Integrated immune monitoring of HCMV infection in pregnant women with complications and its association with adverse pregnancy outcomes

Human Cytomegalovirus (HCMV) infection is associated with bad obstetric history (BOH) and adverse pregnancy outcomes (APO). Here, we characterized antiviral humoral profiles, systemic and virus specific cellular immune responses concurrently in pregnant women (n = 67) with complications including BOH and associated these signatures with pregnancy outcomes. Infection status was determined using nested blood PCR, seropositivity and IgG avidity by ELISA. Systemic and HCMV specific (pp65) cellular immune responses were evaluated by flow cytometry. Seropositivity was determined for other TORCH pathogens (n = 33) on samples with recorded pregnancy outcomes. This approach was more sensitive in detecting HCMV infection. Blood PCR positive participants, irrespective of their IgG avidity status, had higher cytotoxic potential in circulating CD8+ T cells (p < 0.05) suggesting that infection associated cellular dysfunction was uncoupled with avidity maturation of antiviral humoral responses. Also, impaired anamnestic degranulation of HCMV-pp65-specific T cells compared to HCMV blood PCR negative participants (p < 0.05) was observed. APO correlated with HCMV blood PCR positivity but not serostatus (p = 0.0039). Most HCMV IgM positive participants (5/6) were HCMV blood PCR positive with APO. None were found to be IgM positive for other TORCH pathogens. Multiple TORCH seropositivity however was significantly enriched in the APO group (p = 0.024). Generation of HCMV specific high avidity IgG antibodies had no bearing on APO (p = 0.9999). Our study highlights the utility of an integrated screening approach for antenatal HCMV infection in the context of BOH, where infection is associated with systemic and virus specific cellular immune dysfunction as well as APO.

Seroprevalence and risk factors of Toxoplasma gondii infection in women with recurrent fetal loss from the province of Khyber Pakhtunkhwa, Pakistan

BACKGROUND

In women with a bad obstetric history (BOH), infection is an established cause of recurrent fetal loss. A common infecting agent is the protozoan parasite Toxoplasma gondii (T. gondii). The aim of this study was to measure the prevalence of toxoplasmosis in women with recurrent fetal loss from the Khyber Pakhtunkhwa province of Pakistan.

METHODS

The study included 360 females aged 16-40 years, of which 180 had a bad obstetric history (study group) and the other 180 had no such history (control group). Blood serum samples were tested for toxoplasma IgM antibodies by Enzyme Linked Immunosorbent Assay and for toxoplasma IgG antibodies using an Immunochromatographic technique.

RESULTS

The overall seroprevalence of toxoplasma infection in study group females was 40.6% and in control group females it was 7.2%. Specifically, IgM prevalence was 12.8% in the study group and 1.1% in the control group. IgG prevalence was 23.9% in the study group and 6.1% in the control group. IgM and IgG combined prevalence was 3.9% in the study group cases. There is a statistically significant association between BOH and seropositivity for T. gondii (p < 0.0001, Chi square test). Various risk factors associated with T. gondii seroprevalence in study and control groups were analyzed.

CONCLUSION

The seroprevalence of toxoplasmosis was significantly higher in women with a bad obstetric history compared to those with no such history. Associated risk factors had no significant effects on the results.

Seroepidemiology of TORCH antibodies in the reproductive-aged women in China

TORCH, the acronym of Toxoplasma gondii (TOX), others, rubella virus (RUV), cytomegalovirus (CMV) and herpes simplex virus (HSV), is a major contributor to congenital infection. National population-based study on the seroepidemiology of TORCH in women is yet lacking, and it is still obscure whether TORCH infection in the women was associated with adverse pregnancy outcomes. A total of 48,406 asymptomatic women from eight hospitals in China which covered the most areas of mainland China were enrolled in this study, and 26,400 were simultaneously subjected to 7 detection tests for TORCH specific antibodies. Chemiluminescent immunoassay was performed to detect TORCH Immunoglobulin M (IgM) and/or Immunoglobulin G (IgG) antibodies, and IgG avidities of TOX and CMV IgM and IgG positive serum samples. The overall IgG prevalence of TOX, RUV, CMV and HSV-(1 + 2) in the reproductive-aged women was 1.71 %, 81.97 %, 95.09 % and 90.15 % respectively. The corresponding IgM prevalence of TOX, RUV and CMV was 0.30 %, 0.89 % and 0.52 %. Moreover, the rates of primary TOX and CMV infections were at least 0.08 % (21/26,400) and 0.03 % (7/26,400) in the studied population. The distributions of TORCH positive women in various age, season and region groups were different (P < 0.05). The CMV IgM-positive rate was higher in the pregnant women than those in non-pregnant women (P < 0.05). The higher past infection rates of RUV, CMV and HSV in women with bad obstetric history (BOH) imply that TORCH infections are associated with BOH. These data suggest that TORCH infections in the prenatal women, especially with BOH, are worthwhile to be screened by detections of specific IgG and IgM antibodies, and even IgG avidities.

