pregnant women

Labetalol may be best option for pregnant women with hypertension

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Among antihypertensive medications commonly prescribed for pregnant women, all reduced risk for severe hypertension, but labetalol also reduced odds of other poor outcomes, researchers reported.

Jeffrey N. Bone, MS, statistician and PhD candidate in the department of obstetrics and gynecology at the University of British Columbia in Vancouver, Canada, and colleagues conducted a systematic review and meta-analysis of 61 trials covering 6,923 pregnant women to determine which antihypertensive medications were best for controlling nonsevere hypertension.

pregnant woman with pills

Outcomes of interest included severe hypertension, proteinuria/preeclampsia, fetal/newborn death, small for gestational age infants and admission to neonatal care.

The commonly prescribed antihypertensive medications analyzed were labetalol, other beta-blockers, methyldopa, calcium channel blockers and mixed/multidrug therapy, and all reduced risk for severe hypertension by 30% to 70% compared with placebo or no therapy, Bone and colleagues wrote.

Compared with placebo or no therapy, labetalol was associated with reduced odds of proteinuria/preeclampsia (OR = 0.73; 95% credible interval [CrI], 0.54-0.99) and fetal/newborn death (OR = 0.54; 95% CrI, 0.3-0.98), the researchers wrote.

Compared with methyldopa (OR = 0.66; 95% CrI, 0.44-0.99) and calcium channel blockers (OR = 0.63; 95% CrI, 0.41-0.96), labetalol was associated with reduced odds of proteinuria/preeclampsia, according to the researchers.

Bone and colleagues found no significant differences for any other therapy in any other outcome, but noted the credible intervals were wide.

When the researchers conducted a trial sequential analysis, they determined that definitive evidence would require 2,500 to 10,000 women per arm for severe hypertension and safety outcomes and 15,000 women per arm for fetal/newborn death.

“It is unsurprising that antihypertensive therapy outperforms, by a large margin, placebo/no therapy in lowering BP. Many national and international guidelines now recommend that practitioners offer antihypertensive therapy to women to normalize BP in pregnancy,” Bone and colleagues wrote. “Notwithstanding neonatal concerns, it may be reasonable to recommend first-line therapy with labetalol, given the additional potential benefits of reduced proteinuria/preeclampsia and perinatal death.”

Outcomes After Zika Virus Infection in Pregnant Women

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A lower rate of possible Zika-related deficits was found in offspring of women in French territories in the Americas than has been reported in Brazil.

During the past year, Latin American countries and the U.S have reported on the outcomes of pregnancies of women infected with Zika virus. Reports, primarily from Brazil, demonstrate teratogenic effects, mainly on the ocular and central nervous systems. Now, researchers report on the outcomes of pregnancies of Zika-infected women in the French territories in the Americas (French Guiana, Guadeloupe, and Martinique). The investigators prospectively examined pregnant women with suspected Zika virus infection and enrolled 546 women in any stage of pregnancy who had laboratory-confirmed Zika virus infection on the basis of a positive result on a reverse-transcriptase polymerase chain reaction assay on blood, urine, or both.

The pregnancies included 555 fetuses and resulted in 11 miscarriages (2.0%), 32 cases of microcephaly of any degree (defined as greater than 2 standard deviations below the mean for sex and gestational age; 5.8%), and 28 other cases of central nervous system defects (5.0%). Overall, 7% of fetuses or infants had either neurologic or ocular defects possibly associated with Zika. The rate of neurologic or ocular defects was highest when Zika virus infection occurred during the first trimester of pregnancy (12.7%) versus the second or third trimester (3.6% and 5.3%, respectively).

Comment

The proportion of ocular and nervous system birth defects reported in this population is similar to a report from the U.S. (6%) but much lower than in a report from Brazil (42%). This difference is largely unexplained except if the predominant Zika strain differs among different countries. As the authors note, some defects may not be evident until these offspring are followed for a longer period.

Fetal Exposure to Montelukast and Congenital Anomalies: A Population Based Study in Denmark

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Abstract

Background

The objective was to study pregnancy outcomes between groups of Danish women, with pregnancy ending between 1998 and 2009, according to their exposure to montelukast.

