Is there a role for magnetic resonance imaging in cesarean scar pregnancy after the first trimester?

Magnetic resonance imaging (MRI) can provide additional information in cases of cesarean scar pregnancy beyond the first trimester. MRI and 3D reconstructions can demonstrate the relationships between the uterus, cervix, bladder, and placenta, improving the spatial perspective of the pelvic anatomy in cases requiring surgical management. MRI and 3D reconstructions can also provide more comprehensive images for parental counseling, virtual and face-to-face multidisciplinary team discussion, and medical record storage.

Management of placenta accreta spectrum in low- and middle-income countries

Placenta accreta spectrum (PAS) can be associated massive intra- and post-operative hemorrhage which when not controlled can lead to maternal death. Important advances have occurred in understanding the pathophysiology and therapeutic options for this condition. The prevalence of PAS at birth is direct association with the cesarean delivery (CD) rate in the corresponding population and is increasing worldwide. Limited health infrastructure in low- and middle-income countries increases the morbidity and mortality of patients with PAS at birth. In many cases, obstetricians working in limited resources settings cannot follow some of the international guideline's recommendations and have to opt for low-cost management procedures. In this review, we describe the particularities of managing PAS care in low- and middle-income countries from of prenatal evaluation of patients at risk of PAS at birth, therapeutic options, and inter-institutional collaboration. We also propose a management protocol based on training of the local obstetric teams rather than on sophisticated technological resources that are almost never available in low-resource scenarios.

Incidence of Respiratory Syncytial Virus-Associated Lower Respiratory Tract Illness in Infants in Low- and Middle-Income Regions During the Coronavirus Disease 2019 Pandemic

Background

Incidence data of respiratory syncytial virus-associated lower respiratory tract illness (RSV-LRTI) are sparse in low- and middle-income countries (LMICs). We estimated RSV-LRTI incidence rates (IRs) in infants in LMICs using World Health Organization case definitions.

Methods

This prospective cohort study, conducted in 10 LMICs from May 2019 to October 2021 (largely overlapping with the coronavirus disease 2019 [COVID-19] pandemic), followed infants born to women with low-risk pregnancies for 1 year from birth using active and passive surveillance to detect potential LRTIs, and quantitative reverse-transcription polymerase chain reaction on nasal swabs to detect RSV.

Results

Among 2094 infants, 32 (1.5%) experienced an RSV-LRTI (8 during their first 6 months of life, 24 thereafter). Seventeen (0.8%) infants had severe RSV-LRTI and 168 (8.0%) had all-cause LRTI. IRs (95% confidence intervals [CIs]) of first RSV-LRTI episode were 1.0 (.3-2.3), 0.8 (.3-1.5), and 1.6 (1.1-2.2) per 100 person-years for infants aged 0-2, 0-5, and 0-11 months, respectively. IRs (95% CIs) of the first all-cause LRTI episode were 10.7 (8.1-14.0), 11.7 (9.6-14.0), and 8.7 (7.5-10.2) per 100 person-years, respectively. IRs varied by country (RSV-LRTI: 0.0-8.3, all-cause LRTI: 0.0-49.6 per 100 person-years for 0- to 11-month-olds).

Conclusions

RSV-LRTI IRs in infants in this study were relatively low, likely due to reduced viral circulation caused by COVID-19-related nonpharmaceutical interventions.

Clinical Trials Registration

NCT03614676.

Urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders: systematic review and meta-analysis

OBJECTIVE

To report on the occurrence of urological complications in women undergoing Cesarean section for placenta accreta spectrum disorders (PAS).

METHODS

MEDLINE, EMBASE and the Cochrane databases were searched electronically up to 1 November 2022. Studies reporting on the urological outcome of women undergoing Cesarean section for PAS were included. Two independent reviewers performed data extraction using a predefined protocol and assessed the risk of bias using the Newcastle-Ottawa scale for observational studies, with disagreements resolved by consensus.The primary outcome was the overall occurrence of urological complications. Secondary outcomes were the occurrence of any cystotomy, intentional cystotomy, unintentional cystotomy, ureteral damage, ureteral fistula and vesicovaginal fistula. All outcomes were explored in the overall population of women undergoing surgery for PAS. In addition, we performed subgroup analyses according to the type of surgery (Cesarean hysterectomy, or conservative surgery or management), severity of PAS at histopathology (placenta accreta/increta and placenta percreta), type of intervention (planned vs emergency) and number of cases per year. Random-effects meta-analyses of proportions were used to analyze the data.

