Effect of Genital Sampling Site on the Detection and Quantification of Ureaplasma Species with Quantitative Polymerase Chain Reaction during Pregnancy.

Objective. This study aimed to compare the qualitative and quantitative reproducibility of quantitative PCR (qPCR) for Ureaplasma species (Ureaplasma spp.) throughout pregnancy and according to the genital sampling site. Study Design. Between 5 and 14 weeks of gestation (T1), vaginal, fornix, and two cervical samples were taken. Sampling was repeated during the 2nd (T2) and 3rd (T3) trimester in randomly selected T1 positive and negative women. Qualitative and quantitative reproducibility were evaluated using, respectively, Cohen's kappa (κ) and interclass correlation coefficients (ICC) and repeated measures ANOVA on the log-transformed mean number of DNA copies for each sampling site. Results. During T1, 51/127 women were positive for U. parvum and 8 for U. urealyticum (4 patients for both). Sampling was repeated for 44/55 women at T2 and/or T3; 43 (97.7%) remained positive at the three timepoints. κ ranged between 0.83 and 0.95 and the ICC for cervical samples was 0.86. Conclusions. Colonization by Ureaplasma spp. seems to be very constant during pregnancy and vaginal samples have the highest detection rate.

Primary maternal cytomegalovirus infections: accuracy of fetal ultrasound for predicting sequelae in offspring.

BACKGROUND: Cytomegalovirus infection is the most common perinatal viral infection that can lead to severe long-term medical conditions. Antenatal identification of maternal cytomegalovirus infections with proven fetal transmission and potential postnatal clinical sequelae remains a major challenge in perinatology. There is a need to improve the prenatal counseling offered to patients and guide future clinical management decisions in cases of proven primary cytomegalovirus infection. OBJECTIVE: We sought to evaluate the accuracy of fetal ultrasound for predicting sequelae in fetuses infected with congenital cytomegalovirus after maternal primary infection. STUDY DESIGN: We conducted a prospective observational study from 1996 through 2012 in pregnant women with serological evidence of primary cytomegalovirus infection and proven vertical transmission to the fetus, based on viral load in the amniotic fluid. Fetal ultrasound was performed in all patients. Pregnancy termination was presented as an option for infected fetuses. Hearing and neurological clinical assessments were performed for all neonates with cytomegalovirus-positive urine samples. RESULTS: A total of 67 patients (69 fetuses) with proven vertical transmission were included in this study, including 64 singleton and 3 twin pregnancies. Eight fetuses were lost to follow-up. Of the remaining 61 fetuses, termination of the pregnancy was performed for 26, including 11 with fetal ultrasound anomalies. Autopsy provided histological evidence of fetal cytomegalovirus infection in all cases. In the 15 terminated fetuses without ultrasound anomalies, histological evidence of damage caused by fetal infection was detected in 13 cases. Among the 35 live-born infants, 12 had fetal ultrasound anomalies suggestive of congenital infection. Of these 12 infants, 6 had normal clinical evaluations, whereas 6 presented with either hearing and/or neurological anomalies, classified as severe in 4 cases. Among the 23 live-born infants with normal prenatal ultrasound, 5 developed hearing impairments and 1 showed mild neurological developmental delay. CONCLUSION: Fetal ultrasound anomalies were detected in 37.7% of pregnant women with primary cytomegalovirus infection acquired in early pregnancy and proven fetal infection, and were confirmed by autopsy or postnatal clinical evaluation in 73.9%. Autopsy or postnatal clinical evaluation also detected cytomegalovirus-related anomalies in 55% of infants with normal fetal ultrasound evaluations.

Congenital cytomegalovirus infection: contribution and best timing of prenatal MR imaging.

OBJECTIVE: To predict sensorineural hearing loss (SNHL) and neurological impairment in congenital cytomegalovirus (cCMV) infection using MR imaging and define the best timing in pregnancy for prenatal assessment. METHODS: In 121 patients with confirmed cCMV infection, brain features at MR imaging were respectively graded from 1 to 5: normal; isolated frontal/parieto-occipital hyperintensity; temporal periventricular hyperintensity; temporal/occipital cysts and/or intraventricular septa; migration disorders. Grading was correlated with postnatal SNHL and neurological impairment using regression analysis. In 51 fetuses with MR examinations at 26.9 and 33.0 weeks, the predictive value of SNHL and neurological impairment was compared using ROC curves. RESULTS: Postnatal follow-up showed SNHL in 18 infants and neurological impairment in 10. MR grading was predictive of SNHL and of neurological impairment (P < 0.001). In grade 1 or 2, none had SNHL and 1/74 had neurological impairment. The areas under ROC curves for prediction of postnatal SNHL and of neurological impairment from first and second MR examination were comparable. CONCLUSION: Our data suggest that in cCMV infection, prediction of SNHL and neurological impairment is feasible by fetal MR imaging with a high negative predictive value and can equally be done at 27 or 33 weeks of gestation. KEY POINTS: • In cCMV, isolated periventricular T2-weighted signal hyperintensity has a good postnatal prognosis. • In cCMV, SNHL and neurological impairment can be predicted at 27 or 33 weeks. • In cCMV, fetal MR has a high NPV in predicting SNHL. • In cCMV, fetal MR has a high NPV in predicting neurological impairment.