Prevalence of torch infections and its associated poor outcome in high-risk pregnant women of Central India: Time to think for prevention strategies

Introduction

The TORCH infections during pregnancy are associated with adverse congenital abnormalities, poor foetal outcome and subsequent reproductive failures. The absence of baseline data on status of TORCH infections and associated foetal outcomes prompted us to conduct the current study in Central India.

Materials and Methods

: A total of 144 high-risk pregnant women attending tertiary care unit, suspected for TORCH infections were enrolled from August 2017 to December 2018. All the participants were tested for the presence of IgM and IgG antibodies and followed up to record the foetal outcome.

Results

The overall TORCH infection (IgM positivity) positivity rate was 61.1% (88/144). Rubella was the most prevalent infection (46.5%) followed by herpes simplex virus (HSV) 1 and 2 (41%) and cytomegalovirus (CMV) (34.7%). The highest IgG sero-positivity was recorded against CMV (88.6%), followed by Rubella (86.8%), HSV 1 and 2 (28.4%), and toxoplasmosis (15.2%). Follow-up of IgM TORCH positive pregnant women revealed that majority of the neonates/infants are having congenital cardiac abnormalities (39.2%), followed by microcephaly/hydrocephaly (25%), low birth weight (10.7%), and deafness (3.6%). Thirty-two percent of neonatal mortality was associated to multiple TORCH infections.

Conclusion

A high prevalence of IgM seropositivity of TORCH infection was noted in the present study with the increased rate of poor foetal outcome warrants the need of proper prenatal counselling, universal immunisation and nutritional supplements during pregnancy.

Pregnancy and Its Successful Outcome in a Patient with Multiple Myeloma

Multiple myeloma is a B-cell neoplastic disorder and represents 1% of all cancers and 13% of hematological malignancies. It is predominantly a disease of elderly, and less than 3% of all cases are below the age of 40 years. We present the case of a 29-year-old lady with multiple myeloma who had spontaneous conception during maintenance therapy and subsequently a successful pregnancy outcome. She gave birth to a healthy female infant through normal vaginal delivery and subsequently could remain off therapy for 5 years. Since the patient had a history of abortions and stillbirth, it was a precious pregnancy and we could successfully salvage both the mother and the baby. Young female patients of myeloma who are in remission can be encouraged to start a family during their reproductive years with the support of a comprehensive care team of hematologists/oncologists and obstetricians.

Complex Chromosomal Rearrangement: A Case Report to Emphasize the Need for Parental Karyotyping and Genetic Counseling

Complex chromosomal rearrangements (CCRs) are rare structural rearrangements which involve at least three or more chromosomal breaks. The present report emphasizes the significance of parental karyotyping and the need of genetic counseling for couples with bad obstetric history (repeated abortions/miscarriages). The report includes the cytogenetic assessment of the proband and the mother, carried out at our accredited laboratory. The karyotype analysis of the proband revealed an apparently balanced translocation, identified to have been familially inherited from the mother having CCRs with double two-way translocations involving four chromosomes.

Determining the Cause of Recurrent Miscarriages in a Couple: Importance of NOR in the Era of NGS

BACKGROUND

Chromosomal abnormalities are a significant cause of human disorders. The characterization of such abnormalities helps in the identification of known/ new genes. The purpose of the present study was to identify the cause of miscarriages in a couple by using combined molecular and cytogenetic techniques.