RESULTS

There were 62 studies included in the systematic review and 56 were included in the meta-analysis. Urological complications occurred in 15.2% (95% CI, 12.9-17.7%) of cases. Cystotomy complicated 13.5% (95% CI, 9.7-17.9%) of surgical operations. Intentional cystotomy was required in 7.7% (95% CI, 6.5-9.1%) of cases, while unintentional cystotomy occurred in 7.2% (95% CI, 6.0-8.5%) of cases. Urological complications occurred in 19.4% (95% CI, 16.3-22.7%) of cases undergoing hysterectomy and 12.2% (95% CI, 7.5-17.8%) of those undergoing conservative treatment. In the subgroup analyses, urological complications occurred in 9.4% (95% CI, 5.4-14.4%) of women with placenta accreta/increta and 38.5% (95% CI, 21.6-57.0%) of those described as having placenta percreta, and included mainly cystotomy (5.5% (95% CI, 0.6-15.1%) and 22.0% (95% CI, 5.4-45.5%), respectively). Urological complications occurred in 15.4% (95% CI, 8.1-24.6%) of cases undergoing a planned procedure and 24.6% (95% CI, 13.0-38.5%) of those undergoing an emergency intervention. In subanalysis of studies reporting on ≥ 12 cases per year, the incidence of urological complication was similar to that reported in the primary analysis.

CONCLUSIONS

Women undergoing surgery for PAS are at high risk of urological complication, mainly cystotomy. The incidence of these complications was particularly high in women described as having placenta percreta at birth and in those undergoing emergency surgical intervention. The high heterogeneity between the included studies highlights the need for a standardized protocol for the diagnosis of PAS to identify prenatal imaging signs associated with the increased risk of urological morbidity at delivery. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Severe Adams-Oliver Syndrome after Maternal COVID-19 Infection Could Be Another Effect of the SARS-CoV-2 Inflammatory Storm? Case Report

Background. Adams-Oliver syndrome is a congenital disease whose main findings are aplasia cutis congenita of the scalp and terminal transverse limb defects. The pathogenesis is unknown, but it is postulated that ischemic events in susceptible tissues cause the lesions in the embryonic period.Case report. We present a newborn with a severe phenotype of Adams-Oliver syndrome. The infant's mother had a SARS-CoV-2 infection in the first trimester of pregnancy. Prenatal ultrasound indicates a probable worsening of the disease after the first trimester.Conclusion. This study shows a previously unpublished severe AOS phenotype in a term newborn. There are some signs that the disease could have progressed beyond the first trimester, either spontaneously or by the inflammatory mechanisms of SARS-CoV-2.

Risk of adverse outcomes in offspring with RT-PCR confirmed prenatal Zika virus exposure: An individual participant data meta-analysis of 13 cohorts in the Zika Brazilian Cohorts Consortium

Background

Knowledge regarding the risks associated with Zika virus (ZIKV) infections in pregnancy has relied on individual studies with relatively small sample sizes and variable risk estimates of adverse outcomes, or on surveillance or routinely collected data. Using data from the Zika Brazilian Cohorts Consortium, this study aims, to estimate the risk of adverse outcomes among offspring of women with RT-PCR-confirmed ZIKV infection during pregnancy and to explore heterogeneity between studies.

Methods

We performed an individual participant data meta-analysis of the offspring of 1548 pregnant women from 13 studies, using one and two-stage meta-analyses to estimate the absolute risks.

Findings

Of the 1548 ZIKV-exposed pregnancies, the risk of miscarriage was 0.9%, while the risk of stillbirth was 0.3%. Among the pregnancies with liveborn children, the risk of prematurity was 10,5%, the risk of low birth weight was 7.7, and the risk of small for gestational age (SGA) was 16.2%. For other abnormalities, the absolute risks were: 2.6% for microcephaly at birth or first evaluation, 4.0% for microcephaly at any time during follow-up, 7.9% for neuroimaging abnormalities, 18.7% for functional neurological abnormalities, 4.0% for ophthalmic abnormalities, 6.4% for auditory abnormalities, 0.6% for arthrogryposis, and 1.5% for dysphagia. This risk was similar in all sites studied and in different socioeconomic conditions, indicating that there are not likely to be other factors modifying this association.

Interpretation

This study based on prospectively collected data generates the most robust evidence to date on the risks of congenital ZIKV infections over the early life course. Overall, approximately one-third of liveborn children with prenatal ZIKV exposure presented with at least one abnormality compatible with congenital infection, while the risk to present with at least two abnormalities in combination was less than 1.0%.

Effects of Initiating Raltegravir-Based Versus Efavirenz-Based Antiretroviral Regimens During Pregnancy on Weight Changes and Perinatal Outcomes: NICHD P1081

BACKGROUND

Integrase inhibitors have been associated with excess gestational weight gain that may lead to adverse pregnancy outcomes (APOs). This post hoc analysis of NICHD P1081 compared antepartum changes in weight and body mass index (BMI) in pregnant women initiating raltegravir- or efavirenz-based combined antiretroviral therapy (cART) and examined associations between rates of weight gain and APOs.

SETTING

NICHD P1081 enrolled antiretroviral-naive pregnant women living with HIV in the second and third trimester in Brazil, Tanzania, South Africa, Thailand, Argentina, and the United States.

METHODS

Two hundred eighty-one women enrolled between 20 and 31 gestational weeks were randomized to raltegravir- or efavirenz-based cART and followed for ≥4 weeks. A low rate of weight gain was defined as <0.18 kg/wk and high as >0.59 kg/wk. We compared weight gain and BMI increase between treatment arms using Kruskal-Wallis tests. Logistic regression was used to investigate the association between weight gain and APOs.