Does recent sexual intercourse during pregnancy affect the results of the fetal fibronectin rapid test? A comparative prospective study.

OBJECTIVE: We conducted a prospective comparative cohort study to determinate the influence of coitus on quantitative fetal fibronectin test results under normal pregnancy conditions. We also compared values obtained in cervical and vaginal secretions. METHODS: In a population of women with normal singleton pregnancies between 22 and 28 weeks gestation, we have performed (cervical and vaginal) quantitative fetal fibronectin tests in two separate groups classified according to timing after coitus (one group of women had intercourse within 24 h before sampling and the control group had intercourse >24 h before sampling). The main outcome measures were the proportion of positive tests in both groups and the correlation between cervical and vaginal values through the Pearson correlation coefficient. RESULTS: Both groups were similar in terms of general characteristics and pregnancy outcomes. The proportions of positive results in the vaginal secretions were 7.5% and 25.0% (P=0.007) in the control and coitus group, respectively. In the cervical secretions, the proportions of positive tests were greater, but not statistically different (39.7% and 40.0%, respectively). The Pearson correlation coefficients were very low (<0.3) indicating poor correlation between both sampling locations. Even if the cervical values were generally greater than the vaginal values, they were lower in 26% of the women. CONCLUSIONS: Coitus definitely interferes with vaginal fetal fibronectin test results. In cervical secretions, the positive rate was so high that coitus had no influence, but cervical sampling in this location should be avoided.

Determinants of folic acid use in a multi-ethnic population of pregnant women: a cross-sectional study.

AIMS: To investigate the possible differences in folic acid use and to identify the determinants of antenatal folic acid use among multi-ethnic pregnant women. METHODS: Three hundred and fifty pregnant women participated in this cross-sectional study in a university hospital in Brussels, Belgium. A questionnaire was used to obtain data on socio-demographic characteristics and folic acid use. χ(2)-tests and binary logistic regression analyses were performed using SPSS 17. RESULTS: In the overall cohort, 59.2% used folic acid supplements during pregnancy. This supplement use was associated with an age of 26-35 years, being of Western origin, with high education and employment status, understanding physician's instructions, and early booking for antenatal care. Education (odds ratio, OR: 2.24; 95% confidence interval, CI: 1.08-4.63) and early booking for antenatal care OR: 2.45; 95% CI: 1.11-5.40) were the most important determinants. In particular for Arab/Turkish women, a lower employment status OR: 0.42; 95% CI: 0.24-0.73) was associated with a higher risk of not using folic acid supplements. CONCLUSIONS: The lower use of folic acid supplements in Arab/Turkish ethnicities, which may be associated with an increased risk of neural tube defects, is related to socio-economic factors rather than to lower educational attainment. As recommended by other studies, fortification of ethnic minority food may be warranted to reduce the risk of neural tube defects.

Specific congenital malformations after exposure to cyclophosphamide, epirubicin and 5-fluorouracil during the first trimester of pregnancy.

The treatment of pregnant women with chemotherapeutic drugs leads to congenital malformations in 10-20% of newborn children. We present a case of an ongoing 19-week-long pregnancy which was diagnosed in a 39-year-old woman who was being treated with CEF (cyclophosphamide, epirubicin, 5-fluorouracil) chemotherapy for an infiltrating ductal carcinoma of the breast. After termination of the pregnancy, subsequent examination of the fetus revealed micrognathia and bilateral malformations of the hands and feet. The peak exposure of the fetus to the chemotherapeutic agents was in the 5th to 6th week of the pregnancy. Both the nature of the malformations and the timing of the administration of chemotherapy are similar to another case reported previously. We conclude that chemotherapy treatments with CEF in the 5th to 6th week of pregnancy specifically generate hand and foot abnormalities and micrognathia, which is consistent with an inhibition of proliferation, leading to cell death at this embryonic stage.

Association of abnormal vaginal flora and Ureaplasma species as risk factors for preterm birth: a cohort study.

