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Maternal use of antidepressant drugs and twin deliveries
Letters to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 164 (2012) 234–238
*Corresponding author. Tel.: +972 4 6288250; fax: +972 4 6494577; mobile: +972 50 2202313 E-mail address: [email protected] (R. Beck-Fruchter) 2 March 2012 http://dx.doi.org/10.1016/j.ejogrb.2012.05.006
Maternal use of antidepressant drugs and twin deliveries Dear Editors, We have explored the association between maternal use of antidepressants in early pregnancy and a reduced twinning rate, specifically after use of selective serotonin reuptake inhibitors, SSRI, which was noted in surveys of delivery outcome after maternal use of antidepressants [1,2]. We used the Swedish Medical Birth Register [3] in order to find out if the association concerns dizygotic or monozygotic twinning and if it is specific for certain groups of women. Births occurring in Sweden in the period 1995–2009 were studied and 10,999 like-sexed twin pairs and 5292 unlike-sexed twin pairs were identified. Use of SSRI in early pregnancy (before first antenatal care visit, usually during the first trimester) was reported by 14,039 women. Odds ratio for twinning was estimated using the Mantel-Henszel method with adjustment for the following variables which could appear as confounders: year of delivery, maternal age, parity, smoking habits in early pregnancy, and BMI. Further methodological details can be obtained from [2]. Table 1 shows that the odds ratio for a twin delivery was reduced after maternal use of SSRI and this was restricted to unlike-sexed pairs (dizygotic twins) while the odds rate for monozygotic twins (estimated by Weinberg’s differential rule) was close to 1.0. When the analysis was repeated on women who did not report any period of unwanted childlessness, the effect on dizygotic twining disappeared while it was strong when women who had a period of unwanted childlessness were analyzed. Within this group three subgroups were formed: women who had had IVF (11.5% twins), women who had had ovarian stimulation but not IVF (6.0% twins), and women who had had neither – either they were untreated or Table 1 Odds ratio (OR) with 95% confidence intervals (95% CI) for use of selective serotonin reuptake inhibitors in early pregnancy and twin delivery in subgroups of women and for all twins and for unlike-sexed (dizygotic) twins. Number of exposed twin pairs
Total number of twin pairs
Number of exposed singletons
Total number of singletons
OR (95% CI)
168
20,918
13,864
1,410,579
Unlike-sexed 58 7319 twins Monozygotic 52 6210 twins Women without unwanted childlessness All twins 137 15,404 12,527
0.78 (0.66–0.92) 0.71 (0.53–0.95) 0.93 (0.71–1.23)
1,280,753
0.89 (0.74–1.06) 0.98 (0.72–1.33)
129,826
0.55 (0.37–0.81) 0.20 (0.08–0.49)
Type of twinning
All women All twins
Unlike-sexed 50 4901 twins Women with unwanted childlessness All twins 31 5514 Unlike-sexed twins
8
2418
1337
235
had received other treatments, e.g., surgery. Numbers in each group were low but in the group not treated with IVF or ovarian stimulation, the odds ratio was 0.68 for any twin and 0.47 for unlike-sexed twins, and after adjustment for these three groups, the odds ratio for unlike-sexed twinning was 0.48 (95% CI 0.24–0.96), based on 8 pairs against the expected number of 16.3. When similar analyses were run for tricyclic antidepressants, no effect on unlike-sexed twinning was found (odds ratio 1.32 (95% CI 0.78–2.24) which suggests that the underlying disease (depression) does not explain the effect. In the study, adjustment was made for some variables which could affect both twinning rate and the use of SSRI drugs. Subfertility was a crucial factor because the reduction of twinning after SSRI was only seen among women who had experienced a period of unwanted childlessness and this seemed independent of the use of IVF or ovarian stimulation. A hypothetical explanation, difficult to prove, could be that SSRI restricts ovulation resulting both in unwanted childlessness and in a reduction of the rate of double ovulation. References [1] Ericson A, Ka¨lle´n B, Wiholm B-E. Delivery outcome after the use if antidepressants in early pregnancy. European Journal of Clinical Pharmacology 1999;55:503–8. [2] Ka¨lle´n B. Drugs during pregnancy. NewYork: Nova Biomedical Books; 2009 , p. 359–68 [chapter 52]. [3] National Board of Health and Welfare. The Swedish medical birth register – a summary of content and quality. Centre for Epidemiology; 2003 , http:// www.socialstyrelsen.se/Publikationer2003/2003-112-3 (accessed September 1, 2011).
