Maternofetal consequences of Coxiella burnetii infection in pregnancy: a case series of two outbreaks.

BACKGROUND: A high complication rate of Q fever in pregnancy is described on the basis of a limited number of cases. All pregnant women with proven Q fever regardless of clinical symptoms should therefore receive long-term cotrimoxazole therapy. But cotrimoxazole as a folic acid antagonist may cause harm to the fetus. We therefore investigated the Q fever outbreaks, Soest in 2003 and Jena in 2005, to determine the maternofetal consequences of Coxiella burnetii infection contracted during pregnancy. METHODS: Different outbreak investigation strategies were employed at the two sides. Antibody screening was performed with an indirect immunofluorescence test. Medical history and clinical data were obtained and serological follow up performed at delivery. Available placental tissue, amniotic fluid and colostrum/milk were further investigated by polymerase chain reaction and by culture. RESULTS: 11 pregnant women from Soest (screening rate: 49%) and 82 pregnant women from Jena (screening rate: 27%) participated in the outbreak investigation. 11 pregnant women with an acute C. burnetii infection were diagnosed. Three women had symptomatic disease. Three women, who were infected in the first trimester, were put on long-term therapy. The remaining women received cotrimoxazole to a lesser extent (n=3), were treated with macrolides for three weeks (n=1) or after delivery (n=1), were given no treatment at all (n=2) or received antibiotics ineffective for Q fever (n=1). One woman and her foetus died of an underlying disease not related to Q fever. One woman delivered prematurely (35th week) and one child was born with syndactyly. We found no obvious association between C. burnetii infection and negative pregnancy outcome. CONCLUSIONS: Our data do not support the general recommendation of long-term cotrimoxazole treatment for Q fever infection in pregnancy. Pregnant women with symptomatic C. burnetii infections and with chronic Q fever should be treated. The risk-benefit ratio of treatment in these patients, however, remains uncertain. If cotrimoxazole is administered, folinic acid has to be added.

PP049. The arterio-venous ratio of retinal vessels in the first trimester as a predictor for preeclampsia.

INTRODUCTION: Retinal changes are known in severe preeclampsia (PE). This is the first study evaluating static retinal vessel analysis in pregnancy to measure retinal vessel diameter and in women destined to develop preeclampsia. METHODS: 51 non-pregnant controls (29±4 years) and 601 pregnant women (30±6 years) arterio-venous ratio (AVR) of retinal arterioles and venules was measured with Dynamic Vessel Analyzer in 1. (12.1±2.5 weeks; T1), 2. (22.6±2.3 weeks; T2), 3. (33.1±3.8 weeks; T3) trimester and postpartum (19.1±15.3 weeks; pp). RESULTS: 38 women developed gestational hypertension (GH), while 143 developed PE. AVR [mean±SD] in the PE-group (28±6 years) was lower (p<0,02) in T1, T2, and pp compared to 420 women who remained normotensive during pregnancy (T1: 0.80±0.06 vs. 0.9±0.08; T2: 0.86±0.06 vs. 0.9±0.11; T3: 0.88±0.09 vs. 0.89±0.1; pp: 0.83±0.08 vs. 0.87±0.1). Non-pregnant controls (0.86±0.1) as well as normotensive pregnancies did not show any differences in AVR-values when compared to those who developed GH later in pregnancy (T1: 0.42±0.20; T2: 0.35±0.18; T3: 0.49±0.09; pp: 0.44±0.19). With a defined cut-off value of <0.83 AVR in the first trimester we were able to predict PE with a positive predictive value of 43.2% and a sensitivity of 86%. CONCLUSION: AVR is lower in women susceptible for PE. These data are the first to provide evidence that microvascular changes of retinal vessels predate PE and even persist after delivery.

PP048. Carotid intima-media-thickness in the first trimester as a predictor of preeclampsia.

INTRODUCTION: Carotid intima media thickness (IMT) is an established marker for endothelial dysfunction and cardiovascular risk. The aim of this study was to assess IMT in the first trimester and it's predictive value for preeclampsia. METHOD: We measured IMT on 51 non-pregnant controls (29±4 years) and 601 pregnant women (30±6 years) in the 1. (12.1±2.5 wks; T1), 2. (22.6±2.3 wks; T2), 3. (33.1±3.8 wks; T3) trimester, and postpartum (19.1±15.3 wks; pp) with high-resolution ultrasound. RESULTS: 38 pregnant women developed gestational hypertension (GH) and 143 preeclampsia (PE). IMT [mean (mm)±SD] of women who later developed PE (28±6 years) was significantly greater (p<0,03) at all visits compared to 420 women who remained normotensive during pregnancy (T1: 0.58±0.1 vs. 0.34±0.16; T2: 0,.3±0.1 vs. 0.34±0.1; T3: 0.49±0.09 vs. 0.34±0.13; pp: 0.56±0.31 vs. 0.39±0.14) and non-pregnant controls (0.44±0.08). IMT of women who later developed GH was not different compared to normotensive pregnant and non-pregnant controls (T1: 0.42±0.20; T2: 0.35±0.18; T3: 0.49±0.09; pp: 0.44±0.19). Using a cut-off value of >0.5 mm we would be able to predict PE already in the first trimester with a positive predictive value of 45.5 % and a sensitivity of 76.9 %. CONCLUSION: IMT is increased starting from first trimester onwards in women who later developed preeclampsia but not in women developing gestational hypertension. In high risk pregnancies measurement of IMT could represent an easy to use early detection method to predict preeclampsia noninvasively.

PP063. Carotid artery stiffness and elasticity in gestational diabetes.

INTRODUCTION: Gestational diabetes (GMD) is gaining in importance in prenatal care due to it's increasing prevalence. These women do have a higher risk for disrupted elasticity and stiffening of the carotid artery. Aim of this study was to assess carotid intima media thickness (IMT) and vessel wall changes during pregnancy and postpartum. METHODS: IMT and vessel wall parameters of the carotid artery were evaluated with high resolution ultrasound during pregnancy and postpartum on 84 women with gestational diabetes and 106 gestational age matched controls. RESULTS: Carotid elasticity (mean (%)±SD) was significantly lower in women with GDM than healthy pregnant women (9.48 (103/kPa)±3.21 vs. 11.01±3.17, p<0.047), whereas blood pressure independent ß-stiffness (mean±SD) was significantly increased in women with GDM (6.08±3.15 vs. 4.68±1.57; p=0.007). Pregnancies complicated by GDM had higher mean arterial pressure then matched controls (93±12 vs. 86±10mmHg, p<0.015). Postpartum, both groups did not show any significant changes. CONCLUSION: Carotid stiffening and rigidity is present in gestational diabetes mellitus during pregnancy and shows postpartal recovery. Therefore GDM dependent vessel wall changes seem to be only temporary and not pre-existing.