Marc Boucher

The relationship between amniotic fluid index and successful external cephalic version: a 14-year experience.

OBJECTIVEnThis study was undertaken to assess the association between amniotic fluid index (AFI), success of external cephalic version (ECV), and obstetric outcome in patients undergoing ECV.nnnSTUDY DESIGNnA prospective observational study was performed that included all patients who had a trial of ECV from 1987 to 2000 in our center. Rates of success, fetal heart decelerations during trial at ECV, and cesarean deliveries were calculated. Groups were divided by an AFI performed immediately before ECV: AFI less than 10 cm, 10 to 15 cm, and more than 15 cm.nnnRESULTSnIn our group of 1361 patients undergoing ECV, the rate of success was related to the AFI in both parous women (49.1%, 63.5% and 72.1% [P<.001] for each AFI group, respectively) and nulliparous women (36.5%, 43.6%, and 57.3% [P<.001]). The rate of cesarean section delivery was related to AFI in nulliparous but not multiparous patients (P<.001). The rate of prolonged fetal heart rate decelerations was not significantly related to the AFI.nnnCONCLUSIONnThe rate of successful ECV and cesarean section deliveries is related to the amniotic fluid volume. This information may be used to consent patient before a trial of ECV.

Characterization of humoral and cell-mediated immune responses directed against hepatitis C virus F protein in subjects co-infected with hepatitis C virus and HIV-1.

Background:Hepatitis C virus (HCV) F protein is encoded in an alternate reading frame overlapping the core protein region. Its precise sequence, biological function and mode of expression are currently unclear. This study was conducted to examine the prevalence and characteristics of host humoral and cell-mediated immune responses directed against F protein in patients co-infected with HCV and HIV-1. Methods:Mutations were introduced to allow the expression of HCV-1a F protein in the absence of core. This recombinant and a truncated form lacking the first 11 amino acid residues shared with core were expressed in Escherichia coli, and their amino acid sequences were verified by mass spectrometry. Vaccinia-F protein recombinants were used to test F protein-specific cytotoxic T lymphocyte (CTL) activity. The binding of F protein-derived peptides to HLA-A*0201 was studied to identify putative CTL epitopes. Results:Sera from 23 of 39 patients infected with various HCV genotypes recognized the truncated form, including 13 of 25 subjects co-infected with HIV-1, indicative of antigenic crossreactivity and consistent with the conservation of F protein coding sequences between HCV genotypes. Crossreactive F protein-specific CTL precursors were detected in nine of 11 HCV-infected subjects, including seven of nine patients co-infected with HCV and HIV-1. Finally, three novel putative HLA-A*0201-restricted CTL epitopes were identified. Conclusion:These results indicate that patients co-infected with HCV and HIV-1 can mount immunoglobulin and CTL responses directed against HCV F protein that are fully comparable in scope and magnitude with those observed in individuals infected with HCV alone.

Impact of maternal HIV-1 viremia on lymphocyte subsets among HIV-exposed uninfected infants: protective mechanism or immunodeficiency

BackgroundReports of increased morbidity and mortality from infectious diseases among HIV Exposed Uninfected (HEU) infants have raised concern about a possible underlying immunodeficiency among them. The objective of this study was to assess the immunological profile of HEU infants born to mothers exhibiting different levels of HIV-1 viremia at the time of delivery.MethodsStudy subjects were enrolled in the Centre maternel et infantile sur le SIDA (CMIS) mother-child cohort between 1997 and 2010 (n =585). Infant CD4+ T cell, CD8+ T cell and CD19+ B cell counts were assessed at 2 and 6xa0months of age, and compared among HEU infants in groups defined by maternal viral load (VL) at the time of delivery (VLu2009<u200950 copies/ml, VL 50–1000 copies/ml, and VLu2009>u20091000 copies/ml) in a multivariable analysis.ResultsAt 2xa0months of age, infants born to mothers with VLu2009>u20091000 copies/ml had lower CD4+ T cell counts compared to those born to mothers with VLu2009<u200950 copies/ml at the time of delivery (44.3% versus 48.3%, pu2009=u20090.007, and 2884 vs. 2432 cells/mm3, pu2009=u20090.02). These differences remained significant after adjusting for maternal and infant antiretroviral drug use, gender, race and gestational age, and persisted at 6xa0months of age. There were no differences in CD8+ T cell count or absolute CD19+ B cell count between groups, though higher CD19+ B cell percentage was seen among infants born to mothers with VLu2009>u20091000 copies/ml.ConclusionsThese results suggest that exposure to high levels of HIV-1 viremia in utero, even in the absence of perinatal transmission, may affect the infant’s developing immune system. While further work needs to be done to confirm these findings, they reinforce the need for optimal treatment of HIV infected pregnant women, and careful follow-up of HEU infants.