OBJECTIVE: To find out whether the presence of Ureaplasma species (U. spp.) in combination with an alteration of the normal vaginal flora is an independent risk factor for preterm delivery. DESIGN: Prospective observational study. SETTING: Department of Obstetrics, University Hospital in Brussels. POPULATION: A total of 1,988 singleton pregnancies were included. METHODS: From each woman, a cervical culture for U. spp. was obtained and the vaginal flora evaluated at the first prenatal visit. The presence of known risk factors for preterm delivery was recorded. Preterm birth was defined as delivery < 37 weeks. RESULTS: There were 97 (4.9%) preterm births. In patients delivered before 37 weeks, abnormal vaginal flora was detected in 22.7% and U. spp. in 53.6% of these. The conditions were found together in 17.5%. In patients delivered at term, an abnormal vaginal flora was detected in 14.4% and U. spp. in 41.4% of these women, while they co-existed in 8.2%. Using a logistic regression analysis taking into account known risk factors for preterm birth and the microbiological parameters, preterm delivery was correlated with the presence of U. spp. (odds ratio (OR) 1.64; 95% confidence interval (CI) 1.08-2.48; p = 0.02) and abnormal vaginal flora in combination with U. spp. (OR 2.35; 95% CI 1.35-4.10; p = 0.003). No significant correlation between the presence of abnormal vaginal flora and preterm delivery (p = 0.09) was found. CONCLUSIONS: Preterm delivery was significantly correlated with the presence of U. spp. The risk for preterm delivery increased when U. spp. was associated with an abnormal vaginal flora.

A 10-year prospective study of sensorineural hearing loss in children with congenital cytomegalovirus infection.

OBJECTIVE: To determine the incidence, characteristics, and evolution of sensorineural hearing loss (SNHL) in infants with a congenital cytomegalovirus infection (cCMV). STUDY DESIGN: In a prospective 10-year study, 14 021 unselected live-born infants were screened for cCMV by virus isolation in urine. Congenitally infected newborns were evaluated for SNHL during the first 5 years of life. RESULTS: A total of 74 of the 14 021 infants (0.53%) were congenitally infected; of these, 4 (5.4%) were symptomatic at birth. Hearing testing could be performed in 60 of the infants. SNHL was found in 21% of the asymptomatic and in 33% of symptomatic congenitally infected infants. Late-onset hearing loss was detected in 5%, progression in 11%, fluctuation in 16%, and improved hearing threshold in 18% of the infants with cCMV. SNHL was observed in 15% of infected infants born after a maternal primary infection, in 7% born after a maternal recurrent infection, and in 40% after a maternal infection of indeterminate timing. CONCLUSIONS: In our study population, 0.53% of the infants had cCMV infection, 22% of whom developed SNHL. Long-term follow up and repeated audiologic testing is needed, because progression, fluctuation, improvement, and late-onset hearing loss are important features of cCMV infection. The search for a neonatal screening program to detect all cCMV is worthwhile.

Monochorionic high-order multiple pregnancies and multifetal pregnancy reduction.

OBJECTIVE: To study the frequency and obstetric outcome of monochorionic multiple pregnancies in a population referred for fetal reduction. METHODS: Data charts of all patients with multifetal (> or =3) pregnancies referred for fetal reduction over the last 10 years were reviewed for the presence of monochorionic twin pairs or triplets. RESULTS: Twenty-nine of 239 high-order multiple pregnancies contained a monochorionic component (12.1%), eight of which were monochorionic triplets. Half of all naturally conceived pregnancies contained a monochorionic component. High-order multiple pregnancies with a monochorionic component resulted significantly more frequently from natural conceptions (7 of 29) than multichorionic pregnancies (7 of 210) (P =.001). Fetal reduction of the monochorionic twin pair in 21 pregnancies resulted in eight twin and 13 singleton pregnancies; mean gestational age at delivery was, respectively, 34.3 +/- 2.9 and 39.2 +/- 1.4 weeks. Pregnancy loss rate was one of 21 (4.8%). In the remaining eight multiple pregnancies with a monochorionic triplet present, three were complicated by a twin reversed arterial perfusion sequence, and two couples requested a first trimester termination of pregnancy. Fetal reduction of the monochorionic triplet in a dichorionic quadruplet pregnancy resulted in a normal pregnancy outcome. In two monochorionic triplet pregnancies, fetal reduction to monochorionic twin pregnancies with bipolar coagulation of the umbilical cord resulted in a favorable pregnancy outcome. CONCLUSION: Monochorionic twins or triplets are frequently part of naturally conceived high-order multiple pregnancies. Reduction of the monochorionic twin pairs improves pregnancy outcome. Monochorionic triplet pregnancies show a high complication rate, but may benefit from fetal reduction by cord coagulation.

Hearing thresholds in children with a congenital CMV infection: a prospective study.

