Adriana Suely de Oliveira Melo

Congenital Zika Virus Infection: Beyond Neonatal Microcephaly

Importance Recent studies have reported an increase in the number of fetuses and neonates with microcephaly whose mothers were infected with the Zika virus (ZIKV) during pregnancy. To our knowledge, most reports to date have focused on select aspects of the maternal or fetal infection and fetal effects. Objective To describe the prenatal evolution and perinatal outcomes of 11 neonates who had developmental abnormalities and neurological damage associated with ZIKV infection in Brazil. Design, Setting, and Participants We observed 11 infants with congenital ZIKV infection from gestation to 6 months in the state of Paraíba, Brazil. Ten of 11 women included in this study presented with symptoms of ZIKV infection during the first half of pregnancy, and all 11 had laboratory evidence of the infection in several tissues by serology or polymerase chain reaction. Brain damage was confirmed through intrauterine ultrasonography and was complemented by magnetic resonance imaging. Histopathological analysis was performed on the placenta and brain tissue from infants who died. The ZIKV genome was investigated in several tissues and sequenced for further phylogenetic analysis. Main Outcomes and Measures Description of the major lesions caused by ZIKV congenital infection. Results Of the 11 infants, 7 (63.6%) were female, and the median (SD) maternal age at delivery was 25 (6) years. Three of 11 neonates died, giving a perinatal mortality rate of 27.3%. The median (SD) cephalic perimeter at birth was 31 (3) cm, a value lower than the limit to consider a microcephaly case. In all patients, neurological impairments were identified, including microcephaly, a reduction in cerebral volume, ventriculomegaly, cerebellar hypoplasia, lissencephaly with hydrocephalus, and fetal akinesia deformation sequence (ie, arthrogryposis). Results of limited testing for other causes of microcephaly, such as genetic disorders and viral and bacterial infections, were negative, and the ZIKV genome was found in both maternal and neonatal tissues (eg, amniotic fluid, cord blood, placenta, and brain). Phylogenetic analyses showed an intrahost virus variation with some polymorphisms in envelope genes associated with different tissues. Conclusions and Relevance Combined findings from clinical, laboratory, imaging, and pathological examinations provided a more complete picture of the severe damage and developmental abnormalities caused by ZIKV infection than has been previously reported. The term congenital Zika syndrome is preferable to refer to these cases, as microcephaly is just one of the clinical signs of this congenital malformation disorder.

Congenital Brain Abnormalities and Zika Virus: What the Radiologist Can Expect to See Prenatally and Postnatally

Purpose To document the imaging findings associated with congenital Zika virus infection as found in the Instituto de Pesquisa in Campina Grande State Paraiba (IPESQ) in northeastern Brazil, where the congenital infection has been particularly severe. Materials and Methods From June 2015 to May 2016, 438 patients were referred to the IPESQ for rash occurring during pregnancy or for suspected fetal central nervous system abnormality. Patients who underwent imaging at IPESQ were included, as well as those with documented Zika virus infection in fluid or tissue (n = 17, confirmed infection cohort) or those with brain findings suspicious for Zika virus infection, with intracranial calcifications (n = 28, presumed infection cohort). Imaging examinations included 12 fetal magnetic resonance (MR) examinations, 42 postnatal brain computed tomographic examinations, and 11 postnatal brain MR examinations. Images were reviewed by four radiologists, with final opinion achieved by means of consensus. Results Brain abnormalities seen in confirmed (n = 17) and presumed (n = 28) congenital Zika virus infections were similar, with ventriculomegaly in 16 of 17 (94%) and 27 of 28 (96%) infections, respectively; abnormalities of the corpus callosum in 16 of 17 (94%) and 22 of 28 (78%) infections, respectively; and cortical migrational abnormalities in 16 of 17 (94%) and 28 of 28 (100%) infections, respectively. Although most fetuses underwent at least one examination that showed head circumference below the 5th percentile, head circumference could be normal in the presence of severe ventriculomegaly (seen in three fetuses). Intracranial calcifications were most commonly seen at the gray matter-white matter junction, in 15 of 17 (88%) and 28 of 28 (100%) confirmed and presumed infections, respectively. The basal ganglia and/or thalamus were also commonly involved with calcifications in 11 of 17 (65%) and 18 of 28 (64%) infections, respectively. The skull frequently had a collapsed appearance with overlapping sutures and redundant skin folds and, occasionally, intracranial herniation of orbital fat and clot in the confluence of sinuses. Conclusion The spectrum of findings associated with congenital Zika virus infection in the IPESQ in northeastern Brazil is illustrated to aid the radiologist in identifying Zika virus infection at imaging. (©) RSNA, 2016 Online supplemental material is available for this article.