Bengt Ka¨lle´n* Tornblad Institute, University of Lund, Biskopsgatan 7, SE-223 62 Lund, Sweden *Tel.: +46 46 2227536; fax: +46 46 2224226 E-mail address: [email protected] (B. Ka¨lle´n) 4 January 2012 http://dx.doi.org/10.1016/j.ejogrb.2012.06.005
Chronic isolated fallopian tube torsion associated with huge hydrosalpinx and hemosalpinx in a postmenopausal woman: a case report and brief review
Dear Editor, Isolated fallopian tube torsion (IFTT) is a rare condition, especially in postmenopausal women. Reports in the literature have referred to cases of acute presentation of tubal torsion but, to the best of our knowledge, the current case is the first reported case of chronic tubal torsion in a post-menopausal woman. Furthermore, it is the biggest torsioned hydrosalpinx ever reported. A 72-year-old rural woman, G5P5, was admitted to hospital with a 5-year history of intermittent right lower abdominal pain. She was not suffering from vomiting, fever, vaginal discharge. Her gynecological history included physiological menopause at the age of 49 years, and she had undergone a bilateral tubal ligation 32 years ago. Her surgical and medical histories were unremarkable. At the beginning of her complaint, she was diagnosed as having chronic appendicitis with McBurney’s point tenderness and she received 14 i.v. antibiotic therapies in a poor conditions rural clinic in the past five years, without any additional examination.
*Corresponding author. Tel.: +972 4 6288250; fax: +972 4 6494577; mobile: +972 50 2202313 E-mail address: [email protected] (R. Beck-Fruchter) 2 March 2012 http://dx.doi.org/10.1016/j.ejogrb.2012.05.006
Maternal use of antidepressant drugs and twin deliveries Dear Editors, We have explored the association between maternal use of antidepressants in early pregnancy and a reduced twinning rate, specifically after use of selective serotonin reuptake inhibitors, SSRI, which was noted in surveys of delivery outcome after maternal use of antidepressants [1,2]. We used the Swedish Medical Birth Register [3] in order to find out if the association concerns dizygotic or monozygotic twinning and if it is specific for certain groups of women. Births occurring in Sweden in the period 1995–2009 were studied and 10,999 like-sexed twin pairs and 5292 unlike-sexed twin pairs were identified. Use of SSRI in early pregnancy (before first antenatal care visit, usually during the first trimester) was reported by 14,039 women. Odds ratio for twinning was estimated using the Mantel-Henszel method with adjustment for the following variables which could appear as confounders: year of delivery, maternal age, parity, smoking habits in early pregnancy, and BMI. Further methodological details can be obtained from [2]. Table 1 shows that the odds ratio for a twin delivery was reduced after maternal use of SSRI and this was restricted to unlike-sexed pairs (dizygotic twins) while the odds rate for monozygotic twins (estimated by Weinberg’s differential rule) was close to 1.0. When the analysis was repeated on women who did not report any period of unwanted childlessness, the effect on dizygotic twining disappeared while it was strong when women who had a period of unwanted childlessness were analyzed. Within this group three subgroups were formed: women who had had IVF (11.5% twins), women who had had ovarian stimulation but not IVF (6.0% twins), and women who had had neither – either they were untreated or Table 1 Odds ratio (OR) with 95% confidence intervals (95% CI) for use of selective serotonin reuptake inhibitors in early pregnancy and twin delivery in subgroups of women and for all twins and for unlike-sexed (dizygotic) twins. Number of exposed twin pairs
