Middle Cerebral Artery Dopplers and Abnormal Neonatal Outcomes among Pregnant Women with Zika Virus Infection.

OBJECTIVE: The aim of this study was to investigate the role of middle cerebral artery (MCA) Doppler measurements for the prediction of abnormal neonatal outcomes in pregnancies affected by Zika virus (ZIKV). METHODS: Secondary analysis of a prospective cohort of pregnant women diagnosed with ZIKV infection from September 2015 to December 2016 at a single regional referral center. Ultrasonography with measurements of MCA peak systolic velocity (PSV), PSV multiples of the median (MoM) for gestational age, and pulsatility index (PI) were collected. The primary outcome was a composite abnormal neonatal outcome. MCA Doppler values of normal and abnormal neonatal outcomes were compared with Wilcoxon rank sum test. The predictive value of MCA Dopplers for development of abnormal neonatal outcome was calculated by logistic regression. RESULTS: One-hundred twenty-seven ZIKV-positive pregnancies with MCA Doppler measurements and known neonatal outcomes were included. Of the 132 neonates, 66 (50%) had an abnormal neonatal outcome. Lower MCA PSV (p = 0.027) and PSV MoM (p = 0.008) were associated with abnormal neonatal outcomes. There was no significant difference in MCA PI. Abnormal neonatal outcomes had lower MCA PSV by 5.36 cm/s (95% confidence interval [CI]: 0.95-9.77, p = 0.018) and lower MCA PSV MoM by 0.13 (95% CI: 0.05-0.22, p = 0.002). MCA PSV of 30 cm/s had a 65% predicted probability of an abnormal neonatal outcome (95% CI: 51-79%). CONCLUSION: In ZIKV-infected pregnancies, lower MCA PSV and PSV MoM measurements were seen with abnormal neonatal outcomes. This may represent a physiologic response to fetal ZIKV infection. Evaluation of MCA Dopplers may be of clinical utility in the surveillance of ZIKV-affected pregnancies. KEY POINTS: · Significantly lower MCA PSV is associated with abnormal neonatal outcomes in ZIKV pregnancies.. · Lower MCA PSV may reflect the underlying neuropathology of ZIKV exposure on the fetus.. · There is potential utility for MCA Doppler evaluation in antepartum surveillance of ZIKV pregnancies..

Association of Prenatal Ultrasonographic Findings With Adverse Neonatal Outcomes Among Pregnant Women With Zika Virus Infection in Brazil.

Importance: Congenital Zika virus infection causes a spectrum of adverse birth outcomes, including severe birth defects of the central nervous system. The association of prenatal ultrasonographic findings with adverse neonatal outcomes, beyond structural anomalies such as microcephaly, has not been described to date. Objective: To determine whether prenatal ultrasonographic examination results are associated with abnormal neonatal outcomes in Zika virus-affected pregnancies. Design, Setting, and Participants: A prospective cohort study conducted at a single regional referral center in Rio de Janeiro, Brazil, from September 1, 2015, to May 31, 2016, among 92 pregnant women diagnosed during pregnancy with Zika virus infection by reverse-transcription polymerase chain reaction, who underwent subsequent prenatal ultrasonographic and neonatal evaluation. Exposures: Prenatal ultrasonography. Main Outcomes and Measures: The primary outcome measure was composite adverse neonatal outcome (perinatal death, abnormal finding on neonatal examination, or abnormal finding on postnatal neuroimaging). Secondary outcomes include association of specific findings with neonatal outcomes. Results: Of 92 mother-neonate dyads (mean [SD] maternal age, 29.4 [6.3] years), 55 (60%) had normal results and 37 (40%) had abnormal results on prenatal ultrasonographic examinations. The median gestational age at delivery was 38.6 weeks (interquartile range, 37.9-39.3). Of the 45 neonates with composite adverse outcome, 23 (51%) had normal results on prenatal ultrasonography. Eleven pregnant women (12%) had a Zika virus-associated finding that was associated with an abnormal result on neonatal examination (adjusted odds ratio [aOR], 11.6; 95% CI, 1.8-72.8), abnormal result on postnatal neuroimaging (aOR, 6.7; 95% CI, 1.1-38.9), and composite adverse neonatal outcome (aOR, 27.2; 95% CI, 2.5-296.6). Abnormal results on middle cerebral artery Doppler ultrasonography were associated with neonatal examination abnormalities (aOR, 12.8; 95% CI, 2.6-63.2), postnatal neuroimaging abnormalities (aOR, 8.8; 95% CI, 1.7-45.9), and composite adverse neonatal outcome (aOR, 20.5; 95% CI, 3.2-132.6). There were 2 perinatal deaths. Abnormal findings on prenatal ultrasonography had a sensitivity of 48.9% (95% CI, 33.7%-64.2%) and a specificity of 68.1% (95% CI, 52.9%-80.1%) for association with composite adverse neonatal outcomes. For a Zika virus-associated abnormal result on prenatal ultrasonography, the sensitivity was lower (22.2%; 95% CI, 11.2%-37.1%) but the specificity was higher (97.9%; 95% CI, 88.7%-99.9%). Conclusions and Relevance: Abnormal results on prenatal ultrasonography were associated with adverse outcomes in congenital Zika infection. The absence of abnormal findings on prenatal ultrasonography was not associated with a normal neonatal outcome. Comprehensive evaluation is recommended for all neonates with prenatal Zika virus exposure.