RESULTS

Raltegravir-based cART was associated with significantly higher antepartum weight gain (median 0.36 kg/wk versus 0.29 kg/wk, P = 0.01) and BMI increase (median 0.14 kg/m 2 /wk versus 0.11 kg/m 2 /wk, P = 0.01) compared with efavirenz-based treatment. Women on raltegravir had less low weight gain (18% versus 36%) and more high weight gain (21% versus 12%) ( P = 0.001). Women with low weight gain were more likely than those with normal weight gain to have small for gestational age infants or a composite of APOs.

CONCLUSIONS

A raltegravir-based antiretroviral regimen was associated with significantly higher antepartum rate of weight gain and BMI increase compared with efavirenz-based treatment in antiretroviral-naive pregnant women.

Peripartum echocardiographic changes in women with hypertensive disorders of pregnancy

OBJECTIVE

Hypertensive disorders of pregnancy (HDP) are associated with significant myocardial dysfunction on echocardiography. The impact of hemodynamic changes related to volume redistribution following delivery on myocardial function in women with HDP has not been evaluated systematically. The aim of this study was to compare echocardiographic findings immediately before and after delivery in women with HDP.

METHODS

This was a prospective longitudinal study including 30 women with a diagnosis of HDP who underwent two consecutive transthoracic echocardiographic (TTE) examinations, before delivery and in the early postpartum period. Paired comparisons of the findings from the two assessments were performed.

RESULTS

Left-ventricular (LV) concentric remodeling or hypertrophy was detected in 21 (70%) patients. There was no significant difference in cardiac morphology indices such as LV mass index (78.9 ± 16.3 g/m² vs 77.9 ± 15.4 g/m² ; P = 0.611) or relative wall thickness (0.45 ± 0.1 vs 0.44 ± 0.1; P = 0.453) before vs after delivery. LV diastolic function did not demonstrate any peripartum variation, with similar left-atrial volume (52.4 ± 15.3 mL vs 51.0 ± 15.6 mL; P = 0.433), lateral E' (0.12 ± 0.03 m/s vs 0.12 ± 0.03 m/s; P = 0.307) and E/E' ratio (7.9 ± 2.2 vs 7.9 ± 1.7; P = 0.934) before vs after delivery. Systolic function indices, such as LV ejection fraction (57.5 ± 3.4% vs 56.4 ± 2.1%; P = 0.295) and global longitudinal strain (-15.3 ± 2.6% vs -15.1 ± 3.1%; P = 0.582), also remained unchanged between before vs after delivery.

CONCLUSIONS

Maternal hemodynamic changes associated with delivery did not influence significantly peripartum TTE indices in women with HDP. Suboptimal maternal echocardiographic findings in HDP are likely to be the consequence of chronic pregnancy cardiovascular load changes or pre-existing maternal cardiovascular impairment. Severity and persistence of myocardial dysfunction in the postpartum period may be related to the long-term maternal cardiovascular disease legacy of HDP. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Perspectives on administration of COVID-19 vaccine to pregnant and lactating women: a challenge for low- and middle-income countries

Women who are in the pregnancy-puerperal cycle or are lactating have been deliberately excluded from participating in COVID-19 vaccine clinical trials that aimed to evaluate either the efficacy of the vaccines in inducing the formation of neutralizing antibodies or the investigational products' safety profile. The exclusion of pregnant and lactating women from such studies certainly and inequitably denies these women access to COVID-19 vaccines, since these products have become increasingly available to nonpregnant people and even to those who are pregnant and are in high-income settings. In this clinical opinion article, we discuss some aspects of the prolonged pandemic, the emergence of viral variants, the risks of severe complications of COVID-19 in pregnant women, and the disproportionate impact of the above on low- and middle-income countries. We argue that the decision to receive the COVID-19 vaccine should be a joint decision between the pregnant or lactating women and the healthcare providers, while considering the available data on vaccine efficacy, safety, the risks of SARS-CoV-2 infection in pregnant women, and the women's individual risks for infection and serious illness. The various types of vaccines that are already in use and their safety, effectiveness, and the potential risks and benefits of their administration to pregnant or lactating women are also reviewed.