Total number of twin pairs
Number of exposed singletons
Total number of singletons
OR (95% CI)
168
20,918
13,864
1,410,579
Unlike-sexed 58 7319 twins Monozygotic 52 6210 twins Women without unwanted childlessness All twins 137 15,404 12,527
0.78 (0.66–0.92) 0.71 (0.53–0.95) 0.93 (0.71–1.23)
1,280,753
0.89 (0.74–1.06) 0.98 (0.72–1.33)
129,826
0.55 (0.37–0.81) 0.20 (0.08–0.49)
Type of twinning
All women All twins
Unlike-sexed 50 4901 twins Women with unwanted childlessness All twins 31 5514 Unlike-sexed twins
8
2418
1337
235
had received other treatments, e.g., surgery. Numbers in each group were low but in the group not treated with IVF or ovarian stimulation, the odds ratio was 0.68 for any twin and 0.47 for unlike-sexed twins, and after adjustment for these three groups, the odds ratio for unlike-sexed twinning was 0.48 (95% CI 0.24–0.96), based on 8 pairs against the expected number of 16.3. When similar analyses were run for tricyclic antidepressants, no effect on unlike-sexed twinning was found (odds ratio 1.32 (95% CI 0.78–2.24) which suggests that the underlying disease (depression) does not explain the effect. In the study, adjustment was made for some variables which could affect both twinning rate and the use of SSRI drugs. Subfertility was a crucial factor because the reduction of twinning after SSRI was only seen among women who had experienced a period of unwanted childlessness and this seemed independent of the use of IVF or ovarian stimulation. A hypothetical explanation, difficult to prove, could be that SSRI restricts ovulation resulting both in unwanted childlessness and in a reduction of the rate of double ovulation. References [1] Ericson A, Ka¨lle´n B, Wiholm B-E. Delivery outcome after the use if antidepressants in early pregnancy. European Journal of Clinical Pharmacology 1999;55:503–8. [2] Ka¨lle´n B. Drugs during pregnancy. NewYork: Nova Biomedical Books; 2009 , p. 359–68 [chapter 52]. [3] National Board of Health and Welfare. The Swedish medical birth register – a summary of content and quality. Centre for Epidemiology; 2003 , http:// www.socialstyrelsen.se/Publikationer2003/2003-112-3 (accessed September 1, 2011).
Bengt Ka¨lle´n* Tornblad Institute, University of Lund, Biskopsgatan 7, SE-223 62 Lund, Sweden *Tel.: +46 46 2227536; fax: +46 46 2224226 E-mail address: [email protected] (B. Ka¨lle´n) 4 January 2012 http://dx.doi.org/10.1016/j.ejogrb.2012.06.005
Chronic isolated fallopian tube torsion associated with huge hydrosalpinx and hemosalpinx in a postmenopausal woman: a case report and brief review
Dear Editor, Isolated fallopian tube torsion (IFTT) is a rare condition, especially in postmenopausal women. Reports in the literature have referred to cases of acute presentation of tubal torsion but, to the best of our knowledge, the current case is the first reported case of chronic tubal torsion in a post-menopausal woman. Furthermore, it is the biggest torsioned hydrosalpinx ever reported. A 72-year-old rural woman, G5P5, was admitted to hospital with a 5-year history of intermittent right lower abdominal pain. She was not suffering from vomiting, fever, vaginal discharge. Her gynecological history included physiological menopause at the age of 49 years, and she had undergone a bilateral tubal ligation 32 years ago. Her surgical and medical histories were unremarkable. At the beginning of her complaint, she was diagnosed as having chronic appendicitis with McBurney’s point tenderness and she received 14 i.v. antibiotic therapies in a poor conditions rural clinic in the past five years, without any additional examination.