Methods

Cross‐sectional observational study in Danish women, selecting live births and stillbirths (Birth Registry) and spontaneous abortions and induced terminations (Patient Registry). Montelukast exposure was obtained from the Prescription Registry (ATC code R03DC03). Exposure period was from 3 months before the last menstrual period until the end of the first trimester. Four groups were studied: (1) women with prescription for montelukast, (2) women with prescription for montelukast and other anti‐asthmatic medications, (3) women with prescription for other anti‐asthmatic medications, (4) women without prescription for any anti‐asthmatic medications.

Results

A total of 754,300 singleton pregnancies (> 12 weeks) were identified: 401 pregnancies in group 1, 426 pregnancies in group 2, 24878 in group 3 and 728,595 in group 4. Risk of preterm birth, maternal preeclampsia and gestational diabetes was increased for pregnancies exposed to montelukast. No significant differences were found for the risk of major congenital anomalies (CA). Adjusted odds ratio for CA was 1.4 (95% CI 0.9–2.3) for the group 1 and 1.0 (95% CI 0.6–1.8) for group 2.

Conclusion

Pregnant women with prescriptions for montelukast had a higher risk of preterm birth and maternal complications. These risks are known to be associated with maternal asthma, no increased risk of CA was found. Further analysis including more exposed pregnancies will be needed to determine the risk of specific CA.

Helping Pregnant Women and Clinicians Understand the Risk of Ondansetron for Nausea and Vomiting During Pregnancy

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Nausea and vomiting during pregnancy (sometimes termed morning sickness) are among the most common medical issue to arise during pregnancy. Most pregnant women experience some form of nausea and vomiting, and prevalence rates are as high as 50% to 80%.1 Conservative measures, such as dietary modifications and avoidance of triggers, often do not control symptoms, so medications and other nondrug therapies are tried.2 Nausea and vomiting is one of the most common indications for prescriptions during pregnancy.3 Because this is a condition mainly of the first trimester, pregnant women and clinicians have concerns about the potential effects these therapies might have on the developing fetus.

In this issue of JAMA, Huybrechts and colleagues4 attempt to clarify associations of a commonly used antiemetic, ondansetron, with fetal congenital malformations. Because these malformations are typically rare, establishing cause and effect of a single drug and an anomaly is extremely difficult. Association studies using robust data sets often provide the best available evidence for establishing risk or safety of a drug. The authors describe some of the limitations of prior association studies and detail how the Medicaid Analytic eXtract (MAX) database is ideally suited to overcome some of these prior limitations. Because the authors have used these data for other pregnancy exposure studies, they are well-suited for the current analysis.

In this study, the authors used data from more than 1.8 million pregnancies, allowing for a large number of analyses and adjustments. Focusing on cardiac malformations and oral clefts (the main congenital anomalies identified with any consistency in prior studies), the authors found no significant association between ondansetron and cardiac abnormalities (14 577 abnormalities among 1 727 947 unexposed infants and 835 abnormalities among 88 467 exposed infants; adjusted risk difference, −0.8; 95% CI, −7.3 to 5.7 per 10 000 births; adjusted relative risk, 0.99, 95% CI; 0.93 to 1.06). They also detected a small but statistically significant increased risk of oral clefts with first-trimester exposure to ondansetron (1912 abnormalities among unexposed infants and 124 abnormalities among exposed infants; adjusted risk difference, 2.7; 95% CI, 0.2 to 5.2 per 10 000 births; adjusted RR, 1.24; 95% CI, 1.03 to 1.48). After multiple adjustments, the authors also found no difference in the risk of cardiac or overall congenital anomalies for infants of women exposed to ondansetron.

According to the American College of Obstetricians and Gynecologists (ACOG)–endorsed treatment algorithm, ondansetron, a serotonin receptor antagonist, is not the first-line drug for treatment of nausea and vomiting.1 However, it is one of the most commonly used agents in practice.3,5 This may be because of its different formulations, including an oral dissolving tablet, and its perceived effectiveness. Thus, it is important that clinicians and pregnant women have accurate safety information about its use during pregnancy.