Cranial US in Infants Exposed to Zika Virus: The NATZIG Cohort

Background Studies addressing neuroimaging findings as primary outcomes of congenital Zika virus infection are variable regarding inclusion criteria and confirmatory laboratory testing. Purpose To investigate cranial US signs of prenatal Zika virus exposure and to describe frequencies of cranial US findings in infants exposed to Zika virus compared to those in control infants. Materials and Methods In this single-center prospective cohort study, participants were enrolled during the December 2015-July 2016 outbreak of Zika virus infection in southeast Brazil (Natural History of Zika Virus Infection in Gestation cohort). Eligibility criteria were available cranial US and laboratory findings of maternal Zika virus infection during pregnancy confirmed with RNA polymerase chain reaction testing (ie, Zika virus-exposed infants). The control group was derived from the Zika in Infants and Pregnancy cohort and consisted of infants born to asymptomatic pregnant women who tested negative for Zika virus infection during pregnancy. Two radiologists who were blinded to the maternal Zika virus infection status independently reviewed cranial US scans from both groups and categorized them as normal findings, Zika virus-like pattern, or mild findings. Associations between cranial US findings and prenatal Zika virus exposure were assessed with univariable analysis. Results Two hundred twenty Zika virus-exposed infants (mean age, 53.3 days ± 71.1 [standard deviation]; 113 boys) and born to 219 mothers infected with Zika virus were included in this study and compared with 170 control infants (mean age, 45.6 days ± 45.8; 102 boys). Eleven of the 220 Zika virus-exposed infants (5%), but no control infants, had a Zika virus-like pattern at cranial US. No difference in frequency of mild findings was observed between the groups (50 of 220 infants [23%] vs 44 of 170 infants [26%], respectively; P = .35). The mild finding of lenticulostriate vasculopathy, however, was nine times more frequent in Zika virus-exposed infants (12 of 220 infants, 6%) than in control infants (one of 170 infants, 1%) (P = .01). Conclusion Lenticulostriate vasculopathy was more common after prenatal exposure to Zika virus, even in infants with normal head size, despite otherwise overall similar frequency of mild cranial US findings in Zika virus-exposed infants and in control infants. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Benson in this issue.

Persistence of Anti-ZIKV-IgG over Time Is Not a Useful Congenital Infection Marker in Infants Born to ZIKV-Infected Mothers: The NATZIG Cohort

Confirming ZIKV congenital infection is challenging because viral RNA is infrequently detected. We compared the presence of anti-ZIKV-IgM and the persistence of anti-ZIKV-IgG antibodies over 18 months in two cohorts of infants born to ZIKV-infected mothers: Cohort one: 30 infants with typical microcephaly or major brain abnormalities (Congenital Zika Syndrome-CZS); Cohort two: 123 asymptomatic infants. Serum samples obtained within 6 months of age were tested for anti-ZIKV-IgM. Anti-ZIKV-IgG was quantified in sequential samples collected at birth, 3-6 weeks, 3, 6, 12, and 18 months. ZIKV-RNA was never detected postnatally. Anti-ZIKV-IgM antibodies were detected at least once in 15/25 (60.0%; 95%CI: 38.7-78.9) infants with CZS and in 2/115 (1.7%; 95%CI: 0.2-6.1) asymptomatic infants. Although anti-ZIKV-IgG was always positive within 3-6 weeks of age, IgG levels decreased similarly over time in both cohorts. IgG levels decreased similarly in ZIKV-IgM-positive and ZIKV-IgM-negative CZS infants. Differently from other congenital infections, IgM would fail to diagnose 40% of severely symptomatic infants, and the persistence of IgG is not a useful marker for discriminating congenital infection among infants exposed to maternal ZIKV infection.

Effectiveness of contingent screening for placenta accreta spectrum disorders based on persistent low-lying placenta and previous uterine surgery

OBJECTIVES

Maternal mortality related to placenta accreta spectrum (PAS) disorders remains substantial when diagnosed unexpectedly at delivery. The aim of this study was to evaluate the effectiveness of a routine contingent ultrasound screening program for PAS.

METHODS

This was a retrospective study of data obtained between 2009 and 2019, involving two groups: a screening cohort of unselected women attending for routine mid-trimester ultrasound assessment and a diagnostic cohort consisting of women referred to the PAS diagnostic service with a suspected diagnosis of PAS. In the screening cohort, women with a low-lying placenta at the mid-trimester assessment were followed up in the third trimester, and those with a persistent low-lying placenta (i.e. placenta previa) and previous uterine surgery were referred to the PAS diagnostic service. Ultrasound assessment by the PAS diagnostic service consisted of two-dimensional grayscale and color Doppler ultrasonography, and women with a diagnosis of PAS were usually managed with conservative myometrial resection. The final diagnosis of PAS was based on a combination of intraoperative clinical findings and histopathological examination of the surgical specimen.

RESULTS

In total, 57 179 women underwent routine mid-trimester fetal anatomy assessment, of whom 220 (0.4%) had a third-trimester diagnosis of placenta previa. Seventy-five of these women were referred to the PAS diagnostic service because of a history of uterine surgery, and 21 of 22 cases of PAS were diagnosed correctly (sensitivity, 95.45% (95% CI, 77.16-99.88%) and specificity, 100% (95% CI, 99.07-100%)). Univariate analysis demonstrated that parity ≥ 2 (odds ratio (OR), 35.50 (95% CI, 6.90-649.00)), two or more previous Cesarean sections (OR, 94.20 (95% CI, 22.00-656.00)) and placenta previa (OR, 20.50 (95% CI, 4.22-369.00)) were the strongest risk factors for PAS. In the diagnostic cohort, there were 173 referrals, with one false-positive and three false-negative diagnoses, resulting in a sensitivity of 96.63% (95% CI, 90.46-99.30%) and a specificity of 98.81% (95% CI, 93.54-99.97%).

CONCLUSIONS

A contingent screening strategy for PAS is both feasible and effective in a routine healthcare setting. When linked to a PAS diagnostic and surgical management service, adoption of such a screening strategy has the potential to reduce the maternal morbidity and mortality associated with this condition. However, larger prospective studies are necessary before implementing this screening strategy into routine clinical practice. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

How to set up a regional specialist referral service for Placenta Accreta Spectrum (PAS) disorders?