HIV-1 Genetic Diversity in Antenatal Cohort, Canada

Non-B HIV-1 was consistent with patients’ area of origin.

Screening for trisomy 21 with ultrasonographic determination of biparietal diameter/femur length ratio

Ultrasonographic determination of biparietal diameter/femur length ratios performed at 16 or 17 weeks gestation in fetuses with trisomy 21 were not statistically different from those of 155 normal fetuses. It appears that this test could not be used for screening for trisomy 21.

Sublingual nitroglycerin versus placebo as a tocolytic for external cephalic version: a randomized controlled trial in parous women ☆

OBJECTIVEnThe purpose of this study was to evaluate the efficacy of sublingual nitroglycerin as a tocolytic agent for external cephalic version in parous women.nnnSTUDY DESIGNnA double-blinded randomized controlled trial was performed. Patients with parity of >or=1 at 36 to 40 weeks of gestation who were eligible for external cephalic version were included. Patients were randomized to receive either two sublingual sprays of 400 mug of nitroglycerin or two sprays of placebo 3 minutes before the trial of external cephalic version. Rates of successful external cephalic version and side effects were compared between groups.nnnRESULTSnOf 99 patients in the study, 50 patients received sublingual nitroglycerin, and 49 patients received placebo. There were no differences in maternal age, gestational age, estimated fetal weight, amniotic fluid index, and placental location between the two groups. The success rate of external cephalic version was 48% in the nitroglycerin group compared with 63% in the placebo group (P=.13). There was a higher incidence of headaches in the nitroglycerin group (42% vs 4%, P<.001).nnnCONCLUSIONnSublingual nitroglycerin was associated with a higher rate of headache and did not improve the rate of successful external cephalic version.

Perinatal Listeriosis: Canada’s 2008 Outbreaks

BACKGROUNDnListeriosis is one of the most severe foodborne illnesses worldwide. Most infections with Listeria are sporadic, but outbreaks do occur. Pregnant women exposed to this organism are at increased risk of chorioamnionitis, preterm labour, prematurity and intrauterine fetal demise. Severe neonatal infection can also occur.nnnCASESnTwo recent outbreaks in Canada prompted a reassessment of the prevalence and the perinatal impact of this disease. We describe here three cases of perinatal listeriosis. The aim of our report is to demonstrate the variable clinical presentations and to emphasize the difficulty in diagnosing perinatal listeriosis.nnnCONCLUSIONnPerinatal listeriosis is a severe disease with many possible clinical presentations. Clinical diagnosis may be difficult, so clinicians must maintain a high index of suspicion.

Awareness of cytomegalovirus and risk factors for susceptibility among pregnant women, in Montreal, Canada

