1: Infections in pregnant women

Associations between severe and notifiable respiratory infections during the first trimester of pregnancy and congenital anomalies at birth: a register-based cohort study

BACKGROUND

Evidence regarding the association between acute respiratory infections during pregnancy and congenital anomalies in babies, is limited and conflicting. The aim of this study was to examine the association between acute respiratory infections during the first trimester of pregnancy and congenital anomalies in babies using record linkage.

METHODS

We linked a perinatal register to hospitalisation and disease notifications in the Australian state of New South Wales (NSW) between 2001 to 2016. We quantified the risk of congenital anomalies, identified from the babies' linked hospital record in relation to notifiable respiratory and other infections during pregnancy using generalized Estimating Equations (GEE) adjusted for maternal sociodemographic and other characteristics.

RESULTS

Of 1,453,037 birth records identified from the perinatal register between 2001 and 2016, 11,710 (0.81%) mothers were hospitalised for acute respiratory infection, 2850 (0.20%) had influenza and 1011 (0.07%) had high risk infections (a record of cytomegalovirus, rubella, herpes simplex, herpes zoster, toxoplasmosis, syphilis, chickenpox (varicella) and zika) during the pregnancy. During the first trimester, acute respiratory infection, influenza and high-risk infections were reported by 1547 (0.11%), 399 (0.03%) and 129 (0.01%) mothers. There were 15,644 (1.08%) babies reported with major congenital anomalies, 2242 (0.15%) with cleft lip/ plate, 7770 (0.53%) with all major cardiovascular anomalies and 1746 (0.12%) with selected major cardiovascular anomalies. The rate of selected major cardiovascular anomalies was significantly higher if the mother had an acute respiratory infection during the first trimester of pregnancy (AOR 3.64, 95% CI 1.73 to 7.66). The rates of all major congenital anomalies and all major cardiovascular anomalies were also higher if the mother had an acute respiratory infection during the first trimester of pregnancy, however the difference was no statistically significant. Influenza during the first trimester was not associated with major congenital anomalies, selected major cardiovascular anomalies or all major cardiovascular anomalies in this study.

CONCLUSION

This large population-based study found severe acute respiratory infection in first trimester of pregnancy was associated with a higher risk of selected major cardiovascular anomalies in babies. These findings support measures to prevent acute respiratory infections in pregnant women including through vaccination.

Seroprevalence of antibodies to cytomegalovirus in pregnant women in the Apulia region (Italy)

Introduction

Cytomegalovirus is ubiquitous and easily transmitted by contact. Following the first infection, the virus becomes latent and periodic reactivation could occur due to immunosuppression. If the infection is acquired in pregnancy, especially in the first trimester, the foetal consequences could be serious. The present study was conducted to assess the serological profile of pregnant women with respect to cytomegalovirus in Apulia from 2016 to 2019.

Methods

Serum samples were tested by commercial ELISA kit for the detection of specific IgM and IgG antibodies against cytomegalovirus.

Results

The data showed that most of the pregnant women (70.8%), especially those of ≥ 40 years of age (80.6%), has antibodies against cytomegalovirus, though these do not confer fully protective immunity against infection by different strains nor can prevent the re-activation of the latent one. Conversely, most of the youngest women are seronegative (44.4% in women < 25 years of age) and vulnerable during pregnancy.

Conclusions

Currently, cytomegalovirus screening for pregnant women is not mandatory in Italy. Considering that congenital cytomegalovirus is the leading non-genetic cause of sensorineural hearing loss, it would be extremely useful and cost-saving to screen women of childbearing age and women at early stage of pregnancy for cytomegalovirus infection in addition to increase awareness of cytomegalovirus infection and consequences among pregnant women, health care workers and the public.