There has been an approximately fivefold increase in the incidence of placenta accreta spectrum (PAS) disorders during the last 30 years, believed to be secondary to increasing Caesarean section rates. PAS disorder is associated with significantly increased maternal morbidity and mortality worldwide. Antenatal diagnosis by foetal medicine teams that have a special expertise to diagnose PAS disorder by the use of ultrasound scan, and a dedicated, highly specialised multidisciplinary team (MDT) comprising surgeons who are skilled in complex pelvic surgery and obstetric anaesthetists who have an expertise in high-risk obstetric anaesthesia, supported by haematology, operating theatre, interventional radiology, midwifery, neonatology, high-dependency and intensive care teams have been recommended to improve maternal and perinatal outcomes. Setting up a specialist MDT regional referral service, PAS involves collaboration with all stakeholders, ensuring appropriate funding, developing MDT care pathways, continuously auditing patient outcomes and disseminating knowledge through research, innovation, education and publications.

Stillbirth at term: Does size really matter?

Placental dysfunction has a deleterious influence on fetal size and is associated with higher rates of perinatal morbidity and mortality. This association underpins the strategy of fetal size evaluation as a mechanism to identify placental dysfunction and prevent stillbirth. The optimal method of routine detection of small for gestational age (SGA) remains to be clarified with choices between estimation of symphyseal-fundal height versus routine third-trimester ultrasound, various formulae for fetal weight estimation by ultrasound, and the variable use of national, customized, or international fetal growth references. In addition to these controversies, the strategy for detecting SGA is further undermined by data demonstrating that the relationship between fetal size and adverse outcome weakens significantly with advancing gestation such that near term, the majority of stillbirths and adverse perinatal outcomes occur in normally sized fetuses. The use of maternal serum biochemical and Doppler parameters near term appears to be superior to fetal size in the identification of fetuses compromised by placental dysfunction and at increased risk of damage or demise. Multiparameter models and predictive algorithms using maternal risk factors, and biochemical and Doppler parameters have been developed, but need to be prospectively validated to demonstrate their effectiveness.

ANEMIA E PERFIL DE LIPÍDEOS EM GESTANTES VIVENDO COM O VÍRUS DA IMUNODEFICIÊNCIA HUMANA

A infecção pelo HIV associa-se à anemia e às alterações no perfil de lipídeos de pessoas que vivem com o vírus. O objetivo deste estudo foi descrever a prevalência de anemia e as alterações nos níveis de lipídeos em gestantes que vivem com HIV/aids. O estudo foi do tipo coorte retrospectiva, realizado com 117 gestantes, em uso de terapia antirretroviral combinada, atendidas em ambulatório de pré-natal no período de 2010 a 2012, utilizando-se de dados secundários. A prevalência de anemia foi de 45,6% e nenhuma gestante apresentou anemia severa. Observou-se aumento progressivo das dosagens de colesterol total (p

Predictors of adverse pregnancy outcomes in women infected with HIV in Latin America and the Caribbean: a cohort study

OBJECTIVE

To examine maternal characteristics associated with adverse pregnancy outcomes among women infected with HIV.

DESIGN

Prospective cohort study.

SETTING

Multiple sites in Latin America and the Caribbean.

POPULATION

Women infected with HIV enrolled in the Perinatal (2002-2007) and the Longitudinal Study in Latin American Countries (LILAC; 2008-2012) studies of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) International Site Development Initiative (NISDI).

METHODS

Frequencies of adverse pregnancy outcomes assessed among pregnancies. Risk factors investigated by logistic regression analysis.

MAIN OUTCOME MEASURES

Adverse pregnancy outcomes, including preterm delivery (PT), low birthweight (LBW), small for gestational age (SGA), stillbirth (SB), and neonatal death.

RESULTS

Among 1512 women, 1.9% (95% confidence interval, 95% CI, 1.3-2.7) of singleton pregnancies resulted in a stillbirth and 32.9% (95% CI 30.6-35.4) had at least one adverse pregnancy outcome. Of 1483 singleton live births, 19.8% (95% CI 17.8-21.9) were PT, 14.2% (95% CI 12.5-16.1) were LBW, 12.6% (95% CI 10.9-14.4) were SGA, and 0.4% (95% CI 0.2-0.9) of infants died within 28 days of birth. Multivariable logistic regression modelling indicated that the following risk factors increased the probability of having one or more adverse pregnancy outcomes: lower maternal body mass index at delivery (odds ratio, OR, 2.2; 95% CI 1.4-3.5), hospitalisation during pregnancy (OR 3.3; 95% CI 2.0-5.3), hypertension during pregnancy (OR 2.7; 95% CI 1.5-4.8), antiretroviral use at conception (OR 1.4; 95% CI 1.0-1.9), and tobacco use during pregnancy (OR 1.7; 95% CI 1.3-2.2). The results of fitting multivariable logistic regression models for PT, LBW, SGA, and SB are also reported.

