Toxoplasmosis in pregnancy: determination of IgM, IgG and avidity in filter paper-embedded blood

OBJECTIVE

To detect immunoglobulin M (IgM) anti-Toxoplasma gondii antibodies and determine immunoglobulin G (IgG) titer and avidity in filter paper-embedded blood (FPEB) samples of pregnant women.

STUDY DESIGN

A total of 100 FPEB samples of pregnant women (30 positive and 70 negative) were analyzed for anti-T. gondii-specific IgM antibodies. Eleven and nine pairs of serum and FPEB samples were used to standardize IgG titration and avidity, respectively. Then, the correlation of avidity results was determined with 23 serum/FPEB pairs from IgG-positive cases.

RESULT

IgM detection in FPEB was 92% sensitive and 100% specific. The titration of IgG antibodies in FPEB correlated with that of serum (r >or=0.9). Significant difference in avidity between the acute and the undetermined/chronic cases was observed in both samples. As expected, no correlation was found between IgM levels and avidity.

CONCLUSION

The FPEB is useful to infer infection phase, and thus to speed clinical decisions in congenital toxoplasmosis management.

[Factors associated with acceptance of postpartum tubal ligation among HIV-infected women]

OBJECTIVE

To identify the factors associated with the acceptance of tubal ligation after childbirth among HIV-infected patients.

MATERIAL AND METHODS

A case-control study was conducted from March 1988 to February 1999, at Mexico's National Institute of Perinatology (INPer), in 72 HIV-positive pregnant women. Cases were 49 women who accepted postpartum tubal ligation after childbirth, and controls were 23 women who refused this birth control method. Data collected for each patient were demographic characteristics, sexual and reproductive history, and HIV status. Statistical analysis consisted of descriptive measures, Chi 2 or Fisher's exact test for categorical variables, and Student's t test for continuous variables. Odds ratios (OR) with 95% CI were used to compare groups and potential confounders were assessed by stratified analysis with the Mantel-Haenszel method.

RESULTS

The patients' mean age was 25.5 +/- 5.5 years. The median gestation period was 27 weeks (range 7 to 40 weeks); 16 women (22.2%) had no prenatal care visits at INPer. The median time of HIV positivist awareness was 9 months (range 1 to 108). Variables associated with acceptance of tubal ligation were: having a prior childbirth (OR 11.1, 95% CI 3.4 to 36), pregnancy care from 1995 onward (OR 4.7, 95% CI 1.7 to 13.3), and having given birth to an HIV-infected child (OR 4.6, 95% CI 1.05 to 23.1). Stratified analysis showed no modification of the strength of association of these variables with acceptance of tubal ligation.

CONCLUSIONS

A prior childbirth was the most important predictor of tubal ligation acceptance. The English version of this paper is available at: http://www.insp.mx/salud/index.html.

[Clinical manifestations and lethality of descending necrotizing mediastinitis]

OBJECTIVE

To describe the clinical manifestations, treatment and lethality of a series of patients with descending necrotizing mediastinitis (DNM).

DESIGN

Retrospective study of a series of cases. SITE OF STUDY: The Infectious Diseases Hospital (IDH) of the Mexican Social Security Institute, Mexico City; a national reference hospital.

PATIENTS AND METHODS

From January 1996 through December 1998, 18 consecutive patients with diagnostic criteria for DNM were treated in the IDH. Demographic variables, precedents, clinical manifestations, characteristics of paraclinical studies, and treatment results were recollected from the chart of each patient. We made a comparison between patients who survived and the patients who died.

RESULTS

The mean age of the patients was 48.8 +/- 19.1 years; 13 (72.5%) were men. Nine (50%) had an underlying disease, being diabetes mellitus the most frequent one. In 13 (72.5%) cases an odontogenic abscess was the original infection; three (16.6%) patients had retropharyngeal abscesses. The mean time between the beginning of symptoms and admission to the hospital was 10.6 +/- 6.7 days. The most frequent symptoms were fever, dyspnea, dysphagia, and hypotension. The treatment was medical and surgical in all cases, with antibiotics, thoracotomy, drainage and debridement. The most frequent complications were septic shock, nosocomial pneumonia and ARDS. Nine patients died, the lethality rate was 50%. Patients who died had, at admission lower leukocytes and platelets counts; higher glycemia, and developed more frequently cardiovascular complications and septic shock.