O volume do colo uterino na gravidez: comparação entre aferição sonográfica bidimensional e tridimensional / The volume of the uterine cervix in pregnancy: a comparison between two-dimensional and three-dimensional sonographic measurement

Objetivo: Comparar as medidas do volume do colo uterino pela US3D utilizando a técnica VOCAL com o método manual utilizando as medidas de US 2D e a fórmula geométrica para cilindros. Metodologia: Foram incluídas 48 mulheres grávidas assintomáticas entre 20 e 24 semanas de gestação sob baixo risco de parto prematuro. Elas passaram por exame de ultrassonografia transvaginal para medição do comprimento e aquisição do volume 3D do colo uterino no momento do exame de rastreio de malformações do feto do segundo trimestre. Os conjuntos de dados adquiridos foram armazenados na máquina de ultrassonografia e analisados por dois observadores independentes posteriormente. Os cálculos de volume foram realizados pelo software VOCAL e pela fórmula geométrica para cilindros. A análise de confiabilidade para os dois métodos foi feita pelo coeficiente de correlação intraclasse (ICC) e a concordância intermétodos foi feita pelo método de Bland-Altman. Resultados: A concordância intermétodos foi considerada aceitável, com correlação de r=0,87 para o observador 1 e r=0,71 para o observador 2 (p<0,001). O ICC foi de 0,58 (IC95% 0,25 - 0,76) para o observador 1 e 0,80 (IC95% 0,64 ­ 0,88) para o observador 2. A concordância intraobservador foi excelente para ambos os métodos, ICC 0,93 (IC92% 0,87 ­ 0,96) para a técnica VOCAL e 0,92 (IC95% 0,87 ­ 0,96) para o método manual. A concordância interobservadores foi boa para a técnica VOCAL, ICC 0,81 (IC 95% 0,67 ­ 0,89), e ruim para o método manual, ICC 0,37 (IC95% -0,10 ­ 0,65). Conclusões: Este estudo de comparação de métodos mostrou que a fórmula geométrica para cilindros tem concordância aceitável com o VOCAL na medição do volume do colo uterino. As duas técnicas utilizadas apresentaram boa reprodutibilidade intraobservador. O método manual apresentou baixa reprodutibilidade interobservadores. A técnica VOCAL demonstrou maior confiabilidade por apresentar boa reprodutibilidade intra e interobservadores.

Objectives: To compare uterine cervix volume measurements by US3D using the VOCAL technique with the manual method using US 2D measurements and geometric formula for a cylinder. Methods: We included 48 asymptomatic pregnant women at 20 to 24 weeks gestation under low risk of preterm birth. They underwent transvaginal ultrasonography to measure the length and acquisition of the 3D volume of the cervix at the time of second trimester fetal malformations screening. The acquired data sets were stored on the ultrasound machine and analyzed by two independent observers later. The volume calculations were performed by the VOCAL software and by the geometric formula for cylinders. The reliability analysis for the two methods was evaluated by the intraclass correlation coefficient (ICC) and Bland-Altman plots were produced to examine intermethod agreement. Results: Inter-method agreement was considered acceptable, with correlation of r = 0.87 for observer 1 and r = 0.71 for observer 2 (p <0.001). The ICC was 0.58 (95% CI 0.25-0.76) for the observer 1 and 0.80 (95% CI 0.64-0.88) for the observer 2. The intraobserver agreement was excellent for both methods, ICC 0.93 (IC92% 0.87-0.96) for the VOCAL technique and 0.92 (95% CI 0.87-0.96) for the manual method. Interobserver agreement was good for the VOCAL technique, ICC 0.81 (95% CI 0.67-0.89), and poor for the manual method, ICC 0.37 (95% CI -0.10-0.65). Conclusion: This method comparison study shows that the geometric formula for a cylinder has acceptable agreement with VOCAL to measurement of uterine cervix volume. The two techniques used have good intraobserver reproducibility. The manual method presented low interobserver reproducibility. The VOCAL technique demonstrated greater reliability because it presented good intra and interobserver reproducibility.