CONCLUSIONS

Women infected with HIV had a relatively high occurrence of adverse pregnancy outcomes, and some maternal risk factors were associated with these adverse pregnancy outcomes. Interventions targeting modifiable risk factors should be evaluated further.

Hypertension, preeclampsia and eclampsia among HIV-infected pregnant women from Latin America and Caribbean countries

OBJECTIVES

To evaluate the incidence of and risk factors for hypertensive disorders in a cohort of HIV-infected pregnant women.

METHODS

Hypertensive disorders (HD) including preeclampsia/eclampsia (PE/E) and pregnancy induced hypertension, and risk factors were evaluated in a cohort of HIV-infected pregnant women from Latin America and the Caribbean enrolled between 2002 and 2009. Only pregnant women enrolled for the first time in the study and delivered at ≥20 weeks gestation were analyzed.

RESULTS

HD were diagnosed in 73 (4.8%, 95% CI: 3.8%-6.0%) of 1513 patients; 35 (47.9%) had PE/E. HD was significantly increased among women with a gestational age-adjusted body mass index (gBMI) ≥25 kg/m(2) (OR = 3.1; 95% CI: 1.9-5.0), hemoglobin (Hg) ≥11 g/dL at delivery (OR = 2.1; 95% CI: 1.2-3.6) and age ≥35 years (OR = 1.8; 95% CI: 1.1-3.2). PE/E was increased among women with a gBMI ≥25 kg/m(2) (OR = 3.0; 95% CI: 1.5-6.0) and Hg ≥11 g/dL at delivery (OR = 2.8; 95% CI: 1.2-6.5). A previous history of PE/E increased the risk of PE/E 6.7 fold (95% CI: 1.8-25.5). HAART before conception was associated with PE/E (OR = 2.3; 95% CI: 1.1-4.9).

CONCLUSIONS

HIV-infected women, with a previous history of PE/E, a gBMI ≥25 kg/m(2), Hg at delivery ≥11 g/dL and in use of HAART before conception are at an increased risk of developing PE/E during pregnancy.

[Monitoring the prenatal care process among users of the Unified Health Care System in a city of the Brazilian Southeast]

PURPOSE

to evaluate the evolution of adequacy of the care process among pregnant users of the Brazilian Single Health System (SUS, acronym in Portuguese) and to consolidate a methodology for monitoring the prenatal care.

METHODS

this is a multiple time series study with auditing of prenatal cards of pregnant women who were attended for prenatal care in a city of the Brazilian Southeast (Juiz de Fora, Minas Gerais) in the initial semesters of 2002 and 2004 (370 and 1,200 cards, respectively) and gave birth using SUS services in term pregnancies (p < 0.05). A three complementary level sequence was respected: utilization of prenatal care (beginning and number of visits) at level 1; utilization of prenatal care and obligatory clinical-obstetric procedures during prenatal visits (assessment of blood pressure (BP), weight, uterine fundal height (FH), gestational age (GA), fetal heart rate (FHR) and fetal presentation) at level 2; and utilization of prenatal care, obligatory clinical-obstetric procedures and basic laboratory tests, according to the Humanization Program of Prenatal Care and Birth (PHPN, acronym in Portuguese) (ABO/Rh, hemoglobin/hematocrit (Hb/Htc), VDRL, glycemia and urinalisys) at level 3.

RESULTS

it was confirmed the high prenatal care coverage (99%), the increased mean number of visits per pregnant woman (6.4 versus 7.2%) and the decreased gestational age at the time of the first visit (17.4 versus 15.7 weeks). The proper registration of procedures and exams (exceptions: fetal presentation and blood typing) has significantly increased: BP (77.8 versus 83.9%); weight (75.4 versus 83.5%); FH (72.7 versus 81.3%); GA (58.1 versus 71.5%); FHR (79.5 versus 86.7%); Hb/Htc (14.9 versus 29%), VDRL (11.1 versus 20.7%), glycemia (16.5 versus 29%) and urinalisys (13.8 versus 29.8%). As a result, there was significant (p < 0.001) improvement of the adequacy between 2002 and 2004: 27.6 versus 44.8% (level 1); 7.8 versus 15.4% (level 2); 1.1 versus 4.5% (level 3). This trend was also noted in care provided by the majority of the municipal services/teams.

CONCLUSIONS

the persistence of low adequacy, despite good coverage and PHPN implementation, confirmed the need to increase health managers, professionals and users' compliance with the rules and routines of care, including the institutionalization of a monitoring program of prenatal care.

1H MR spectroscopy evidence for the varied nature of asymptomatic focal brain lesions in neurofibromatosis type 1

We present the MRI and 1H MR spectroscopy findings in six patients with neurofibromatosis type 1 (NF1) and asymptomatic focal brain lesions. Variations in imaging appearances were seen, including regression of a previously identified lesion. MR spectra for the lesions and corresponding areas of normal brain show significant differences. The lesions could be separated into two groups, one demonstrating only slight metabolite ratio changes relative to normal brain and the other group showing significant increase in choline and decrease in N-acetyl aspartate. The lesion which regressed fell into the second group. These findings are not in agreement with those previously reported and provide evidence for the varied and possibly transient nature of these asymptomatic lesions. The spectroscopy findings suggest that metabolite changes may be present without visible changes on MRI.