CASE PRESENTATION

In this study, the clinical, cytogenetic and molecular cytogenetic evaluations were performed on a couple with recurrent miscarriages. Several methods like GTG banding, silver nitrate (NOR) staining, fluorescence in-situ hybridization (FISH) using whole chromosome paint probes (WCP) and bacterial artificial chromosome (BAC) clones were used. The chromosomal analysis on the metaphases revealed a karyotype of 46,XX in the wife and 46,XY,13p+ in her husband. To check the satellites on 13p region, NOR was performed which showed absence of satellites and presence of euchromatic material. On careful analysis, the satellites were observed on 11q terminal region. Thus, a balanced reciprocal translocation was detected which was confirmed by WCP and Acro-P-arm FISH. Fine mapping with BAC clones narrowed down the breakpoint regions.

CONCLUSION

The application of the combined cytogenetic methods especially NOR helped in identification of the balanced reciprocal translocation with subsequent systematic characterization and the breakpoint regions were identified. The characterization of the breakpoint regions helped in identification of the carrier status which further paved the way for understanding the cause of recurrent miscarriages and proper genetic counseling.

Natural Micronized Progesterone Sustained Release (SR) and Luteal Phase: Role Redefined!!

Role of progesterone in reproductive medicine is evolving with its suggested clinical role for the hormonal and nonhormonal actions in reproductive medicine. The main function of progesterone is to induce 'secretory' changes in endometrium that is further complimented by its immunomodulatory and anti-inflammatory actions. It positively modulates PIBF, NK cells and HOXA 10 genes for better implantation. MHRA recommends Serum Progesterone levels ≥14ng/ml in the mid-luteal phase for supporting pregnancy adequately. Oral Natural Micronized Progesterone SR formulation represents a therapeutic advance in this direction offering 'therapeutic compliance' with oral formulation while avoiding the local side effects related to long-term patient compliance in reproductive disorders. The formulation offers round the clock efficiency and efficacy with single dose administration thereby improving patient convenience and compliance. This formulation has been marketed globally since 1986 utilizing the well validated drug delivery system involving Methylcellulose base. The clinical utility of this formulation is further suggested especially in various conditions related with luteal phase insufficiency and Bad obstetric history (BOH) or luteal phase support in ART. The level of evidence has been quite robust with several clinical studies including Prescription Event Monitoring and Investigator initiated studies supporting the clinical role of oral NMP SR formulation especially in 'Real world' clinic settings for Luteal phase insufficiency that may be physiological or iatrogenic.

Seroprevalence and Influence of Torch Infections in High Risk Pregnant Women: A Large Study from South India

BACKGROUND

The increased complications to the mother and fetus during or after pregnancy and birth are often caused by a wide array of pathogenic organisms mostly belonging to the TORCH group [toxoplasmosis, rubella, cytomegalovirus (CMV), and herpes simplex virus (HSV)]. These agents cause asymptomatic or mild infection in the mother while serious consequences in fetus. The present study was aimed to find significant etiological pathogens in the causation of high risk pregnancy (HRP) in South Indian population.

MATERIAL AND METHODS

A total of 1,158 HRP women (2010-2013) from Modern Government Maternity Hospital, Hyderabad were considered. Two milliliter of blood was obtained and the serum was analyzed for IgG and IgM antibodies against TORCH agents by ELISA.

RESULTS

Twenty-five percent of the study group had fetal congenital malformation in the present pregnancy (Group 1; N = 291) while 75 % showed bad obstetric history (BOH) (Group 2; N = 867). Maternal age of ≤25 years, primi gravida, and consanguinity showed predisposing role for Group 1 while maternal age ≥30 years and ≥ 3 gravida were contributing risk for Group 2. The seropositvity in HRP women for toxoplasma, rubella, CMV, and HSV was 28, 84, 92, and 61 %, respectively for IgG while it was 6, 3, 4, and 3 % for IgG + IgM. Total seropositvity of toxoplasma, rubella, CMV, and HSV in Group 1 was 29, 97, 97, and 62 % while it was 36, 84, 97, and 65 % in Group 2, respectively.

CONCLUSION

Maternal age of ≤25 years, primi gravida, and consanguinity contributed to fetal congenital malformation in the present pregnancy while maternal age of ≥30 years and ≥ 3 gravida towards BOH. Toxoplasma is protective while rubella and CMV are the infectious agents for HRP. Among the groups, toxoplasma and rubella conferred a predisposing risk towards Group 2 and Group 1, respectively. Sixty-one percent seropositvity of HSV in relation to bad obstetric outcome is the highest prevalence reported so far in India.