Infections in pregnancy

Infections in pregnancy represent a challenging and often underappreciated area of concern for many specialists and general practitioners and can cause serious sequelae. Antenatal status should be highlighted on pathology request forms, as this serves to alert the laboratory of the need to store serum for an extended period. Prior antenatal specimens can be forwarded to other laboratories to enable testing in parallel with the more recent sample. Women with a confirmed, potentially vertically transmissible infection should be referred to a specialist with expertise in the management of perinatal infections. Cytomegalovirus infection is the most common congenital infection. Women who care for young children are at greater risk of exposure to the virus. Preventive steps including hand hygiene and avoiding contact with children's urine, mucous and saliva are recommended for all pregnant women. The incidence of parvovirus B19 infection in pregnancy is unknown. This infection is highly contagious and may result in fetal loss; particularly in the first half of pregnancy, pregnant women should avoid contact with adults or children who may have an infection.

[Enterovirus infection during pregnancy: Underestimated cause of fetal and neonatal complications?]

Enteroviruses are responsible for about one billion infections every year in the world. The clinical expression is in the vast majority asymptomatic cases (90%). Its consequences during pregnancy are rarely described. From the Medline database, we selected and analyzed 34 articles ranging from 1965 to 2015, to analyse the current knowledge of enterovirus infection consequences during pregnancy. We found that enterovirus infections may be the cause of fetal loss. The enterovirus infections during the 2nd and 3rd trimester may also lead to in utero fetal anomalies and death, but also to severe neonatal infections. PCR enterovirus detection should be performed during pregnancy and the peripartum in case of unexplained fever, specific fetal anomalies or unexplained fetal demise.

The influence of body mass on foot dimensions during pregnancy

In this study, a time-series approach was used to measure women's feet to accurately analyze changes in foot size and body mass during pregnancy. One-hundred women who were pregnant for the first time were asked to respond to questions on subjective complaints of foot discomfort listed in a questionnaire. Among these 100 women, a sample of 30 was obtained and used to measure the women's feet from the twentieth week of the gestation period until labor. The data (from 5 of the 30 women) were used to establish a prediction model for the influence of body mass on changes in foot size during pregnancy. The results indicate that the women subjectively complained that their shoes were too tight, resulting in foot discomfort. From the twentieth to the thirty-eighth week of pregnancy, the average increase in foot length, width, and back foot surface was 0.86 cm (3.6%), 0.25 cm (2.6%), and 18.36 cm(2) (11.9%), respectively. The height of the arch decreased by an average of 0.52 cm (-24.2%). Body mass accounted for more than 90% of the variation (R(2)) in foot dimensions during pregnancy and, thus indicated satisfactory predictive ability. The prediction model developed in this study can serve as a reference for clinical applications and shoe design to prevent women from experiencing extreme discomfort in their feet during pregnancy.

Diagnosis of congenital syphilis and toxoplasmosis

Syphilis, toxoplasmosis, and cytomegalovirus represent disparate entities. The bacterial spirochaete Treponema pallidum ssp. pallidum causes syphilis, the ‘The Great Imitator'; the organism's sole natural host is humans and it remains exquisitely sensitive to penicillin. By contrast, the zoonotic parasite Toxoplasma gondii causes toxoplasmosis. Infection is usually self-limited, although serious disease can occur in the immunocompromised. Meanwhile, the human cytomegalovirus (CMV; human herpesvirus 5) is a relatively prevalent enveloped DNA betaherpesvirus with infection specific to humans. Despite nomenclatural, ecological and therapeutic disparities, however, these agents exhibit several concordances, including various, and at times, cryptic syndromes in child and often mother; congenital infections with potentially devastating outcomes; diagnostic dilemmas. This article primarily discusses the latter of these issues in relationship to congenital syphilis and toxoplasmosis in the Australian context.