Trypanosoma cruzi: acute infection affects expression of alpha-2-macroglobulin and A2MR/LRP receptor differently in C3H and C57BL/6 mice

Although a complete cellular and humoral immune response is elicited in Chagas' disease, recent data suggest that other natural elements of innate immunity may also contribute to the initial host primary defense. alpha-Macroglobulins are a family of plasma proteinase inhibitors that are acute-phase reactants in Trypanosoma cruzi-infected mice and humans. Mice contain a tetrameric alpha-2-macroglobulin (MAM) and a monomeric murinoglobulin (MUG). Heterogeneity in their reactions was observed in murine T. cruzi-infected plasma A2M levels despite an overall increase. In addition, up-regulation of the A2M receptor (A2MR/LRP) was observed in peritoneal macrophages during T. cruzi infection. Here, we show that during T. cruzi infection (Y strain), the MAM and MUG hepatic mRNA levels and the corresponding plasma protein levels were up-regulated in C3H and C57BL/6 (B6) mice, but with different kinetics. On the contrary, A2MR/LRP mRNA levels increased in acutely infected C3H mice, but decreased in B6 mice, in both liver and heart. Immunocytochemistry of infected B6 heart cryosections confirmed a less intense endothelium labeling by the fluoresceinated ligand for A2MR/LRP. On the other hand, infected B6 spleen cells displayed higher F-A2M-FITC binding and MAC1 expression, confirming higher A2MR/LRP expression in macrophages. In uninfected mice, as well as after T. cruzi infection, higher A2M plasma levels were measured in C3H mice than in B6 mice. The lower tissue T. cruzi parasitism found in C3H-infected mice could reflect an inhibitory effect of A2M on parasite invasion. Our present data further contribute to clarifying aspects of the role of A2MR/LRP in a model of acute Chagas' disease in different mouse strains.

Genetic alterations in Ki-ras and Ha-ras genes in juvenile nasopharyngeal angiofibromas and head and neck cancer

CONTEXT

Ras gene mutations have been associated to a wide range of human solid tumors. Members of the ras gene family (Ki-ras, Ha-ras and N-ras) are structurally related and code for a protein (p21) known to play an important role in the regulation of normal signal transduction and cell growth. The frequency of ras mutations is different from one type of tumor to another, suggesting that point mutations might be carcinogen-specific.

OBJECTIVES

To study the occurrence of Ki-ras and Ha-ras mutations. We also studied the relative level of Ha-ras mRNA in 32 of the head and neck tumors.

DESIGN

Case series.

SETTING

University referral unit.

PARTICIPANTS

60 head and neck tumors and in 28 Juvenile Nasopharyngeal Angiofibromas (JNA).

DIAGNOSTIC TEST

Using PCR-SSCP we examined the occurrence of Ki-ras and Ha-ras mutations. The relative level of Ha-ras mRNA was examined by Northern blot analysis.

RESULTS

None of the head and neck tumors or JNA samples showed evidence of mutations within codons 12, 13, 59 and 61 of Ki-ras or Ha-ras genes. However, 17 (53%) of the tumors where gene expression could be examined exhibited increased levels of Ha-ras mRNA compared with the normal tissue derived from the same patient.

CONCLUSIONS

Our results demonstrate for the first time that mutations of Ki-ras and Ha-ras genes are not associated with the development of JNA and confirm previous reports indicating that activating ras mutations are absent or rarely involved in head and neck tumors from western world patients. Furthermore, our findings suggest that overexpression of Ha-ras, rather than mutations, might be an important factor in the development and progression of head and neck tumors.

Detection of alpha-macroglobulin in the heart of mice infected with Trypanosoma cruzi

The aim of this work was to investigate the presence of alpha-macroglobulin (AM) in the heart of mice during acute experimental Chagas' disease and to study its localization as related to the presence of the parasite and/or to their antigens. Frozen heart tissue sections obtained from Swiss albino male mice at different days postinfection with Trypanosoma cruzi were examined for triple immunofluorescence in response to parasite antigen (green), AM (red), and nuclei (blue) from both cells. AM was found in the heart of all the infected animals studied. Parasites were seen arranged in nests inside heart muscle cells. Usually, AM staining corresponded in position to parasite nests and to their antigens spread in large areas of the myocardium. The most intense staining of AM was observed at days 9 and 11 postinfection, when the highest tissue-infection level occurs. These observations relate the presence of AM to that of T. cruzi antigen in the same areas of the inflamed myocardium of the chagasic animals.