Treatment of nausea and vomiting can be difficult and must be tailored to the individual patient. Often, a single treatment or combination of treatments that work for one woman will be ineffective for another. In the population studied by Huybrecht et al, 139 932 pregnant women (7.7%) also filled a prescription for promethazine, 52 818 (2.9%) filled a prescription for metoclopramide, and 9036 filled a prescription for pyridoxine (vitamin B6, 0.5%)—3 commonly used agents for nausea and vomiting. According to the treatment algorithm proposed by the ACOG Practice Bulletin, pyridoxine, alone or in combination with doxylamine, is listed as the first-line agent. Ondansetron appears as a third-line option in the algorithm.1

Ondansetron is metabolized by cytochrome P450 (CYP) enzymes that are polymorphic, such as CYP 2D6. Understanding how genetic differences among individuals cause varied responses to the same drug may have implications for prescribing.6 Because there are often genetic-based differences in activity of common drug-metabolizing enzymes, transporters, and receptors among individuals, pharmacogenomics can help guide therapeutic choices in several disease states.7 Further research is needed for ondansetron and other drugs for nausea and vomiting to determine if pharmacogenomic or specific phenotype characteristics can help personalize treatment for improved outcomes.8,9

In the evolving era of personalized medicine, rapidly determining the most effective therapy can have tangible benefits. Women with severe nausea and vomiting have decreased work productivity, more time away from personally fulfilling activities, and may have higher rates of adverse pregnancy outcomes.10,11 Additionally, severe nausea and vomiting was cited as a reason for higher rates of pregnancy termination from the Motherisk project in Canada.12 Thus, early and effective safe treatment of nausea and vomiting is crucial.

The article by Huybrechts and colleagues provides important and helpful information for physicians and other clinicians to use when counseling women about the safety of treatment options. The safety of some other options, such as pyridoxine, has been established.13 The current article documents clearly that while the adjusted relative risk of oral clefts was elevated, the absolute risk increase is very low. The multiple adjustments and comparison groups presented, including accounting for the potential baseline risk of nausea and vomiting, demonstrate the robustness of the authors’ conclusions.

In addition, the authors acknowledge the typical limitations of these types of analyses. Because of the low frequency of congenital anomaly outcomes, randomized trials would need to have enormous sample sizes to detect differences between drug exposures. Thus, observational data are best suited for these studies. One additional relevant limitation of the data set is that prescriptions for the current recommended first-line treatment, pryidoxine (with or without doxylamine), may not have been completely captured. The prescription combination of doxylamine and pyridoxine was approved by the US Food and Drug Administration in 2013, the final year the MAX data were queried. Many women may have obtained these components over-the-counter, and thus the true polypharmacy rates for nausea and vomiting treatment are not accounted for in the data set.

Utilizing a large data set, the study by Huybrechts et al provides some reassurance for obstetricians and other clinicians, as well as for pregnant women regarding the safety of a commonly used medication for nausea and vomiting. The potential risk and safety findings must be weighed with the effectiveness of ondansetron in treating nausea and vomiting and avoiding hyperemesis gravidarum. The analysis also provides additional reassurance of no increased risk of cardiac or total congenital malformations. As clinicians and pregnant women engage in informed, shared decision-making surrounding treatment for nausea and vomiting, the current information is important for contextualizing risks in light of the potential benefits.

It Is Time for Women (and Men) to Be BraveA Consequence of the #MeToo Movement

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It is telling that TIME Magazine’s Person of the Year honor was shared by “the silence breakers,” 61 women and men, from familiar actors to ordinary people, who came forward to report sexual assault and harassment, mostly in the workplace.1 Their stories are powerful and, sadly, not at all unfamiliar.

From the perspective of a female surgeon, one of the first female chairs of surgery, and now as one of a handful of female medical center chief executive officers and medical school deans, it appears that US society is on the cusp of a change in addressing sexual harassment and abuse.

