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.

Avaliação da antecipação do nascimento nas gestações de mães aloimunizadas Rh (D) com baixo risco para anemia fetal e neonatal assistidas no Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira / Evaluation of early delivery in pregnancies of Rh (D) alloimmunized mothers at low risk for fetal and neonatal anemia assisted at the National Institute of Women, Children and Adolescents Health Fernandes Figueira

Avaliação da antecipação do nascimento nas gestações de mães aloimunizadas Rh(D) com baixo risco para anemia fetal e neonatal assistidas no IFF/FIOCRUZ INTRODUÇÃO O melhor momento para interrupção das gestações complicadas por aloimunização Rh (D) é um tema controverso e com evidência limitada na literatura. A opção pela antecipação do parto na faixa de idade gestacional de prematuridade merece especial atenção quando lidamos com o grupo de baixo risco para anemia OBJETIVO Analisar as razões potenciais que levaram ao parto pré-termo nas gestações com baixo risco para anemia neonatal no IFF/FIOCRUZ, comparando o grupo dos recém nascidos a termo com o dos recém nascidos pré-termo quanto ao maior múltiplo da mediana do pico de velocidade sistólica na artéria cerebral média e hematócrito ao nascimento. MATERIAL E MÉTODOS Estudo observacional retrospectivo, com obtenção dos dados por análise dos prontuários das mães e recém-nascidos de gestações assistidas no IFF/Fiocruz por aloimunização Rh(D) com baixo risco para anemia definido por características da história obstétrica e acompanhamento pré-natal e com parto nesta instituição entre janeiro de 2004 e dezembro de 2014. RESULTADOS Foram avaliadas 177 gestações com aloimunização Rh(D) e baixo risco para anemia. O parto foi indicado exclusivamente pela doença hemolítica perinatal em 77,4% dos casos (IC 95% 70,5-83,3%). A prevalência de prematuridade por qualquer causa foi de 35,6% (IC95% 28,6-43,1%) e de prematuridade indicada exclusivamente pela doença hemolítica 24,9% (IC95% 18,7-31,9%). No grupo com nascimento pré-termo foi encontrada uma maior proporção de casos com PV ACM > 1,30MoM, com diferença estatisticamente significativa (p valor < 0,05). A comparação da média do hematócrito entre os dois grupos também mostrou diferença estatisticamente significativa, com o grupo dos nascidos pré-termo com média mais baixa do hematócrito ao nascimento (p valor < 0,05). CONCLUSÕES Esses resultados sugerem que mesmo no grupo de baixo risco para anemia provavelmente há uma proporção de casos que se beneficiam do nascimento prematuro para parada da progressão da doença intra-útero e instituição precoce de tratamento neonatal. Talvez um ponto de corte diferente daquele utilizado para indicação de transfusão intra útero possa identificar os fetos que se beneficiariam do nascimento prematuro dentro do grupo de baixo risco.

The delivery anticipation in pregnancies with Rh(D) alloimmunization and low risk of fetal and neonatal anemia assisted at IFF/FIOCRUZ INTRODUCTION The optimal timing for delivery in pregnancies complicated by Rh(D) alloimmunization it's a controversial topic, with little evidence in literature. The decision for anticipation of delivery in a gestational age before term deserves special attention when we deal with the subgroup with low risk of anemia. PURPOSE Analyze the potential reasons that lead to a preterm birth in pregnancies with low risk of fetal and neonatal anemia at IFF/FIOCRUZ, comparing pregnancies with term neonates with the ones with preterm neonates in means of highest multiple of the mean of median cerebral artery peak velocity and neonatal hematocrit after delivery. MATERIAL AND METHODS Retrospective observational study, getting information from medical record of mother and neonate of pregnancies followed at IFF/FIOCRUZ for Rh(D) alloimmunization and low risk for fetal and neonatal anemia, defined by characteristics of obstetric history and prenatal care, that delivered at the same institution between January 2004 and December 2014. RESULTS Medical records of one hundred seventy-seven pregnancies with Rh(D) alloimmunization and low risk for fetal and neonatal anemia were evaluated. Delivery was indicated exclusively by perinatal hemolytic disease in 77,4% of them (IC 95% 70,5-83,3%). Prevalence of prematurity by any reason was 35,6% (IC95% 28,6-43,1%) and of prematurity exclusively indicated by perinatal hemolytic disease 24,9% (IC95% 18,7-31,9%). In the group with preterm delivery a higher proportion of cases with PV ACM > 1,30MoM was found, with statistical significance (p < 0,05). Comparing the hematocrit mean between groups a statistic significant difference was also found, with the preterm birth neonates mean hematocrit lower (p < 0,05). CONCLUSIONS These results suggest that even in the low risk of anemia group there is a proportion of cases that get benefit from the preterm delivery as it stops progression of intrautero perinatal hemolytic disease and provides early institution of neonatal treatment. A new threshold different of that used for indication of intrautero transfusion might identify fetuses in the low risk of anemia group that could get benefit of premature delivery.