Last updated:
8/7/2023
Years published: 2003, 2019, 2023
NORD gratefully acknowledges Mariana Bundra Todosiev, PharmD, RPh, and Dr. Kelly-Ann Eastwood, Consultant in Obstetrics and Fetal Medicine, UHBW NHS Foundation Trust for assistance in the preparation of this report.
Fetal retinoid syndrome is a pattern of mental and physical birth defects (congenital malformations) that can result from a mother taking retinoids during pregnancy. The absolute risk of congenital malformations following oral isotretinoin therapy is currently unclear. Overall malformation rates in liveborn infants from prospectively reported pregnancies range from 5% to 20%.
Retinoids are the synthetic (man-made) forms of vitamin A used to treat various skin (dermatological) conditions. The most well-known retinoid is isotretinoin (commonly referred to by one of its former brand names, Accutane or Roaccutane, a drug used to treat severe cystic acne. Isotretinoin and its commercially available brands, although effective in the treatment of acne, can cause developmental abnormalities in the fetus (teratogenic effects) and therefore should not be used during pregnancy due to the risk of birth defects. The range and severity of associated abnormalities are variable and dependent on timing of exposure in pregnancy. However, characteristic features may include malformations of the skull and facial (craniofacial) region; central nervous system (CNS) abnormalities; heart abnormalities; and/or additional physical findings. Additional anomalies may include renal, thymus gland abnormality and parathyroid gland abnormalities.
Characteristic features of infants with fetal retinoid syndrome include abnormalities of the craniofacial region, CNS and cardiovascular system. The specific symptoms and physical findings can vary from one infant to another. Affected infants may not have all the symptoms listed below.
Craniofacial differences
Some affected infants may have small heads (microcephaly) and small, low-set ears (microtia) with narrowing (stenosis) of the ear canals or are born missing ears. Abnormalities of the middle and inner ears may also be present including hearing loss. Additional craniofacial findings include widely spaced eyes (hypertelorism), incomplete closure of the roof of the mouth (cleft palate), an abnormal groove in the upper lip (cleft lip) and/or underdevelopment of the middle area of the face (midface hypoplasia). Some affected infants may experience paralysis (palsy) of certain facial nerves.
Cardiovascular abnormalities
Potential cardiovascular abnormalities following retinoid exposure include structural (anatomical) malformations of the heart such as transposition of the great vessels; hypoplastic left heart syndrome; ventricular septal defects (VSDs) and tetralogy of Fallot.
Hypoplastic left heart syndrome is characterized by underdevelopment of the left ventricle, the aortic and/or mitral valves and the ascending aorta.
VSDs are abnormal openings that may occur in any portion of the ventricular septum, the fibrous partition that divides the heart’s two lower pumping chambers (ventricles). The size and location of the defect will determine the severity of symptoms. Small VSDs may close without treatment or become less significant as affected infants mature and grow. If a moderately-sized defect is present, the heart may be unable to pump blood effectively, resulting in an abnormally rapid rate of breathing (tachypnea), wheezing, an unusually fast heartbeat (tachycardia) and/or failure to grow and gain weight at the expected rate (failure to thrive). In some children, without appropriate treatment, large VSDs may cause life-threatening complications during infancy.
Tetralogy of Fallot is a rare form of cyanotic heart disease. Cyanosis is the abnormal bluish discoloration of the skin and mucous membranes (lips and tongue) that occurs due to low levels of circulating oxygen in the blood. Tetralogy of Fallot consists of a combination of four different heart defects: a ventricular septal defect; obstructed outflow of blood from the right ventricle to the lungs due to an abnormal narrowing of the opening between the pulmonary artery and the right ventricle of the heart (pulmonary stenosis); a displaced aorta that causes blood to flow into the aorta from both the right and left ventricles and abnormal enlargement of the right ventricle.
CNS abnormalities
Some infants with fetal retinoid syndrome may develop CNS abnormalities including hydrocephalus, a condition in which accumulation of excessive cerebrospinal fluid (CSF) in the skull causes pressure on the tissues of the brain, resulting in a variety of symptoms. In some children, the forebrain (prosencephalon) may fail to develop resulting in holoprosencephaly.
Infants with fetal retinoid syndrome may have neurodevelopmental delays, for example, they may have learning disabilities and have delays in reaching developmental milestones such as sitting or crawling.
Affected infants may also develop a condition known as microcephaly, where the head circumference is smaller than would be expected for their age and gender due to developmental issues. This can also result in developmental and intellectual disabilities. Additional complications that may arise due to microcephaly include balance and coordination problems as well as seizures.
Additional abnormalities
Infants with fetal retinoid syndrome may experience abnormalities of thymus function. The thymus gland is located below the thyroid gland in the neck in front of the chest and is the primary gland of the lymphatic system. The thymus gland makes white blood cells needed to protect the body from infection.
Other reported abnormalities include webbing of the fingers (syndactyly), skeletal malformations affecting the legs and spine, and/or low muscle tone (hypotonia). Some infants may also develop eye problems such as microphthalmia, a condition where one or both eyeballs are very small, leading to possible vision loss. Some infants are born with their eyes missing (anophthalmia).
Maternal use of synthetic vitamin A (retinoids) such as isotretinoin (Accutane) during pregnancy can result in multiple effects on the developing embryo and fetus including miscarriage, premature delivery and a variety of birth defects. Commercially available isotretinoin brand products include, Absorica, Amnesteem, Claravis, Myorisan and Zenatane; as well as various types of generics available globally.