Perfil lipídico e estado nutricional de adolescentes

OBJETIVOS: Avaliar a associacao entre obesidade e dislipidemias em adolescentes do ensino publico e privado de Campina Grande-PB, Brasil. METODOS: Estudo transversal com 180 adolescentes de 14 a 17 anos matriculados no ensino publico e privado de Campina Grande-PB. O estado nutricional foi classificado segundo os percentis do Indice de Massa Corporal para sexo e idade. Foi realizada coleta sanguinea para avaliacao do perfil lipidico (colesterol total, fracoes HDL-colesterol, LDL-colesterol e triglicerideos). Considerou-se dislipidemia a existencia de alteracao em pelo menos um dos exames. As analises estatisticas foram realizadas a partir do Epi Info 3.3 e Stata 7.0. RESULTADOS: A prevalencia de sobrepeso foi de 14,4% enquanto que 83,9% dos estudantes eram eutroficos e 1,7% apresentavam baixo peso. Nao foram encontradas diferencas estatisticamente significantes para o estado nutricional quando estratificado por sexo e tipo de escola. Todas as taxas bioquimicas investigadas mostraram algum nivel de alteracao. Chamou a atencao a prevalencia de dislipidemia, observada em 66,7% dos estudantes, e a alteracao do HDL-colesterol, verificada em 56,7% destes. Registrou-se associacao estatisticamente significante (p<0,05) do Indice de Massa Corporal, categorizado em tercis, com o colesterol total e sua fracao LDL, inclusive quando estratificados por sexo e tipo de escola. CONCLUSOES: Considerando-se a faixa etaria estudada, foram elevados os achados de sobrepeso e dislipidemia. Recomenda-se a adicao de medidas preventivas, a fim de evitar que cada vez mais criancas e adolescentes venham a se tornar adultos portadores de obesidades e outras doencas cronicas.

Estado nutricional materno, ganho de peso gestacional e peso ao nascer

INTRODUCTION: Maternal nutritional status and gestational weight gain have been addressed because of their importance to fetal growth and birth weight. Inadequate birth weight is a major concern to public health given it has been associated with increasing morbidity-mortality during the first year of life and with increased risks of chronic diseases in adult life such as metabolic syndrome for cases of low birth weight and diabetes and obesity for macrossomic infants. The objective of this study was to describe a cohort of pregnant women according to their nutritional status, gestational weight gain, uterine artery notches, and birth weight. METHODS: A cohort of 115 pregnant women attending the Family Health Program in Campina Grande, PB, was evaluated every four gestational weeks. The initial maternal nutritional status was determined through the body mass index (kg/m2) and women were classified according to Atalah´s criteria for gestational age. Arterial resistance was assessed through Doppler velocimetry on the 20th week of pregnancy. RESULTS: overweight and obesity were observed in 27% of the sample whereas 23% were undernourished. A high incidence of excessive weight gain was found in the second (44%) and in the third quarter (45%). Birth weight distribution indicated that 10% were of low birth weight and there were 9% of macrossomic babies. A high prevalence of uterine artery diastolic notches of was observed.