CONCLUSIONS

Odontogenic abscesses are the most frequent primary infections in patients with DNM. This is an infectious problem with high lethality. Septic shock is the principal cause of death.

Neonatal outcome of children born to women with tuberculosis

BACKGROUND

As the incidence of tuberculosis (TB) has increased worldwide, it is expected that pregnant women will acquire this infection more frequently. Mycobacterium tuberculosis infection during pregnancy may represent a risk for maternal and neonatal complications.

METHODS

We studied the perinatal events of 35 consecutive pregnancies complicated by TB from March 1990 to June 1998; 105 apparently healthy pregnant women were included as controls, matched in age, gestational age upon arrival at the Institute, and socioeconomic status. Frequency and type of neonatal complications were recorded. Relative risk (RR) with 95% confidence interval (CI) was calculated. To control potentially confounding variables, a stratified analysis was performed.

RESULTS

Seventeen (48.5%) tuberculous mothers had a pulmonary infection and 18 (51.5%), an extrapulmonar localization of the TB. The neonatal morbidity rate in children born to women with TB was 23% against 3.8% of the children of the control cohort (p <0.05). Average weight of newborn infants of tuberculous mothers was 2,859 +/- 78.5 g, while average weight at birth of control neonates was 3,099 +/- 484 g (p = 0.03). Newborns of women with TB had a higher risk of prematurity (RR 2.1; 95% CI 1-4.3), perinatal death (RR 3.1; 95% CI 1.6-6), and weight at birth less than 2,500 g (RR 2.2; 95% CI 1.1-4.9). Pulmonary localization of the TB and late start of the treatment in the mothers increase the risk of perinatal death and neonatal morbidity.

CONCLUSIONS

Children born to women with TB have an increased risk of morbidity and mortality in the neonatal period.

[Pregnancy outcome in women infected with the human immunodeficiency virus]

OBJECTIVE

To identify the medical complications in a cohort of HIV-infected, pregnant women and to determine the risk of having the virus in the development of these complications.

MATERIAL AND METHODS

A cohort study of 44 HIV-infected and 88 seronegative pregnant women was performed. Pregnancy was followed and perinatal results were compared. HIV-infected women were asymptomatic with CD4 count > 200 mm3. Patients were matched for age and socioeconomic status.

RESULTS

In 42 (95.4%) of HIV patients the disease had been transmitted sexually; 35 (79.5%) had been infected for less than one year and 15 (34%) received antiviral treatment during pregnancy. HIV-infected patients showed greater risk of infectious disorders (RR3.1, CI95% 1.9-52), cervical infections (RR 2.2, CI95% 1-48) and sexually transmitted diseases (RR 18, CI95% 2.3-137). Newborns showed low birth weight and were premature, and neonatal affections were similar in the two groups compared. Stratified analysis showed that no antiretroviral treatment and more than three sexual partners increase the risk of infections.

CONCLUSIONS

HIV-seropositive, asymptomatic, pregnant women with > 200/mm3 CD4 count did not show greater medical risk along pregnancy and birth, although higher incidence of infections was detected.

[The outcome of pregnancies complicated by rubella, 1990-1997]

OBJECTIVE

To describe the experience of management of pregnant women complicated with rubella and to evaluate the perinatal outcome.

MATERIAL AND METHODS

A total of 67 pregnant women with positive IgM test for rubella were studied in the period from January 1st, 1990 to October 31st, 1997. Sixty-six of these women were followed until the end of gestation, in 4 patients an elective abortion was performed and 1 patient had a molar pregnancy. The effects of rubella on gestation and on the product were evaluated in sixty-one of the patients. Anti-rubella IgM was determined at birth and positive infants were subjected to evaluation by echocardiogram, brainstem auditory evoked potentials (BAEP) and ophthalmological study.