There is debate in the medical literature as to the specific risks for individual pregnancies following retinoid exposure. However, it is known that there is an increased risk of birth defects in women who become pregnant while taking retinoids such as isotretinoin. It is estimated that a 35% risk of fetal retinoid syndrome exists in infants of women who take isotretinoin beyond the 15th day following conception. Some researchers believe that birth defects do not occur in women who discontinue isotretinoin one month before conception. It is also unknown what specific dosage of retinoids may result in birth defects. More research is needed to determine the specific risks and long-term effects when women are inadvertently exposed to retinoids during pregnancy.
Fetal retinoid syndrome affects males and females in equal numbers. The exact incidence of fetal retinoid syndrome is unknown and because many children with fetal retinoid syndrome often go unrecognized. The disorder is under-diagnosed, making it difficult to determine the true frequency of the disorder in the general population.
Confirmed diagnosis of fetal retinoid syndrome is made following clinical examination of an affected infant in conjunction with a history of retinoid exposure during pregnancy.
Prenatal diagnosis may be possible by ultrasound where fetal abnormalities such as central nervous system and heart abnormalities may be detected.
Prevention
Due to the severity of the birth defects that an infant may develop following retinoid exposure, use of oral retinoids is strictly prohibited during pregnancy. Women should be counselled carefully regarding the risks of isotretinoin treatment and should be screened and monitored for pregnancy while on the medication. Throughout the course of isotretinoin therapy, two forms of contraception are recommended, and pregnancy should be avoided until the isotretinoin therapy has been discontinued.
Continual use of birth control (contraception) is needed for safety precautions during isotretinoin therapy in women of childbearing age. Evidence from medical literature states that contraception use should be started one month before isotretinoin therapy and continued for three months after therapy has been stopped.
Treatment
The treatment of fetal retinoid syndrome is directed toward the specific problems affecting each individual. Treatment may require the coordinated efforts of a team of specialists. Pediatricians, surgeons, cardiologists, specialists who assess and treat hearing problems (audiologists), eye specialists and additional health care professionals may need to plan an affected child’s treatment systematically and comprehensively. Other treatment is symptomatic and supportive.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Toll-free: (800) 411-1222
TTY: (866) 411-1010
Email: [email protected]
Some current clinical trials also are posted on the following page on the NORD website:
https://rarediseases.org/for-patients-and-families/information-resources/info-clinical-trials-and-research-studies/
For information about clinical trials sponsored by private sources, contact:
www.centerwatch.com
For information about clinical trials conducted in Europe, contact:
https://www.clinicaltrialsregister.eu/
JOURNAL ARTICLES
Browne H, Mason AG, Tang T. Retinoids and pregnancy: an update. The Obstetrician & Gynaecologist 2014;16:7–11.
Choi JS, Koren G, Nulman I. Pregnancy and isotretinoin therapy. CMAJ. 2013 Mar 19; 185(5): 411–413.
Moerike S, et al. Temporal bone pathology in fetuses exposed to isotretinoin. Pediatr Dev Pathol. 2002;5:405-9.
Nau H. Teratogenicity of isotretinoin revisited: species variation and the role of all-trans-retinoic acid. J Am Acad Dermatol. 2001;45:S183-7.
Orfanos CE, Zouboulis CC. Oral retinoids in the treatment of seborrhoea and acne. Dermatology. 1998;196(1):140-7.
Lammer EJ. Longitudinal study of infants exposed to isotretinoin (13-cis-retinoic acid) in utero. Toxicologist. 1997;36:54.
Guillonneau M, Jacqz-Aigrain E. Teratogenic effects of vitamin A and its derivatives. Arch Pediatr. 1997;4:867-74.
Coberly S, et al. Retinoic acid embryopathy: case report and review of literature. Pediatr Pathol Lab Med. 1996;16:823-36.
Benifla JL, et al. Fetal tissue dosages of retinoids. Experimental study concerning a case of isotretinoin (Roaccutan) administration and pregnancy. Fetal Diagn Ther. 1995;10:189-91.
Adams J, Lammer EJ. Human isotretinoin exposure: the teratogenesis of a syndrome of cognitive deficits. Neurotoxicol Teratol. 1995;17:386.
Heckel S, et al. Teratogenicity of retinoids. A case and review of literature. J Dynecol Obstet Biol Reprod (Paris). 1993;22:43-47.
Ayme S, et al. Isotretinoin dose and teratogenicity. Lancet. 1988;1:655.
Lammer EJ, Chen DT, Hoar RM, et al. Retinoic acid embryopathy. N Engl J Med. 1985 Oct 3;313(14):837-41.
Stern RS, et al. Isotretinoin and pregnancy. J Am Acad Dermatol. 1984;10:851-54.
INTERNET
Isotretinoin. MotherToBaby. October 2021. https://mothertobaby.org/fact-sheets/isotretinoin-accutane-pregnancy/ Accessed August 7, 2023.
Isotretinoin and Other Retinoids During Pregnancy. March of Dimes. June 2019. https://www.marchofdimes.org/pregnancy/isotretinoin-and-other-retinoids-during-pregnancy.aspx Accessed August 7,2023.
Isotretinoin tablets. May 2018 .bumps – best use of medicine in pregnancy (medicinesinpregnancy.org) Accessed August 7, 2023.
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