Pub.: 03 Aug '16, Pinned: 30 Jun '17
Abstract: This study examined the association between certain paternal occupational exposures during the periconceptional period and the risk of congenital malformations.A case-control study was carried out from December 2009 to April 2010; on 242 congenital malformation cases and 270 controls. Paternal occupational exposure to certain workplace hazards was assessed by a detailed questionnaire to evaluate the occupational exposure for both fathers and mothers including pesticides, solvents, welding fumes, lead, working with video display terminals (VDTs) and computer monitors. In addition, the questionnaire assessed the presence of other risk factors such as consanguinity, smoking and history of any maternal diseases during the pregnancy with the child.The results revealed that the odds of having a child with congenital malformation was higher (P < 0.01) if the father was occupationally exposed to pesticides (OR: 3.42, 95% CI: 1.97-5.92), solvents (OR: 5.63, 95% CI: 2.77-11.42), or welding fumes (OR: 2.98, 0.99-8.54) during the periconceptional period. However, consanguinity (OR: 1.91, 95% CI: 1.25-2.92) was a risk factor of developing congenital malformations among offspring.Control of workplace exposures and adherence to threshold limit values of those hazards should be adopted to minimize the risk of developing congenital malformations among offspring.
Pub.: 19 May '11, Pinned: 30 Jun '17
Abstract: Most fetal defects are associated with genetic and environmental causes, among them, exposure of pregnant women to intensive pesticide use. Agribusiness is the economic basis of the state of Mato Grosso, the largest consumer of pesticides of all Brazilian states. The objective of this study was to investigate the association between past parental exposure to pesticides and the occurrence of congenital malformations in children in Mato Grosso, Brazil.This hospital-based case-control study was conducted in Cuiabá, the capital of Mato Grosso, from March to October 2011. Data was collected in all public, private, and health plan referral hospitals that provide care for pregnant women in the state of Mato Grosso and were situated in Cuiabá. Cases were children under 5 years of age with congenital malformations classified in Chapter XVIII of the International Classification of Diseases-10 and controls were children within the same age range, without congenital malformations, treated at the same hospitals. Malformation-related data was obtained from the patients' medical records. Socioeconomic data and information about parental exposure to pesticides were obtained in an interview with the mother using a standardized questionnaire. We conducted multivariate logistic regression to assess the relation between parent report of past pesticide use and congenital malformations. We also assessed effect modification to verify whether low maternal education level modified the association between exposure and our outcome.We observed positive effect modification of the association of paternal past exposure to pesticide and congenital malformation in the offspring by maternal education for mothers with low educational level (OR = 8.40, 95 % CI 2.17-32.52), father's work related to farming (OR = 4.65, 95 % CI 1.03-20.98) and paternal past exposure to pesticides (OR = 4.15, 95 % CI 1.24-13.66).These findings provide further evidence that paternal exposure to pesticides, especially when associated with a low maternal education level, may be related to higher rates of fetal malformation in Mato Grosso, Brazil.
Pub.: 16 Aug '16, Pinned: 30 Jun '17
Abstract: Publication date: Available online 9 November 2016 Source:Médecine Palliative : Soins de Support - Accompagnement - Éthique Author(s): Pierre Bétrémieux, Marie-Luce Huillery Lorsqu’une malformation fœtale grave est diagnostiquée in utero, la femme peut choisir l’interruption médicale de grossesse ou bien continuer à vivre la grossesse, avec l’espoir de rencontrer l’enfant vivant et l’accompagner dans sa vie en soins palliatifs. Les équipes formées aux soins palliatifs en période périnatale peuvent répondre d’une manière adaptée aux demandes concernant la malformation, le déroulement de la grossesse, l’accouchement, la douleur éventuelle que ressentirait ce bébé, sa durée de vie et les soins qui lui seront prodigués. La pratique médicale nous entraîne à éliminer l’incertitude diagnostique ; quand tous les examens complémentaires ont été réalisés conduisant à porter un pronostic défavorable sur un fœtus ou un nouveau-né, ouvrant ainsi le champ de la démarche palliative, il reste une frange d’incertitude incompressible qui induit souvent une culpabilité chez les équipes soignantes. Mais l’anticipation n’a pas vocation à évacuer complètement les zones d’ombre. Au contraire, l’incertitude fait le lit de l’espoir qui permet au couple de vivre. Les médecins doivent apprendre à l’intégrer positivement dans leur pratique. Il est nécessaire qu’un lien étroit entre les professionnels et les parents se tisse dans le cheminement décisionnel, puis dans l’accueil du nouveau-né. Lorsque parents et professionnels ont pu parcourir ce chemin ensemble et que l’enfant a pu être accueilli, il est probable que la santé psychique de la famille est préservée. Chacun – famille et professionnels – pourra faire son deuil et s’en remettre. When a severe fetal malformation is diagnosed in utero, the mother may choose between termination of pregnancy or to continue the pregnancy with the hope of meeting the child alive and accompanying him/her in his/her life in palliative care. Teams trained in palliative care in the perinatal period can answer appropriately to questions about the malformation, the course of pregnancy, the childbirth, the pain the baby may possibly feel, his/her life, and the care that will be provided. Medical practice leads us to eliminate the diagnostic uncertainty; when all additional examinations have been performed, which conclude to a poor prognosis for a fetus or a newborn thereby opening the field of palliative approach, a fringe of irreducible uncertainty is left that often induces guilt in health care staff. But anticipation is not intended to completely evacuate the shadows. Rather, uncertainty prompts hope that allows the couple to live. Doctors must learn to integrate uncertainty positively in their practice. It is necessary that a close link is established between professionals and parents during the decision-making process and when the baby is born. When parents and professionals have been through this journey together and have been able to say goodbye to the child, it is likely that the mental health of the family is preserved. Everyone – family members and professionals – will mourn and recover.
Pub.: 14 Nov '16, Pinned: 30 Jun '17
Abstract: Three-/four-dimensional (3D/4D) imaging enables a more detailed survey of the embryo and the fetus compared to two-dimensional (2D) ultrasound. The availability of several display modes and standardized examinations permits the demonstration of both the normal and abnormal fetal anatomy in controlled planes and rendered images from different angles. This allows the demonstration of even subtle fetal defects in an ideal sectional plane in a precisely rendered surface or transparent image viewed from an optimal angle. When counseling the parents, the rendered images can help them understand the severity of an existing malformation or, conversely, ensure them of the absence of any fetal abnormality. This is particularly useful in cases with an increased recurrence risk of a specific fetal malformation.
Pub.: 06 Feb '17, Pinned: 30 Jun '17