Newton Eduardo Busso

Zika Virus Infection in Pregnant Women and Microcephaly

From the discovery of the Zika virus (ZIKV) in 1947 in Uganda (Africa), until its arrival in South America, it was not known that it would affect human reproductive life so severely. Today, damage to the central nervous system is known to be multiple, and microcephaly is considered the tip of the iceberg. Microcephaly actually represents the epilogue of this infections devastating process on the central nervous system of embryos and fetuses. As a result of central nervous system aggression by the ZIKV, this infection brings the possibility of arthrogryposis, dysphagia, deafness and visual impairment. All of these changes of varying severity directly or indirectly compromise the future life of these children, and are already considered a congenital syndrome linked to the ZIKV. Diagnosis is one of the main difficulties in the approach of this infection. Considering the clinical part, it has manifestations common to infections by the dengue virus and the chikungunya fever, varying only in subjective intensities. The most frequent clinical variables are rash, febrile state, non-purulent conjunctivitis and arthralgia, among others. In terms of laboratory resources, there are also limitations to the subsidiary diagnosis. Molecular biology tests are based on polymerase chain reaction (PCR) with reverse transcriptase (RT) action, since the ZIKV is a ribonucleic acid (RNA) virus. The RT-PCR shows serum or plasma positivity for a short period of time, no more than five days after the onset of the signs and symptoms. The ZIKV urine test is positive for a longer period, up to 14 days. There are still no reliable techniques for the serological diagnosis of this infection. If there are no complications (meningoencephalitis or Guillain-Barré syndrome), further examination is unnecessary to assess systemic impairment. However, evidence is needed to rule out other infections that also cause rashes, such as dengue, chikungunya, syphilis, toxoplasmosis, cytomegalovirus, rubella, and herpes. There is no specific antiviral therapy against ZIKV, and the therapeutic approach to infected pregnant women is limited to the use of antipyretics and analgesics. Anti-inflammatory drugs should be avoided until the diagnosis of dengue is discarded. There is no need to modify the schedule of prenatal visits for pregnant women infected by ZIKV, but it is necessary to guarantee three ultrasound examinations during pregnancy for low-risk pregnancies, and monthly for pregnant women with confirmed ZIKV infection. Vaginal delivery and natural breastfeeding are advised.

Vaginal management of a “late” ectopic pregnancy after vaginal hysterectomy

OBJECTIVE To describe the first vaginal approach to an ectopic pregnancy after hysterectomy. DESIGN Case report. SETTING Private hospital. PATIENT(S) A 38-year-old woman presenting with an ectopic pregnancy 5 months after having a vaginal hysterectomy due to uterine myomatosis. INTERVENTION(S) Vaginal adnexectomy. MAIN OUTCOME MEASURE(S) Vaginal surgery as a plausible approach for this very particular situation (ectopic pregnancy in hysterectomized patient). RESULT(S) After vaginal surgery with removal of the left tube (containing a gestacional sac) and ovary, the patient fully recovered. CONCLUSION(S) Vaginal surgery can be a safe option for ectopic pregnancy resolution in noncomplicated cases.

Fertilização in vitro com injeção intracitoplasmática de espermatozóide em ciclos naturais

PURPOSE: to evaluate the efficacy of in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) in natural cycle (NC). METHODS: retrospective clinical trial that evaluated 70 treatment cycles in 60 couples that were submitted to IVF treatment with ICSI in NC performed in private clinic from 1999 until 2003. It was performed daily ultrasound monitorization or on alternate days, and urinary LH dosage when the follicle reached 16 mm of diameter. It was scheduled egg retrieval when the follicle reached 18 mm of diameter and 36 hours after hCG administration when the LH test was negative. Embryo transfer was performed 48 to 52 hours after ICSI. RESULTS: 70 ICSI cycles in 60 patients were performed and the indications of treatment included: male factor (47.1%), tubal factor (37.1%), associated factors (8.7%), unknown infertility (7.1%). Out of 70 cycles, 18 cycles were cancelled (25.7% of cancellation rate). Out of 52 patients that were submitted to ovarian punction to oocyte retrieval we found mature oocytes in 77% of the cases (40 cycles), in four cases we collected immature oocytes and in eight cases we could not found it. We had 70% of fertilization rate and only one fertilized oocyte did not achieve the cleavage stage. So, the transfers rate per punction and per mature oocyte was 52% and 67.5%, respectively. We had 11.4% of pregnancy rate per cycle, 15.4% per punction and 29.6% per embryo transfer. CONCLUSIONS: FIV/ICSI in NC seem to be a satisfactory option of treatment, with low costs and complications (multiple gestation and Ovarian Hyperstimulation Syndrome), mainly in poor responder patients and in poor populations.

Abnormal inhibin A and inhibin B secretion in obese women with and without insulin resistance.

Aim. The present study aimed to establish inhibin A and B serum levels during the menstrual cycle of obese women, and its usefulness as an index of luteal-phase follicular development. Materials and methods. Twenty-one obese patients (mean body mass index: 34.9 ± 3.7 kg/m2; range: 30.0–45.0 kg/m2) were submitted to basal hormonal measurements and an oral glucose tolerance test after challenge with 75 g glucose. Progesterone and inhibin A and B levels were determined 5–7 days after the menstrual cycle and 7 days prior to expected menses. Results. As expected, an increase in inhibin A and a decrease in inhibin B were observed when first-phase samples were compared with samples obtained after 15–20 days. On the other hand, the percentage variation of both inhibin A and B was at least four times smaller than the values for normal women described previously by other authors employing the same enzyme-linked immunosorbent assays. A small number of obese women presented ovulatory cycles characterized by progesterone concentration higher than 5.8 ng/ml. The percentage elevation ( > 190%) of inhibin A in the second samples was in agreement with the progesterone levels, but it seemed to be more sensitive for the detection of follicle luteinization. Conclusion. We conclude that obese women present less percentage variation of both inhibin A and B during the menstrual cycle, associated with a low frequency of ovulatory cycles. In obese women, the percentage increase of inhibin A can represent an additional marker to recognize follicle luteinization.