Risk factors for pregnancy in adolescence in a teaching maternity in Paraíba: a case-control study

PURPOSE To identify factors associated with gestation in adolescence in a State of the northeast of Brazil. METHODS A case-control study in the ratio of one 10 to 19-year-old adolescent (case) for two 20 to 35-year-old women (controls), with a total of 168 cases and 337 controls. The variables analyzed were: schooling, marital status, origin, family income per capita in Brazilian currency, paid job, mothers schooling, and presence of adolescents father at home. Reproductive variables such as age at the first intercourse, mothers history of adolescence pregnancy, gynecological appointments before the pregnancy, knowledge, access and use of contraceptive methods were also included in the analysis. RESULTS The following variables were associated with gestation in adolescence: schooling lower than eight years, lack of a regular mate, and maternal history of adolescence gestation. Also, the age at the first intercourse was significantly lower among the adolescents and that they had a lower rate of gynecological appointments. Knowledge of hormonal methods and access to contraceptive methods were also less frequent among the adolescents. After the multiple logistic regression analysis, risk factors for pregnancy at adolescence were: low schooling (OR=2.3; CI 95%=1.3-3.8), age at the first intercourse lower than 15 years old (OR=3.6; CI 95%=2.2-5.7), history of maternal pregnancy at adolescence (OR=2.6; CI 95%=1.7-3.4). The history of previous gynecological appointments (OR=0.3; CI 95%=0.2-0.4) and the use of hormonal methods (OR=0.6; CI 95%=0.4-0.9) were protecting variables. CONCLUSIONS The main factors associated with pregnancy in adolescence were: the adolescents low schooling, maternal history of adolescence gestation, lack of previous gynecological appointments and lack of access to contraceptive methods.

Risk factors for macrosomia in newborns at a school-maternity in northeast of Brazil

OBJECTIVE to determine the frequency of macrosomia in babies born alive at a reference obstetric service, and its association with maternal risk factors. METHODS a transversal descriptive study, including 551 women at puerperium, hospitalized at Instituto de Saúde Elpídio de Almeida, in Campina Grande (PB), Brazil, from August to October, 2007. Women, whose deliveries had been assisted at the institution, with babies born alive from one single gestation and approached in the first postpartum day, were included in the study. The nutritional and sociodemographic maternal characteristics were analyzed, and the ratio of macrosomia (birth weight >or=4.000 g) and its association with maternal variables were determined. Macrosomia was classified as symmetric or asymmetric according to Rohrers index. Statistical analysis has been done through Epi-Info 3.5 software; the prevalence ratio (PR) and the confidence interval at 95% (CI 95%) were calculated. The research protocol was approved by the local Ethics Committee and all the participants signed the informed consent. RESULTS the mean maternal age was 24.7 years old, and the mean gestational age was 38.6 weeks. Excessive gestational weight gain was observed in 21.3% of the pregnant women, and 2.1% of the participants had a diagnosis of diabetes mellitus (gestational or clinic). A ratio of 5.4% of macrosomic newborns was found, 60 were asymmetric. There was no significant association between macrosomia, mothers age and parity. There was an association between macrosomia and overweight/obesity in the pre-gestational period (PR=2.9; CI 95%=1.0-7.8) and at the last medical appointment (PR=4.9; CI 95%=1.9-12.5), excessive weight gain (PR = 6.9; CI 95%:2.8-16.9), clinical or gestational diabetes (PR = 8.9; CI 95%:4.1-19.4) and hypertension (PR=2.9; CI 95%=1.1-7.9). The factors that persisted significantly associated with macrosomia in the multivariate analysis were the excessive weight gain during the gestation (RR=6.9; CI 95%=2.9-16.9) and the presence of diabetes mellitus (RR=8.9, CI 95%=4.1-19.4). CONCLUSIONS considering that excessive gestational weight gain and diabetes mellitus were the factors more strongly associated with macrosomia, it is important that precocious detection measurements and adequate follow-up of such conditions be taken, aiming at preventing unfavorable perinatal outcomes.

Immune Activation in Amniotic Fluid from Zika Virus-Associated Microcephaly.

Recent advances in the understanding of neuropathogenesis associated with Zika virus (ZIKV) infection has led to descriptions of neonatal microcephaly cases. However, none of these reports have evaluated the humoral response during ZIKV infection. We report here polyfunctional immune activation associated with increased interferon‐gamma‐inducible protein 10, interleukin (IL)‐6, IL‐8, vascular endothelial growth factor (VEGF), monocyte chemoattractive protein 1 (MCP‐1), and granulocyte colony‐stimulating factor (G‐CSF) levels in the amniotic fluid of ZIKV‐positive pregnant women with neonatal microcephaly. These cytokines have been associated not only with neuronal damage, but also with differentiation and proliferation of neural progenitor cells. Our results suggested that the immune activation caused by ZIKV infection in the uterine environment could also interfere with fetal development. ANN NEUROL 2017;81:152–156