Change often starts with the familiar basics: policies, education, and training. The harassment policy at Wake Forest Baptist Medical Center is clear and direct: Respectful behavior in the workplace is nonnegotiable. All staff members are responsible for making the medical center a safe, inclusive place where every individual feels valued, respected, and able to do his or her best work. There are no excuses and no exceptions to allow or enable anything less.

Similar policies are in place in hospitals across the country with similar important language: Discrimination or harassment of any employee or student based on sex, race, color, religion, national origin, sexual orientation, gender identity, age, or disability will not be tolerated. But policies are not always practiced and incidents are not always reported, due to fear of retaliation or harm to career advancement.

Health care workers in the United States are not alone with respect to sexual harassment. Around the world, there are reports of harassment, disrespect, and bullying in health care and science. In some countries, these behaviors border on unsafe. In a recent study, 83% (100/120) of physicians, nursing, and support staff at Bahrain Defense Force Hospital emergency departments, at 1-year follow-up, reported experiencing verbal abuse (78%), followed by physical abuse (11%), and sexual abuse (3%).2 In another recent study involving a survey of 137 residents at a children’s hospital in Mexico, 32% reported bullying and 82% reported harassing behaviors.3 Being female and younger than 29 years of age were reported as factors significantly associated with workplace bullying.3

If current methods and policies to prevent harassment and bias in health care are not working, what can leaders and others do to address this, especially if staff members do not feel there is someone they can talk with openly? Some organizations have set up an independent intermediary or outside organization with a hotline to report inappropriate actions or conversations and to manage the matter through to resolution. Other health care systems require staff to take real-time or virtual training to learn how to address being bullied or what to do when they see someone else being disrespected.4

Policies and training are well meaning and necessary, but gender bias and harassment must be eliminated. It is an issue that affects all of society. In the enormous public response to publicity around harassment and gender bias—across multiple industries and organizations over the last several months—society has decided: This is wrong.

Medical training teaches physicians to step up and say something. Physicians learn to say “I have a concern” when they need to stop before a surgical procedure for the safety of the patient. Today, surgeons see this play out every day, but in previous years, that was not the case. No one spoke in the operating room, except the surgeon. Now, anyone can speak up, and should do so, when necessary.

Physicians need to take this process, built upon safety, and encourage those in medicine to be brave and to speak out when they are, or witness someone else who is, being harassed or disrespected. Every physician, female or male, should feel empowered and encouraged to speak up, without fear, if she or he ever experiences or observes behavior that betrays the values central to a person’s identity. Every physician, female or male, should be brave enough to say, “This behavior makes me feel uncomfortable” or “I feel disrespected” to anyone who is inappropriate or disrespectful.

When it comes to respect, everyone must speak the same language and understand the same definitions. How physicians treat each other and other members of the health care organization creates the workplace culture and affects the health care environment, regardless of the person and his or her academic rank or clinical role; regardless of the clinical, administrative, or supporting duties and responsibilities; and regardless of the location, from operating rooms to board rooms. More importantly, leaders must ensure that issues brought to their attention involving disrespect of others, sexual harassment, or other unprofessional behaviors are immediately recognized, addressed, and resolved.

The medical and research communities are taking notice. Many recent publications,5,6 journal articles, and commentaries have addressed the issue of gender bias and harassment in medicine, including one that suggested 2018 would be the “year of reckoning for gender equality,” as well as the “year of reckoning for women in science.”7 Similarly, a committee of the National Academies of Science, Engineering, and Medicine will deliver a consensus report in 2018 on sexual harassment of women in science, engineering, and medicine and its effect on career advancement.

Medicine is at a tipping point. For the first time, in 2017, the number of women entering medical schools outnumbered men.8 With these students come different perspectives and active voices. This millennial generation knows that discrimination and harassment are not right. But for the young people of this generation, as well as people of the generations that preceded them and who work in academic medical centers, health care institutions, and other settings, now is the time for mutual respect, for utmost civility, and for women (and men) to be brave in putting an end to sexual harassment and abuse.