Detection of follicular fluid and serum antibodies by protein microarrays in women undergoing in vitro fertilization treatment

A protein microarray serological assay was used to assess the antibody profile of 102 women subjected to in vitro fertilization treatment. The studies were conducted on pairs of serum and follicular fluid samples, collected from each woman on the same day at the time of oocyte recovery. The samples, stored as frozen aliquotes, were assessed by both microarray and ELISA. Follicular fluids and sera were screened to detect the presence of specific IgG and IgM antibodies against seven vertically transmitted pathogens. The IgG reactivity of follicular fluids closely mirrored that of serum in all the patients and for all the antigens, with an agreement of more than 85%. IgM antibodies were undetectable in follicular fluids. The antibody patterns were subsequently related to the biological and clinical outcomes of in vitro fertilization cycles. The results showed that varicella zoster virus (VZV) IgG positive women and cytomegalovirus (CMV) IgG negative women had on average a higher number of inseminated, good quality oocytes compared to VZV IgG negative and CMV IgG positive women. In addition, the rate of successful embryo transfers was significantly higher in Toxoplasma gondii IgG negative women than in their positive counterparts. Overall, the microarray was proven to be a suitable tool for detecting analytes in follicular fluids, therefore supporting its application in a wide spectrum of investigations.

A protein microarray immunoassay for the serological evaluation of the antibody response in vertically transmitted infections

The detection of specific serum antibodies is mainly achieved by enzyme-linked immunosorbent assay (ELISA). Here, we describe the setting up of a microarray-based serological assay to screen for IgG and IgM against vertically transmitted pathogens (Toxoplasma gondii, rubella virus, cytomegalovirus, herpes simplex virus types 1 and 2, varicella zoster virus, Chlamydia trachomatis). The test, accommodated onto a restricted area of a microscope slide, consists of: (a) the immobilization of antigens and human IgG and IgM antibody dilution curves, laid down in an orderly manner; (b) addition of serum samples; (c) detection of antigen-serum antibodies complexes by indirect immunofluorescence. The IgG and IgM curves provide an internal calibration system for the interpolation of the signals from the single antigens. The test was optimized in terms of spotting conditions and processing protocol. The detection limit was 400 fg for the IgG assay and 40 fg for the IgM assay; the analytical specificity was >98%. The clinical sensitivity returned an average value of 78%, the clinical specificity was >96%, the predictive values were >73%, and the efficiency was >88%. The results obtained make this test a promising tool, suitable for introduction in the clinical diagnostic routine of vertically transmitted infections, in parallel (and in future as an alternative) to ELISA.

Pregnancy increases the risk of mortality in West Nile virus-infected mice

West Nile fever outbreaks in the USA have caused over 700 human deaths, primarily due to neurological disease. The usual transmission route of West Nile virus (WNV) involves mosquito bites; however, alternative routes, including intrauterine infection, have also been reported. Here, the pathogenicity of WNV in mice during gestation has been investigated. An extremely high mortality rate was observed in pregnant mice (98 %, 60/61) compared with non-pregnant mice (52 %, 28/53; P<0.001), independent of the infecting dose or the week of pregnancy. Antibody titres were similar between pregnant and non-pregnant mice and between surviving and non-surviving animals. WNV RNA titres in brains were also similar between pregnant and non-pregnant mice. WNV RNA could be detected in placentas and fetuses. These observations suggest strongly that, in the mouse model, pregnancy increases the risk of severe WNV infection and may help to understand the pathogenic mechanisms involved in WNV infection during pregnancy.

Dietary behaviour of pregnant versus non-pregnant women

This study investigates dietary behaviour and the perceived role of food for health of pregnant versus non-pregnant women. Data were collected between 15 January 2003 and 15 March 2003 in Belgium. One hundred and forty-eight pregnant and 130 non-pregnant women aged between 20 and 40 years completed a self-administered questionnaire about their dietary behaviour and nutritional attitudes. Both sub-samples match with respect to individual factors such as relevant socio-demographics and general food perceptions. Pregnant women report higher consumption of fruits, which results in a better score for fibre intake. They also report higher consumption of beef and dairy products, as well as a higher fat intake. No difference in fish consumption between pregnant and non-pregnant women is observed. In line with recommendations, pregnant women report reduced consumption of food products with heightened safety-related risks, lower use of alcohol and tobacco, and safer food handling practices. Reduced intake of raw vegetables for food safety reasons is not compensated by higher intake of cooked vegetables. Pregnant women also report a lower frequency of moderate physical activity. Most differences in food choice by pregnant versus non-pregnant women pertain to the avoidance of specific, potentially harmful food groups. A substantial share of pregnant women does not follow upon recommendations with respect to alcohol use and exposure to tobacco. Personal medical sources for pregnant women and personal social sources for non-pregnant women are reported as the most attended sources of diet-related information. The perceived role of food for health is not different between pregnant and non-pregnant women, and there were no significant interaction effects between pregnancy and presence of children, which indicates that the observed differences in dietary behaviour can be attributed to the state of being pregnant.

