María de la Calle

Initial experience with imported Zika virus infection in Spain.

INTRODUCTION A considerable increase of imported Zika virus (ZIKV) infection has been reported in Europe in the last year. This is the result of the large outbreak of the disease in the Americas, along with the increase in the numbers of travellers and immigrants arriving from ZIKV endemic areas. METHODS A descriptive study was conducted in the Tropical Medicine Unit of Hospital La Paz-Carlos III in Madrid on travellers returning from an endemic area for ZIKV from January to April 2016. Demographic, clinical and microbiological data were analyzed. RESULTS A total of 185 patients were screened for ZIKV (59.9% women, median age of 37.7±10.3 years). Main purpose of the travel was tourism to Colombia, Brazil, and México. Just under three-quarters (73%) were symptomatic, mostly with fever and headache. A total of 13 patients (7% of those screened) were diagnosed with ZIKV infections, of which four of them were pregnant. All of them were symptomatic patients, the majority immigrants, and mainly from Colombia. Diagnostic tests were based on positive neutralization antibodies (8 cases, 61.6%) and a positive RT-PCR in different organic fluids (7 cases, 53.8%) The four infected pregnant women underwent a neurosonography every 3 weeks, and no alterations were detected. RT-PCR in amniotic fluid was performed in three of them, with negative results. One of the children has already been born healthy. CONCLUSIONS Our cases series represents the largest cohort of imported ZIKV to Spain described until now. Clinicians must increase awareness about the progression of the ZIKV outbreak and the affected areas so that they can include Zika virus infection in their differential diagnosis for travellers from those areas.

Lipoprotein abnormalities in patients with asymptomatic acute porphyria

There have been discrepancies in reports of total cholesterol and low density lipoprotein (LDL)-cholesterol levels in patients with acute porphyria. Some studies have found that acute porphyria patients have increased levels while others do not. The aim of this study has been to evaluate the lipid profile in a series of patients with acute porphyria, in order to help clarify these differences. Serum lipoprotein levels were studied in 30 patients (25 women and five men; age:38+/-10 years) with asymptomatic acute porphyria. Controls were 30 healthy volunteers matched for age and gender. For 13 patients and 15 controls, lipoprotein lipase and hepatic lipase activities were determined. Patients exhibited increased levels of total-cholesterol, LDL-cholesterol, high density lipoprotein (HDL)-cholesterol and apolipoprotein (apo)-A1 compared with controls (P4 mmol/l in 15 patients (50%). Levels of total triglycerides, very low density lipoprotein (VLDL)-triglycerides, VLDL-cholesterol, apo-B and lipoprotein(a) were similar in patients and controls. The hepatic lipase activity tended to be lower in patients than controls (33.8+/-17.7 vs. 50.4+/-23.0 pkat/ml; P=0.05). In conclusion, in patients with asymptomatic acute porphyria an increase of total and LDL-cholesterol was found. The cardiovascular risk conferred by this factor may be attenuated by increased HDL-cholesterol and apo-A1.

Maternal morbidity on 147 triplets: single institution experience

Objectives: To evaluate the incidence and characteristics of maternal complications in triple pregnancies. An additional objective was to study the relation between assisted reproductive techniques and maternal complications. Material and methods: Retrospective study on 147 triplets assisted at the Gynecology and Obstetrics department of La Paz University Hospital between 2000 and 2010. We analyzed the incidence of maternal complications and their relation to assisted reproductive techniques. Results: One triplet was observed every 711 pregnancies. The most frequent maternal complications were spontaneous preterm labor (56%), premature rupture of membranes (28.9%), anemia (24.4%) and preeclampsia (20.4%). Triplets conceived by assisted reproductive techniques were significantly more likely to develop spontaneous preterm labor than spontaneous pregnancies (60% vs. 40%, respectively; p = 0.045). Conclusions: Triplets have a very high risk of maternal complications such as preeclampsia. Moreover, the presence of spontaneous preterm labor is more frequent in triplets conceived by assisted reproductive techniques than in those spontaneously conceived.

Prevention and treatment of fetal cytomegalovirus infection with cytomegalovirus hyperimmune globulin: a multicenter study in Madrid