Incidence of Spontaneous subarachnoid hemorrhage rising in pregnant women

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https://speciality.medicaldialogues.in/incidence-of-spontaneous-subarachnoid-hemorrhage-rising-in-pregnant-women/

More Pregnant Women Are Using Marijuana, But We Still Don’t Know The Risks

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Numbers in California have nearly doubled since 2009.

More women – especially younger women – are testing positive for marijuana use during pregnancy in Northern California, according to a new study.

The research letter, published in the Journal of the American Medical Association, analysed the results of urine tests administered during standard prenatal care of 280,000 women enrolled in the Kaiser Permanente Northern California health-care system.

It found that from 2009 to 2016, the percentage of women who tested positive for marijuana at roughly 8 weeks into pregnancy rose from 4 percent to 7 percent.

Marijuana use was particularly prevalent among those younger than 18 (22 percent), and women between ages 18 and 24 (19 percent).

The rate of marijuana use among pregnant women age 25 and older was considerably lower, at less than 5 percent.

In part because of the plant’s mixed legal status, the risks of pot use during pregnancy aren’t fully understood.

Evidence indicates that maternal marijuana use may impair foetal growth and brain development, but conclusive links between marijuana and prenatal complications haven’t been conclusively established the way those have been for, say, alcohol or tobacco.

Marijuana use may be less harmful during pregnancy than that of alcohol or tobacco, in other words, or it may turn out to be more harmful. But at present we simply don’t know either way.

The study was limited to Northern California, a region that’s not exactly representative of behaviours and attitudes toward marijuana nationwide.

After California legalised medical marijuana in 1996, a robust marijuana growing industry took hold in the Emerald Triangle region of the northern part of the state.

Marijuana cultivation and use are woven into the culture of Northern California like no place else in the country.

It’s also possible that for many women in the study, the findings reflect marijuana use that occurred before they knew they were pregnant.

Marijuana is detectable in the urine up to 30 days after the last use, and many women do not realise they are pregnant until several weeks into their pregnancy.

“Prenatal use before vs after women realised they were pregnant could not be distinguished,” the study’s authors note.

Still it’s clear that nationwide, changing attitudes toward the plant are spilling over into the realm of pregnancy. Marijuana has been shown to be effective at treating nausea, and prior research indicates that some pregnant women are using it to treat morning sickness.

A study published earlier this year found that 4 percent of pregnant American women reported using marijuana in the past month of their pregnancy in 2014, up from 2 percent in 2002.

By comparison, the rate of past-month alcohol consumption is roughly 10 percent among pregnant American women.

In part because of the lack of knowledge about marijuana’s effects during pregnancy, the American College of Obstetricians and Gynaecologists has a simple recommendation for moms-to-be contemplating pot use: don’t do it.

Obstacles to riding safely through pregnancy revealed: Study

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In the UK, the National Institute for Clinical Excellence (NICE) and the National Health Service (NHS) both recommend pregnant women engage in daily exercise, but when it comes to cycling, the advice dries up: there are no clear recommendations women can use to decide whether to continue cycling.

Riding During Pregnancy
During pregnancy, depending on women’s proportions and the type of bike, the growing belly can feel physically restrictive.

Pregnant women could get on their bikes and stay healthy with better support, but according to a new study, they are encountering obstacles to riding.

Medical advice from risk-averse health professionals may contribute to some women’s decisions to stop cycling to work during pregnancy, meaning they miss out on the potential benefits of the active commute. The recent research revealed the reasons why women decide to stop or continue cycling to work when they are pregnant, including often ambiguously worded or overly-cautious advice from medical guidelines, midwives and obstetricians.

More people than ever are commuting to work by bicycle in London. According to data from the 2011 census, the city saw a 144% increase in cycle-commuting over the previous decade. This has big health benefits, for the health of the individual cyclist as well as for public health more broadly, as it helps people move more as part of their everyday activities.

In the UK, the National Institute for Clinical Excellence (NICE) and the National Health Service (NHS) both recommend pregnant women engage in daily exercise to help manage common discomforts, reduce pregnancy complications like preeclampsia, reduce discomfort and improve mood. But when it comes to cycling, the advice dries up: there are no clear recommendations women can use to decide whether to continue cycling.