Zwangerschap, infectieziekten en werk

Onder de veelheid van factoren die de zwangerschapsuitkomsten kunnen beïnvloeden, nemen de biologische agentia een speciale plaats in. Niet in de laatste plaats omdat ze overal kunnen voorkomen zowel binnen als buiten het werk. Maar ook omdat, indien er sprake is van een risicofactor op het werk, vaak een gerichte preventieve aanpak mogelijk is bijvoorbeeld door hygiëne of vaccinatie. Belangrijke begrippen bij het bepalen van de risico’s die een zwangere en haar vrucht lopen zijn: biohazards, transmissiewijze en de gevoeligheid van de zwangere vrouw en die van haar ongeboren kind. Voor de bedrijfsarts is het geven van een preventief advies aan iedere zwangere werkneemster, maar ook aan iedere werkneemster die van plan is zwanger te worden een belangrijke taak. Op bedrijfsniveau geldt dit voor de werkgever, de leidinggevenden en de preventiewerker.

Humoral immune response to primary rubella virus infection

An assay capable of distinguishing between the immune response generated by recent exposure to rubella virus and the immune response existing as a result of past exposure or immunization is required for the diagnosis of primary rubella virus infection, especially in pregnant women. Avidity assays, which are based on the premise that chaotropic agents can be used to selectively dissociate the low-avidity antibodies generated early in the course of infection, have become routinely used in an effort to accomplish this. We have thoroughly investigated the immunological basis of an avidity assay using a viral lysate-based assay and an enzyme-linked immunosorbent assay (ELISA) based on a peptide analogue of the putative immunodominant region of the E1 glycoprotein (E1208-239). The relative affinities of the antibodies directed against E1208-239 were measured by surface plasmon resonance and were found to correlate well with the avidity index calculated from the ELISA results. We found that the immune response generated during primary rubella virus infection consists of an initial low-affinity peak of immunoglobulin M (IgM) reactivity followed by transient peaks of low-avidity IgG3 and IgA reactivity. The predominant response is an IgG1 response which increases in concentration and affinity progressively over the course of infection. Incubation with the chaotropic agent used in the avidity assay abolished the detection of the early low-affinity peaks of IgM, IgA, and IgG3 reactivity while leaving the high-affinity IgG1 response relatively unaffected. The present study supported the premise that avidity assays based on appropriate antigens can be useful to confirm primary rubella virus infection.

Human Cytomegalovirus-Induced Inhibition of Cytotrophoblast Invasion in a First Trimester Extravillous Cytotrophoblast Cell Line

Human cytomegalovirus (HCMV) is the leading cause of congenital viral infection in the United States and intrauterine transmission of HCMV occurs in approximately 40% of pregnant women with primary HCMV infection. Although HCMV infection during pregnancy clearly may be detrimental to fetal development, its consequences on placentation remain largely unexplored. In this study, the effects of HCMV infection on cytotrophoblast (CTB) invasion were investigated utilizing the first trimester extravillous CTB cell line SGHPL-4. HCMV infection significantly inhibited SGHPL-4 proliferation, epidermal growth factor (EGF)- and hepatocyte growth factor (HGF)-induced migration and invasion, as well as the secretion of matrix metalloproteinase (MMP)-2 and MMP-9. Both HCMV and EGF activated the EGF receptor (EGFR), inducing receptor tyrosine phosphorylation at specific residues. Of interest, EGFR was differentially activated by HCMV, and viral gene transcription was not required for the observed inhibitory effect on CTB invasiveness. These findings demonstrate that HCMV infection impairs CTB differentiation along the invasive pathway and that the differential regulation of EGFR by HCMV may contribute to impaired CTB function. Elucidating the mechanisms by which HCMV impairs placentation may be key in understanding fetal and maternal pathologies associated with intrauterine HCMV infection.