Abstract Introduction: Cytomegalovirus (CMV) is the leading cause of congenital infection worldwide. Data about the management of CMV infection in pregnant women are scarce, and treatment options are very limited. The aim of the study is to investigate the effectiveness of cytomegalovirus hyperimmune globulin (CMV-HIG) for the prevention and treatment of congenital CMV (cCMV) infection. Materials and methods: A retrospective observational study was conducted in three tertiary hospitals in Madrid. In the period 2009–2015, CMV-HIG (Cytotect® CP Biotest, Biotest) treatment was offered to all pregnant women with primary CMV infection and/or detection of CMV-DNA in amniotic fluid in participating centers. Women were divided into prevention and treatment groups (PG and TG, respectively). Those with primary CMV infection who had not undergone amniocentesis comprised the PG and received monthly CMV-HIG (100 UI/kg). If CMV-DNA was subsequently detected in amniotic fluid, one extra dose of CMV-HIG (200 UI/kg) was given 4 weeks after the last dose. Those women were considered to be part of the PG group despite detection of CMV-DNA in amniotic fluid. In the case of a negative result in CMV-DNA detection in amniotic fluid or if amniocentesis was not performed, monthly HIG was given up to the end of the pregnancy. Results: Thirty-six pregnant women were included. Median gestational age at birth was 39 weeks (interquartile range: 38–40) and two children (5.5%) were premature (born at 28 and 34 weeks’ gestation). Amniocentesis was performed in 30/36 (83.4%) pregnancies and CMV PCR was positive in 21 of them (70%). One fetus with a positive PCR in amniotic fluid that received one dose of HIG after amniocentesis presented a negative CMV-PCR in urine at birth, and was asymptomatic at 12 months of age. Twenty-four children were infected at birth, and 16/21 (76.2%) presented no sequelae at 12 months, while two (9.5%) had a mild unilateral hearing loss and three (14.3%) severe hearing loss or neurological sequelae. Seventeen women were included in the PG and 19 in the TG. In the PG 7/17 (41%) fetuses were infected, one pregnancy was terminated due to abnormalities in cordocentesis and one showed a mild hearing loss at 12 months of age. In the TG, 18/19 children (95%) were diagnosed with cCMV, while the remaining neonate had negative urine CMV at birth. Eight out of the 19 fetuses (42.1%) showed CMV related abnormalities in the fetal US before HIG treatment. Complete clinical assessment in the neonatal period and at 12 months of age was available in 16 and 15 children, respectively. At birth 50% were symptomatic and at 12 months of age, 4/15 (26.7%) showed a hearing loss and 3/15 (20%) neurologic impairment. Fetuses with abnormalities in ultrasonography before HIG presented a high risk of sequelae (odds ratios: 60; 95%CI: 3–1185; p = .007). Discussion: Prophylactic HIG administration in pregnant women after CMV primary infection seems not to reduce significantly the rate of congenital infection, but is safe and it could have a favorable effect on the symptoms and sequelae of infected fetuses. The risk of long-term sequelae in fetuses without US abnormalities before HIG is low, so it could be an option in infected fetuses with normal imaging. On the other hand, the risk of sequelae among infected fetuses with abnormalities in fetal ultrasonography before HIG despite treatment is high.

Efficacy of carbetocin for preventing postpartum bleeding after cesarean section in twin pregnancy

Abstract Objective: This is a prospective observational study whose goal was to compare the effectiveness of carbetocin and oxytocin for prevention of postpartum hemorrhage (PPH) when they are administered in twin pregnancies undergoing a cesarean section. Design: We enrolled 166 twin pregnancies at term undergoing elective or emergency cesarean section. We compared the effect of a single 100 µg dose of carbetocin with the use of oxytocin as a protocol (20 IU in Ringer lactate 500 ml in 10–15 min). The main variables studied were intraoperative bleeding, surgical time, hemoglobin fall, hematocrit drop, additional uterotonic use (Methylergometrine and/or misoprostol), need for blood transfusion, and/or IV iron therapy. Results: In the oxytocin group there was a greater fall in the hemoglobin level (1.7 versus 1.2, p = .02). Along the same line, the control group presented a significantly greater need for blood transfusion (9.3 versus 1.3%, =0.03), as well as treatment for anemia as a composite variable (intravenous (IV) iron therapy and/or blood transfusion) 16.3 versus 3.85% for each group [OR 0.2 (0.05–0.72)]. In addition, the use of carbetocin was associated with a reduction in the need to administer additional treatments (uterotonic and/or treatment for anemia) during the postpartum period compared with the use of oxytocin O.R 0.32 (0.12–0.88). Conclusions: In our population of twin pregnancies delivered by cesarean section, carbetocin appears more effective than oxytocin in preventing PPH.

Impact of oocyte donation on obstetric and perinatal complications in twin pregnancies

Abstract Aim: To evaluate obstetric and perinatal outcomes of twin pregnancies obtained after in vitro fertilization with donated oocytes. Methods: This is a case-control study comparing 50 women with twin pregnancies after oocyte donation (OD) and 50 women after in vitro fertilization with autologous oocytes. Clinical records were reviewed and obstetric and perinatal outcome variables including rates of preeclampsia, gestational diabetes, pregnancy-induced hypertension, preterm delivery, premature rupture of membranes, cesarean delivery, birth weight, Apgar score, pH test were compared. Results: Women in the OD group were significantly older than those in the AO group (mean 40.8 versus 36 years old, p < .001). There were a higher risk of preeclampsia (OD 24% versus AO 8%), cesarean delivery (OD 90% versus AO 66%), and preterm birth before 37 weeks (OD 52% versus AO 32%). After adjustment for maternal age, only the risk of preterm birth remained significantly higher (OR 3.2 (1.15–8.86); p = .025). Comparing neonatal outcomes, there were no differences in birth weight, pH or Apgar score at birth. Conclusions: Twin pregnancies after OD are associated with a higher risk of preterm birth before 37 weeks of gestation. However, this did not translate into increased rate of adverse perinatal outcomes.