Fatores associados ao nascimento pré-termo em Campina Grande, Paraíba, Brasil: um estudo caso-controle

A case-control study (2008-2009) analyzed risk factors for preterm birth in the city of Campina Grande, Paraiba State, Brazil. A total of 341 preterm births and 424 controls were included. A multiple logistic regression model was used. Risk factors for preterm birth were: previous history of preterm birth (OR = 2.32; 95%CI: 1.25-4.29), maternal age (OR = 2.00; 95%CI: 1.00-4.03), inadequate prenatal care (OR = 2.15; 95%CI: 1.40-3.27), inadequate maternal weight gain (OR = 2.33; 95%CI: 1.45-3.75), maternal physical injury (OR = 2.10; 95%CI: 1.22-3.60), hypertension with eclampsia (OR = 17.08; 95%CI: 3.67-79.43) and without eclampsia (OR = 6.42; 95%CI: 3.50-11.76), hospitalization (OR = 5.64; 95%CI: 3.47-9.15), altered amniotic fluid volume (OR = 2.28; 95%CI: 1.32-3.95), vaginal bleeding (OR = 1.54; 95%CI: 1.01-2.34), and multiple gestation (OR = 22.65; 95%CI: 6.22-82.46). High and homogeneous prevalence of poverty and low maternal schooling among both cases and controls may have contributed to the fact that socioeconomic variables did not remain significantly associated with preterm birth.

Padrão de atividade física entre gestantes atendidas pela estratégia saúde da família de Campina Grande - PB

INTRODUCAO: A atividade fisica realizada durante a gestacao vem sendo discutida devido aos seus efeitos beneficos tanto para a saude materna como para o crescimento fetal e desfechos gestacionais, porem ainda sao escassos estudos sobre o padrao de atividade fisica neste periodo. OBJETIVO: Avaliar o padrao de atividade fisica entre gestantes atendidas pela estrategia Saude da Familia (ESF) do municipio de Campina Grande/PB. METODOS:Foi acompanhada uma coorte observacional de gestantes (n=118), a partir da 16a semana gestacional, durante os anos de 2005 a 2006. A cada quatro semanas eram aferidas as condicoes clinicas, socioeconomicas e obstetricas, incluindo a aplicacao de um questionario especifico sobre atividade fisica na 16a, 24a e 32a semanas gestacionais. A avaliacao foi feita a partir da somatoria do equivalente metabolico (METs) e as atividades cotidianas foram divididas em quatro grupos: atividades laboral, domestica e caminhada, alem de inatividade. As gestantes foram classificadas de acordo com o padrao de atividade fisica realizado em: sedentarias, praticantes de atividades fisica leve, moderada e vigorosa. Os dados foram analisados no programa Epi Info 3.4.1. RESULTADOS: As caracteristicas socioeconomicas da coorte estudada indicaram majoritariamente gestantes de baixo poder aquisitivo, baixa escolaridade e baixo percentual de mulheres economicamente ativas. O padrao de atividade fisica observado foi baixo desde o primeiro trimestre gestacional, oscilando entre o leve e o sedentario, e foi diminuindo com o evoluir da gravidez, com 100% das gestantes alcancando o padrao sedentario na 32a semana. Em relacao aos grupos de atividades, observou-se um predominio de atividades domesticas, seguidas pelas atividades de lazer. CONCLUSAO:Na coorte estudada verificou-se um padrao de atividade fisica inadequado desde o inicio da gestacao, agravando-se no terceiro trimestre gestacional.

Avaliação dos exames de rotina no pré-natal: parte 2

Good prenatal care is essential to guarantee maternal and perinatal health. Nowadays, with the constant progress on the diagnostic methods and changes in diseases panorama, like increased frequency of diabetes and sexually transmitted diseases, several diagnostic procedures have been studied. These challenges difficult the selection of prenatal exams by the clinicians, in order to improve maternal and perinatal outcome. This review aimed to evaluate the main prenatal routine exams, according to the best current scientific evidences.