RESULTS

Mean age of the patients was 24.7 +/- 5.5 years; 28 patients were primigravidae. Pregnancies were normal showing no complications due to the rubella episode. In 35 cases (52.2%), the viral infection occurred during the first trimester of pregnancy, in 23 cases (34.5%) during the second and in 9 (13.3%) during the third. Seventy-one percent of infants born to mothers infected during the first trimester of pregnancy were also infected, and 51.6% developed congenital rubella syndrome. The most frequent manifestations of CRS were: prematurity, low birth weight and alterations of the BAEP.

CONCLUSIONS

In Mexico, rubella is still a cause of fetal damage, which shows the need for preventive strategies, such as universal vaccination, to avoid rubella infection during pregnancy.

Amniotic fluid interleukin-6 and the risk of early-onset sepsis among preterm infants

BACKGROUND

High concentrations of interleukin-6 (IL-6) have been demonstrated in amniotic fluid (AF) from women with intra-amniotic infection. Recent studies have reported that IL-6 levels in AF were related to an increase in neonatal morbidity; moreover, higher IL-6 plasma levels have been observed in neonates with sepsis.

METHODS

A cohort study was carried out at the National Institute of Perinatology in Mexico City. Inclusion criteria were the following: 1) preterm singleton pregnancy; 2) intact membranes at time of enrollment, and 3) written informed consent. Women with other complications of pregnancy were excluded. Newborn sepsis during the first 72 h was defined as early-onset sepsis. Amniotic fluid was obtained at the moment of delivery. Amniotic fluid IL-6 (AF IL-6) was determined by enzyme-linked immunoassays.

RESULTS

Ninety-three women met the criteria for enrollment in the study and 31 (33%) of their newborns had early-onset neonatal sepsis. The mean AF IL-6 in mothers of septic newborns was 5779 +/- 2804 pg/ml compared to 729 +/- 382 pg/ml in mothers with non-infected neonates (p < 0.001). AF IL-6 concentrations higher than 1250 pg/ml were significantly associated with early-onset sepsis (OR 33.3; 95% CI 9.4-117.3) (p < 0.001). Gestational age under 32 weeks was also associated with neonatal sepsis (OR 2.56; 95% CI 1.2-9) (p = 0.002). Women whose infants developed neonatal sepsis had a higher frequency of clinical chorioamnionitis (p = 0.02).

CONCLUSIONS

IL-6 determination in AF may be a useful indicator to identify neonates with higher risk of in utero bacterial infection.

[Diagnostic tests for amniotic infection: review of the literature]

The diagnosis of intraamniotic infection (IAI) is not difficult when clinical manifestations are present, but there are patients with subclinical infections, in these cases the examination of the amniotic fluid is the most important diagnostic procedure. We made a critical review of the medical literature of diagnostic tests of IAI, according to the analysis criterion of the medical articles of the Department of Clinical Epidemiology of the McMaster University. The articles were identified looking for in the MEDLINE-CD ROOM and INDEX MEDICUS from 1991 to 1995. We identified 19 articles, none of them complied with all of the analysis criterion, none of the studies were blinded nor independently compared with a gold standard test and only five articles studied a full spectrum of patients. The articles with better methodologic design were those that studied the interleukin-6 role as diagnostic test for IAI; they showed a sensibility between 75 to 89% and a specificity of 97 to 100%; nevertheless it is still necessary to standardize the cut-off point of the interleukin-6 levels.

[Hemorrhagic cystitis in pregnancy: report of a case and analysis of its treatment]

Hemorrhagic cystitis is generally a benign self-limited disorder, however there are some severe cases which are associated to a significant blood loss. The etiology may be either bacterial, viral or chemical in origin; though the cause is not identified in most of the cases. Immunocompromised patients or patients who have undergone chemotherapy or radiation constitute the highest risk group. There are only a few articles about hemorrhagic cystitis in pregnancy, that is the reason why the therapy for this disorder is not uniform. Hemorrhagic cystitis in pregnant women frequently is associated with preterm labor. We describe one patient with a clinical status of hematuria, dysuria, frequency, urgency and premature labor. The cystoscopic study showed data that suggest hemorrhagic cystitis. The various treatment used in this disorder are reviewed here.