Anaesthetic considerations in a parturient with varicella presenting for Caesarean section

A parturient with varicella (chickenpox) presented for an elective Caesarean section and spinal anaesthesia was employed for surgery. A review of the literature is presented and the anaesthetic issues are discussed.

Antenatal screening for sexually transmitted infections in remote Australia

BACKGROUND

Antenatal screening for, and prompt management of, sexually transmitted infections (STI) can prevent adverse maternal, fetal and perinatal outcomes. This is particularly important in areas of high STI endemicity.

AIMS

To assess adherence with antenatal STI screening guidelines in a large remote region, and whether completeness of antenatal syphilis screening improved after the onset of a regional syphilis outbreak in April 2001.

METHODS

Data from the regional antenatal syphilis screening database from 1997 to 2002 were analysed to identify time trends in the completeness of antenatal syphilis screening. Adherence to antenatal screening guidelines was assessed by examining pathology request forms of women undergoing antenatal syphilis screening to determine whether screening for gonorrhoea, chlamydia, hepatitis B and HIV had also been carried out. Logistic regression was used to analyse associations between adherence to the guidelines and patient's age and race, and health service characteristics.

RESULTS

Adherence to syphilis screening guidelines improved from 44.6% in 1997 to 68.9% in 2001 and 81.4% in 2002. After controlling for the time interval between the first antenatal syphilis test and date of delivery, being younger and Aboriginal, and delivering after the syphilis outbreak had been identified were positively associated with adherence to syphilis screening guidelines. Proportions of antenates screened for gonorrhoea/chlamydia, hepatitis B and HIV at booking and for gonorrhoea/chlamydia in the third trimester were 69%, 91%, 68% and 77%, respectively. Aboriginal women were more likely to have been screened for gonorrhoea and chlamydia. Women seen by a doctor were more likely to have undergone HIV screening than those who saw a nurse.

CONCLUSIONS

Significant improvement in adherence to antenatal syphilis screening guidelines occurred after identification of a syphilis outbreak. This achievement is reason for optimism regarding the potential to achieve more complete antenatal screening of other STI.

Gregg's congenital rubella patients 60 years later

BACKGROUND

In 1941, a Sydney ophthalmologist, Norman McAlister Gregg, correctly identified the link between congenital cataracts in infants and maternal rubella early in pregnancy. Fifty of Gregg's subjects with congenital rubella, born in 1939-1944, were reviewed in 1967 and again in 1991. We reviewed this cohort in 2000-2001, 60 years after their intrauterine infection.

METHODS

The subjects underwent full clinical assessment, plus pathology tests, an ophthalmological and cardiological review (including electrocardiography and echocardiography) and HLA histocompatibility testing.

RESULTS

Since they were first seen in 1967, 10 have died (cardiovascular causes [4], malignant disease [4], AIDS [1], and hepatitis C-related cirrhosis [1]). All surviving men came for review (19) and 13 women (eight women declined). Echocardiography showed mild aortic valve sclerosis in 68%. The prevalence of diabetes (22%), thyroid disorders (19%), early menopause (73%) and osteoporosis (12.5%) was increased compared with the Australian population; 41% had undetectable levels of rubella antibodies. The frequency of HLA-A1 (44%) and HLA-B8 (34%) antigens was increased, and the haplotype HLA-A1, B8, DR3, said to be highly associated with many autoimmune conditions, was present in 25%.

CONCLUSIONS

This cohort of people with congenital rubella has illuminated our understanding of viral teratogenesis.