BackgroundAdvances in diagnostic and therapeutic modalities for congenital cytomegalovirus (CMV) infection have generated a mounting interest in identifying mothers susceptible to CMV. The objectives of this study were to evaluate the prevalence and socio-demographic determinants of CMV susceptibility and CMV awareness, among pregnant women, in Montreal, Quebec.MethodsBetween April and December 2012, women delivering at Centre Hospitalier Universitaire Sainte Justine were recruited for the study. Stored serum from the first trimester of pregnancy was tested for CMV IgG. Knowledge about CMV and socio-demographic characteristics were collected via standardized questionnaire.ResultsFour hundred and ninety one women were enrolled in the study. Overall, 225 mothers (46xa0%) were seronegative for CMV, and 85xa0% (nu2009=u2009415) were unaware of CMV or the associated risks in pregnancy. Significant risk factors for CMV seronegative status included Canadian vs. foreign born (aOR 6.88, 95xa0% CI 4.33–10.94), and high vs. low family income (aOR 4.68, 95xa0% CI 2.09–10.48). Maternal employment status was the only significant predictor of CMV unawareness, with unemployed mothers at the highest risk (aOR 85.6, 95xa0% CI 17.3–421.3).ConclusionsNearly half of pregnant women studied were at risk of primary infection, and yet, the majority was unaware of potential risks associated with CMV. Canadian born mothers and those with a high socioeconomic status were more likely to be CMV seronegative. Increased education about CMV infection, through public health interventions and obstetrician/pediatric counseling, is needed for all pregnant women.

Obstetrical and neonatal outcomes following unsuccessful external cephalic version: a stratified analysis amongst failures, successes, and controls.

Abstract Objective: Though on average one out of every two external cephalic versions (ECV) fails to rotate the breech fetus, little is known about the outcomes of pregnancies in which ECV is unsuccessful. The objective of the present study is to compare obstetrical and neonatal outcomes following failure of ECV, relative to cases of breech controls without an attempt at ECV. Study design: We conducted a retrospective, population-based, cohort study using the CDCs Birth Data files from the US for the year 2006. We stratified the cohort according to fetal presentation and ECV status: success, failure, and no ECV (controls). The effect of failure of ECV on the risk of several neonatal and obstetrical outcomes was estimated using logistic regression analysis, adjusting for relevant confounders. Results: We analyzed a total of 4u2009273u2009225 births, out of which 183u2009323 (4.3%) met inclusion criteria. Relative to breech controls, failed ECV occurred more frequently amongst Caucasian, college-educated, married women bearing a female fetus. Compared to no ECV, failure of ECV was associated with increased odds of PROM (aOR, 1.75; 95% CI, 1.60–1.90), elective cesarean delivery (aOR, 1.53; 95% CI, 1.36–1.72), cesarean delivery in labor (aOR, 1.38; 95% CI, 1.21–1.57), abnormal fetal heart tracing (aOR, 1.78; 95% CI, 1.50–2.11), assisted ventilation at birth (aOR, 1.50; 95% CI, 1.27–1.78), 5-min APGAR scores <7 (aOR, 1.35; 95% CI, 1.20–1.51), and NICU admission (aOR, 1.48; 95% CI, 1.20–1.82). The delayed spontaneous fetal restitution rate was 13%. When stratifying controls with regards to trial of labor status, the increased risk of failed ECV persisted for cesarean delivery, NICU admission, assisted ventilation and abnormal fetal tracing, independently of whether a trial of labor took place. Conclusion: Relative to breech controls without attempt at ECV, failure of ECV to restitute cephalic presentation appears to be associated with an increased risk of adverse perinatal and obstetrical outcomes.

Increase in Transaminase Levels Following the Use of Raltegravir in a Woman With a High HIV Viral Load at 35 Weeks of Pregnancy

BACKGROUNDnDespite the efficacy of raltegravir in reducing viral load in HIV-infected patients, evidence for its safety in late pregnancy is lacking. A high rate of placental transfer was recently demonstrated.nnnCASEnA treatment-naïve 34-year-old HIV-1-positive woman of African origin began treatment with zidovudine/lamivudine, lopinavir/ritonavir, and raltegravir at 35 weeks of pregnancy. After 11 days of treatment with raltegravir, a substantial reduction in viral load was achieved. Concurrently, she had a 23-fold increase in serum alanine aminotransferase and a 10-fold increase in serum aspartate aminotransferase, both of which returned to normal when raltegravir treatment was discontinued. A healthy boy was delivered at term. The infants tests for HIV were negative at five months, and he had no health problems at eight months.nnnCONCLUSIONnThis is the first case report, to our knowledge, of increased maternal serum transaminase levels following the use of raltegravir in a woman at a late stage of pregnancy.