[Measles and pregnancy. Evolution and management]

Measles is a highly infectious disease. In Mexico, nevertheless the postvaccine era, continue being an endemic disease. It has been described that measles increase the maternal mortality, because pregnant women have a more severe clinical course of the disease; measles also has negative repercussion on pregnancy, increasing the frequency of premature labor. We report two pregnant women complicated with measles, both of them had a clinical course of the disease and they didn't have obstetric or neonatal complications.

[Prevalence of serologic markers of hepatitis A, B, C, and D viruses in pregnant women]

OBJECTIVE

To determine the seroprevalence of hepatitis A, B, C and D virus infection among pregnant women attending a perinatal care hospital.

MATERIAL AND METHODS

A prospective study was carried out to determine the seroprevalence of hepatitis A virus IgG antibodies (anti-HAV), hepatitis B virus markers (anti-HBcAg and HBsAg) and hepatitis C virus antibodies (anti-HCV) in pregnant women. In HBsAg positive cases. HBeAg and hepatitis D virus antibodies (anti-HDV) were investigated. All analyses were performed with the ELISA technique.

RESULTS

Of the 1500 pregnant women studied. 93.3% were positive for anti-HAV IgG. The HBsAg seroprevalence was 0.26% and anti-HCV seroprevalence was 0.53%. There were no patients with HBeAg or anti-HDV.

CONCLUSIONS

A higher seroprevalence of HBsAg was found in this study than in other studies of pregnant Mexican women. We propose that HBsAg screening become a routine prenatal test.

[Pre- and postgestational vaccination]

Vaccination is one of the most important methods to prevent infectious diseases, it consist of application of an inactive but immunogenic antigen, with the objective of simulating a natural infection and originate an immunological response. Important vaccines used in women's reproductive age are: 1) antirubella, if the woman has not serum antibodies against rubella virus; 2) tetanus toxoid is indicated in all pregnant women which had not been vaccinated against tetanus in the last ten years; 3) hepatitis B vaccine, to be applicated in newborns of women with positive serological indicators of chronic hepatitis B infection; 4) antirabies vaccine and gamaglobulin hiperimmune must be used in women with a recent exposure to rabies virus.

[Nosocomial infections of gynecologic-obstetrical origin at a perinatal care hospital]

Nosocomial infections (NI) are still a major cause of morbidity among gynecology & obstetrics patients (GOP). At the Instituto Nacional de Perinatología (INPer), during 1989, there was an overall NI rate of 2.37 per 100 GOP discharged, while specific NI rates for the subgroups of puerperal and gynecologic surgery patients were 2.11 and 6.3 respectively. Endometritis and infected surgical wounds were the most frequent type of NI, having a multimicrobial etiology. There was a significant increase in hospital days of stay for those patients who developed NI. It is clearly necessary to improve the surveillance of NI as well as the collaboration among different wards dealing with GOP, in order to find more effective and efficient ways to prevent the development of NI.

[Zygomycosis in childhood. A report of 2 cases]

Zygomycosis is a fungal infection which shows a definitive predisposition to attack the compromised host. It is usually associated with poorly controlled diabetes mellitus (DM). In the early infancy the cutaneous and gastrointestinal forms are the most frequent, in older children the most recognized form is that in which the primary impact of the infection is upon facial and intracranial structures. We report two cases of zygomycosis, the first patient was a 15 years old girl with a know systemic lupus erythematosus, and the second was a 14 years old boy with a insulin-dependent type I DM. Both were treated with anphotericin B and aggressive surgical intervention. The favorable outcome was attributed to a prompt diagnosis, early initiation of anphotericin B, surgical intervention and a control of the underlying illness.