“Despite the clear health benefits of cycling and the push to get more people commuting by bike, especially in cities like London, the medical advice on cycling during pregnancy remains murky,” commented author Davara Lee Bennett. “My research aimed to explore why women do – and don’t – cycle to work when they’re pregnant, with a view to supporting informed decision-making – including, if women so wish, rocking the rust off their chains, and bringing their bikes out from under the stairs and into the light.”

Bennett conducted three individual interviews and held three focus group discussions: with a group of women who had stopped cycling early, a group that had carried on into later pregnancy and a mixed group. She recorded and transcribed all of them, and analyzed the transcripts line-by-line to develop themes.

 

The resulting factors that affected women’s decisions fell into a few main areas: physical obstacles and enablers, perceptions of risk and of pregnancy itself and advice. The idea of risk was a key factor in decisions about continued cycling: women adjusted their cycling practices to minimize risk, taking partners’ support or concern into account. Although some women had positive encounters with health professionals, the medical advice they received was often noncommittal or risk-averse.

During pregnancy, depending on women’s proportions and the type of bike, the growing belly can feel physically restrictive. Some women stopped cycling because of this, while others found comfort from their daily aches and pains when they commuted by bike. Either way, more comfortable bikes helped: women preferred Dutch-style, upright designs with a low crossbar and a wide, supportive seat.

Perceptions of pregnancy also had an impact on women’s decisions: some preferred to abandon their active commute, opting for a more peaceful state, while others continued to cycle in a bid to remain connected to their authentic selves.

“Understanding the obstacles to women’s cycling during pregnancy can support the development of safer cycling infrastructure and informed medical guidelines, ultimately offering more women the opportunity to benefit from an active commute,” said Bennett. “By addressing some of the more socially prohibitive public discourses on the topic, I hope that my research will not just enable informed decision-making by women, but also encourage more constructive support and advice for women from health professionals.” The study appears in the Journal of Transport & Health.

Dear Pregnant women, beware! Paracetamol might affect sex drive in male progeny

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The use of pain reliever paracetamol when pregnant is linked to reduced sex drive and aggressive behaviour in males, finds study.

Health
Taking paracetamol during pregnancy might damage the development of male behaviour.

Although paracetamol is usually considered safe during pregnancy, a new research from the University of Copenhagen in Denmark suggests that if you are pregnant, you should think twice before popping these pills as their use is linked to reduced sex drive and aggressive behaviour in males. In an animal model, the use of the popular pain reliever paracetamol was found to damage the development of male behaviour, according to a paper published in the journal Reproduction.

The researchers said that the dosage administered to the mice was very close to the recommended dosage for pregnant women. But they cautioned that because the trials are restricted to mice, the results cannot be transferred directly to humans. However, the researchers’ certainty about the harmful effects of paracetamol means it would be improper to undertake the same trials on humans, explained David Mobjerg Kristensen, who was associated with the University of Copenhagen during the study.

Paracetamol can inhibit the development of the male sex hormone testosterone in male foetuses.

“In a trial, mice exposed to paracetamol at the foetal stage were simply unable to copulate in the same way as our control animals. Male programming had not been properly established during their foetal development and this could be seen long afterwards in their adult life. It is very worrying,” Mobjerg Kristensen, now associated with the Institut de Recherche en Sante, Environnement et Travail (IRSET) in France, said.

Previous studies have shown paracetamol can inhibit the development of the male sex hormone testosterone in male foetuses, thus increasing the risk of malformation of the testicles in infants. But a reduced level of testosterone at the foetal stage is also significant for the behaviour of adult males, Mobjerg Kristensen added. Testosterone is the primary male sex hormone that helps develop the male body and male programming of the brain. The masculine behaviour in mice observed by the researchers involved aggressiveness towards other male mice, ability to copulate and the need for territorial marking.