Alpha-2-macroglobulin receptor is differently expressed in peritoneal macrophages from C3H and C57/B16 mice and up-regulated during Trypanosoma cruzi infection

Chagas' disease is caused by the protozoan Trypanosoma cruzi. The acute phase of T. cruzi infection, which can be conveniently studied in mouse models, is thought to be a determinant of survival and of the pathological features of the chronic phase. With regard to the occurrence of early death and parasitaemia levels C3H and C57/B16 mice are classically classified as 'susceptible' and 'resistant' to T. cruzi infection, respectively. Alpha-2-macroglobulin (A2M) is a physiological proteinase inhibitor found in tissues and in the plasma of mammals. Previous studies showed that A2M plasma levels increase in C3H mice acutely infected by T. cruzi but do not change in C57/B16 mice. This difference might involve two possible phenomena, concerning A2M synthesis and/or clearance by its receptor (A2M-R). In this study, we examined by flow cytometry the binding of A2M-trypsin conjugated with FITC to macrophages from normal and T. cruzi-infected C3H and C57/B16 mice. Our present results show for the first time that A2M-R is expressed more (by approximately 33%) in the surface of cells from normal C57/B16 as compared to C3H mice. We also show that A2M-R expression is up-regulated in both strains during acute T. cruzi infection, but at higher levels and earlier in C57/B16 mice. At the same time, peritoneal cells become activated as judged by: (1) increase of their size and granularity; (2) gradual increase of Fc gamma RII/III expression assayed by 2.4G2 binding; (3) down-modulation of F4/80 binding, a mAb that recognizes an antigen typically expressed in resident macrophages. Finally, our results indicate that as macrophages become activated in vivo a higher expression of A2M-R is observed.

Alpha-2-macroglobulin binds to the surface of Trypanosoma cruzi

Trypanosoma cruzi, the causative agent of Chagas disease, infects vertebrate cells after an initial step of parasite/host-cell recognition. Alpha-2-macroglobulin (A2M), an important type of physiological proteinase inhibitor found in tissues and in the plasma of mammals, inhibits cell invasion by T. cruzi and accumulates in sites of the inflamed myocardium associated with parasite antigens. To study whether A2M would bind to T. cruzi, an indirect immunofluorescence reaction was performed using two different anti-mouse A2M sera. Intense labeling was observed in the membrane lining the cell body and the flagellum of bloodstream trypomastigotes obtained from experimentally infected mice in the peak of parasitemia, suggesting that the antisera recognize plasma A2M associated with the parasite surface. Metacyclic trypomastigotes obtained in a serum-free defined medium reacted with anti-A2M only after previous incubation with purified human A2M. Enzyme-linked immunosorbent assay (ELISA) studies were applied to characterize better the binding of native (N-A2M) and of proteinase-complexed (P-A2M) forms of A2M. The "in vitro" binding of N-A2M to trypomastigotes was better at pH 5.0, followed by pH 10.0 and pH 7.4. Cysteinly and serine proteinase inhibitors, E-64 and STI, respectively, inhibited the reaction. P-A2M also bound to T. cruzi in a dose-dependent way. Flow-cytometry studies showed that about 80% of the parasites stained with fluorescein isothiocyanate (FITC)-labeled P-A2M (50 micrograms/ml) with high affinity at pH 7.4 (but also at pH 10.0) in a process that was reverted by the addition of unlabeled P-A2M or the calcium-chelator agent EDTA and also by incubation at an acid pH (4.0). These results suggest that (a) native-A2M binds to T. cruzi proteinase(s) and (b) T. cruzi expresses a receptor(s) that binds proteinase-complexed A2M.

Magnetic resonance angiography in the management of aneurysmal subarachnoid haemorrhage: a study of 51 cases

We report preliminary experience with the use of magnetic resonance angiography (MRA) in the assessment of intracranial aneurysms. The aims of the study were to confirm that aneurysms could be detected and to assess the quality of the images with a view to early surgery if clinically indicated. We studied 51 patients with recent spontaneous subarachnoid haemorrhage with MRA, using a three-dimensional time-of-flight technique. The results of MRA were subsequently confirmed on intra-arterial digital subtraction angiography (IA-DSA) for anatomical correlation, and were considered satisfactory in 38 patients (74.5%). In 20 patients early surgical obliteration of their aneurysm was possible on the MRA results without recourse to IA-DSA. A total of 37 aneurysms were identified in 32 patients, while the remaining 6 patients did not have an aneurysm. MRA was misinterpreted in 4 patients (7.9%), and in 9 other patients (17.6%) MRA was unsatisfactory due to movement artefacts.

Preliminary results of proton magnetic resonance spectroscopy in motor neurone disease (amytrophic lateral sclerosis)

Possible changes in brain metabolites in motor neurone disease/amytrophic lateral sclerosis (MND/ALS) were investigated using 1H magnetic resonance spectroscopy (MRS). A series of normal, healthy volunteer controls and MND patients have been studied using a spin echo (SE) 135 ms sequence, acquiring spectra from the region of the motor cortex. A further limited series of studies have been made for similar groups of volunteers and MND patients using a STEAM 20 ms sequence (stimulated echo). Analysis of the SE 135 ms spectra indicates there are statistically significant differences in the ratios of N-acetyl-aspartate to creatine and N-acetyl-aspartate to choline between controls and MND patients. Furthermore, metabolites identified using the STEAM 20 ms may be of great importance in the investigations of free radical mediated mechanisms, which have been postulated as being important contributors to the disease process. Preliminary results indicate that 1H MRS may provide important data to help understand the disease processes in MND and it could form a useful method for monitoring the effects of future trial treatment regimens.