Bad Obstetric History: A Prospective Study

BACKGROUND

Death of an infant in utero or at birth has always been a devastating experience for the mother and of concern in clinical practice. Perinatal mortality remains a challenge in the care of pregnant women worldwide, particularly for those who had history of adverse outcome in previous pregnancies. To assess the risk factors and outcome of pregnancies in cases of bad obstetric history (BOH) and compare the results with control group, this study was undertaken.

METHODS

A prospective study from 2003 to 2007 was carried out in 79 pregnancies having BOH (history of unexplained stillbirth/neonatal death, three or more consecutive abortions etc). Test group was analyzed in terms of age, gravida, parity, risk factors and outcome in terms of preterm delivery, stillbirth, mode of delivery, birth weight, pregnancy complications and fetal distress. These parameters were compared with a systematic, randomly selected sample from rest of the deliveries. Necessary advice and treatment was given in cases of hypothyroidism, hypertension, antiphospholipid antibody (APLA) syndrome, gestational diabetes and other risk factors.

RESULT

There was significantly higher incidence of malpresentations, hypertension, APLA, cervical incompetence, preterm deliveries and caesarean section in test group (p< 0.05). In this study, only 47 (59.49%) women out of 79 in BOH group were identified to have possible factor responsible for pregnancy losses. In 32 (40.51%), no probable causes could be identified. Nine (11.39%) patients were identified with more than one risk factor.

CONCLUSION

APLA, hypertension, malpresentation, cervical incompetence, preterm deliveries and caesarean section were found significantly more in BOH group. In a large percentage of pregnancies with BOH, the risk factors for adverse outcome were not identified but pregnancy outcome was generally good in subsequent pregnancies with optimal antenatal care and advice.

Maternal Factors for Low Birth Weight Babies

BACKGROUND

Low birth weight is defined as the live births with less than 2.5 kg weight. It is a key determinant of infant survival, health and development. Low birth weight infants are at a greater risk of having a disability and for diseases such as cerebral palsy, visual problems, learning disabilities and respiratory problems. To reduce the low birth weight deliveries, we studied the maternal factors which adversely affect the fetus in utero and their impact on fetus.

METHODS

A retrospective study was carried out on 40 low birth weight pregnancies out of 650 deliveries from July 2005 to Jun 2006. Maternal factors like age, parity, pre pregnancy body mass index, hemoglobin levels, bad obstetric history (history of stillbirth/neonatal death in previous pregnancies, three or more spontaneous consecutive abortions), pre eclampsia, fetal distress, mode of deliveries were studied. These results were compared with a random sample of 300 pregnant ladies taken from rest of the deliveries. Cases of multiple pregnancies and stillbirths were excluded.

RESULT

We found that prepregnancy maternal body mass index (p<0.01 for BMI <20), unbooked status (p<0.01), pre eclampsia (p <0.01) and bad obstetric history (p<0.01) were the maternal factors which resulted in low birth weight babies in most of the cases. However in 10 (25%) cases, no contributory maternal factor was found.

CONCLUSION

Prepregnancy maternal body mass index, unbooked status, pre eclampsia and bad obstetric history are significant maternal factors resulting in low birth weight babies.

SEROLOGICAL DIAGNOSIS OF TOXOPLASMA GONDII INFECTION IN VARIOUS PATIENT POPULATION IN THE ARMED FORCES

The study included 200 healthy age and sex matched controls (120 healthy volunteers and 80 healthy antenatal cases without any bad obstetric history) and 300 cases comprising patients with bad obstetric history (BOH) 80 cases, seizure or encephalitis 50 cases, cervical lymphadenopathy 30 cases, congenital deformity 30 cases, HIV infected 80 cases and patients on long term immunosuppression 30 cases. Anti-toxoplasma IgG & IgM were measured by ELISA and individuals found positive for anti Toxoplasma gondii IgM or with high titre of IgG were subjected to repeat testing after 3 weeks for rise in titre. True sero-prevalence of T gondii infection was found to be 19% and it increased with increasing age in the population. 2.33% patients were found to have acute toxoplasma infection. Statistical significance was seen only in patients with BOH and children born with congenital abnormality.