“We have demonstrated that a reduced level of testosterone means that male characteristics do not develop as they should. This also affects sex drive,” Mobjerg Kristensen said. But even if paracetamol is harmful, that does not mean it should never be taken, even when pregnant, the researchers said. “I personally think that people should think carefully before taking medicine. These days it has become so common to take paracetamol that we forget it is a medicine and all medicine has side effects. If you are ill, you should naturally take the medicine you need. After all, having a sick mother is more harmful for the foetus,” Mobjerg Kristensen noted.

According to Britain’s National Health Service (NHS), “paracetamol is usually safe to take” during pregnancy. Kristensen emphasised that pregnant women should continue to follow the guidelines given by their country’s health authorities and recommends people to contact their GP if in doubt about the use of paracetamol

Zika threat isn’t over, CDC director warns pregnant women thinking about beach vacations

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Leydiane da Silva, who was eight months pregnant, in Recife, Brazil, a hot spot for Zika-related birth defects, in February.

Over the past year, the Centers for Disease Control and Prevention took the extraordinary step of urging pregnant women to avoid travel to dozens of mainly Latin American countries to stave off infection with the Zika virus. With inclement weather prompting Americans to muse about winter vacations in sunny climes, the CDC wants to make it clear: That recommendation still stands.

CDC Director Tom Frieden admitted he is worried that people may think the worst of Zika is over and that they can let down their guard.

“We do want to emphasize that this will be the new normal until there’s a [Zika] vaccine. That if you’re pregnant, you should not go to a place where Zika is spreading,” Frieden told STAT in a year-end interview on the agency’s Zika response.

“I think there’s a misconception that Zika is either over or was never a serious problem. It’s a devastating problem for families and individuals.”

The Zika outbreak has been an extraordinarily taxing one for the CDC, Frieden noted, leading to a number of firsts for the agency.

One notable first came on Jan. 15, when the CDC advised pregnant women to avoid 13 Latin American countries as well as a part of the United States, Puerto Rico, to avoid infection with the Zika virus.

The recommendation was made several months before the CDC and the World Health Organization concluded there was enough scientific evidence to say that Zika infection in pregnancy was causing microcephaly — abnormally small heads and often under-developed brains — in newborns. But as early as January the agency felt certain the risk was too great to wait for definitive proof; it needed to warn pregnant women.

“That may have been the single most important thing we did,” Frieden said.

But Frieden said that pregnant women, as a group, are more finely attuned to health messaging and more likely to follow advice.

Still, women often don’t know for weeks after conception that they are pregnant. And couples that may not have plans to conceive may end up doing so on a vacation. Infection in the first trimester of pregnancy appears to carry the highest risk of brain-related birth defects.

Some people may feel the risk of infection is low, Frieden acknowledged.

“It’s obviously a rare event, but the problem is it’s a devastating event,” he said. “It’s a life-changing event.”

The CDC’s Zika response to Zika has involved over 2,200 staff from across the agency’s many centers, drawing in experts on infectious diseases, birth defects, reproductive health, mosquito control, and sexually transmitted diseases.

They have rushed to do the studies that have firmed up the link between Zika infection and birth defects and with Guillain-Barré syndrome, a form of progressive paralysis that usually subsides. They have also developed tests to detect Zika infection, participated in about two dozen epidemiological investigations, and written more than 230 scientific articles and guidance documents for the public, physicians, state health departments, and the like.

The agency also established a registry to track the pregnancies of women who were infected, another first.

To date, the United States has recorded 39 pregnancies affected by Zika: 34 babies have been born with Zika-induced birth defects, and in five cases, birth defects are known to have been present but the pregnancy ended with either a miscarriage, a stillbirth or a termination.

CDC scientists acknowledge that these numbers may be an underestimate because it is hard to track pregnancies that end in abortion. If a woman learned she was carrying a fetus with Zika-related birth defects and she decided to terminate that pregnancy, the case might not be recorded in the CDC’s Zika pregnancy registry.

The latest update of findings from the registry for the 50 US states suggests that at least 1,246 pregnant women have been infected with Zika, and at least 824 of those pregnancies have come to term or have ended.

Source:www.statnews.com