OBJECTIVE: Hearing thresholds in children with a congenital cytomegalovirus (cCMV) infection are not always stable. Children can develop late onset hearing loss, fluctuations, progression (worsening) and improvement of hearing loss. Knowledge about these characteristics is important to understand why long term follow up in these children is mandatory. METHODS: We prospectively follow a cohort of 154 children with cCMV infection, 68 of which met the inclusion criteria of at least 3 hearing evaluations over a period of at least 18 months in the absence of other risk factors for hearing loss. In those 68 children we evaluated the occurrence of unstable hearing thresholds: late onset hearing loss, fluctuations, progression and improvement of hearing loss. RESULTS: Unstable hearing thresholds were observed in 29.4% of children with cCMV infection of which 19.2% were found in the group of children with ultimately normal hearing and in 62.5% of children with sensorineural hearing loss (SNHL) (p=0.0027). Fluctuations occurred in 16.2%. Late onset hearing loss occurred in 4.3% of children with a normal hearing at birth. In children with SNHL, progression or worsening of hearing thresholds occurred in 27.3% and improvement of thresholds in 40.9%. Important changes in thresholds only occurred in 13.2% of all children and predominantly in children who finally develop SNHL. CONCLUSIONS: Unstable hearing thresholds are frequently found in children with cCMV infection and occur not only in children who develop hearing losses but also in children who have a normal hearing at the last visit. Important changes in hearing thresholds of > 30 dB are more frequently seen in children who ultimately will develop SNHL.

Nonsurgical treatment of pyomyoma in the postpartum period.

BACKGROUND: Only 13 cases of pyomyoma related to pregnancy have been described since 1945. Treatment consists of hysterectomy, which exposes critically ill patients to operative risks and induces infertility. CASES: Three cases of pyomyoma in the postpartum period are described. Treatment using computed tomography-guided drainage was realized successfully in two cases. CONCLUSION: Therapy via drainage and lavage of pyomyoma is a viable option to preserve patient fertility. In the absence of a proper response to this treatment, total abdominal hysterectomy is the treatment of choice.

Modified real-time PCR for detecting, differentiating, and quantifying Ureaplasma urealyticum and Ureaplasma parvum.

We evaluated a previously described quantitative real-time PCR (qPCR) for quantifying and differentiating Ureaplasma parvum and U. urealyticum. Because of nonspecific reactions with Staphylococcus aureus DNA in the U. parvum PCR, we developed a modified qPCR and designed new primers. These oligonucleotides eradicated cross-reactions, indicating higher specificity. The detection limits of the qPCR were determined at 1 and 3 colony-forming units/ml for U. parvum and U. urealyticum, respectively. The quantification limits of the assay for both Ureaplasma species ranged from 2.10(6) to 2.10(1) copy numbers per PCR. A total of 300 patient samples obtained from the lower genital tract were tested with this newly designed qPCR assay and compared with culture results. Of the samples, 132 (44.0%) were culture positive, whereas 151 (50.3%) tested positive using qPCR. The U. parvum and U. urealyticum species were present in 79.5% and 12.6% of the qPCR-positive samples, respectively. Both species were found in 7.9% of those samples. Quantification of U. parvum and U. urealyticum in the samples ranged from less than 2.5 × 10(3) to 7.4 × 10(7) copies per specimen. In conclusion, the modified qPCR is a suitable method for rapid detection, differentiation, and quantification of U. parvum and U. urealyticum.

WITHDRAWN: Reply to the letter of Soldin et al.

The Publisher regrets that this article is an accidental duplication of an article that has already been published, doi:10.1016/j.cca.2010.09.032. The duplicate article has therefore been withdrawn.

FT4 immunoassays may display a pattern during pregnancy similar to the equilibrium dialysis ID-LC/tandem MS candidate reference measurement procedure in spite of susceptibility towards binding protein alterations.

BACKGROUND: Serum free thyroxine (FT4) testing in pregnancy is known to be challenging for immunoassays (IAs). We verified the reliability of FT4 results by 3 commercial IAs throughout pregnancy, by comparison of the pattern to that obtained with an equilibrium dialysis isotope dilution-mass spectrometry (ED ID-MS) candidate reference measurement procedure. METHODS: Pregnant females (107) and age-matched non-pregnant controls (26) were enrolled. The IAs tested were those performed on the Cobas 6000 (Roche Diagnostics), ARCHITECT i2000SR (Abbott Diagnostics) and Immulite 2000 (Siemens Healthcare) platforms. RESULTS: Compared to the controls (mean FT4: 18.2pmol/L), ED ID-MS gave in the late first trimester pregnancy an 8.8% lower (p<0.05) mean; in the second trimester it was 29.1% lower (p<0.001), to stabilize in the third trimester (p=0.99). Similar observations were made for the Cobas and Immulite IAs. The ARCHITECT IA showed no significant decrease in the late first trimester (mean 13.5pmol/L versus 13.6pmol/L in controls), but a significant, less pronounced, decrease in the second and third trimesters (15% and 14.4%, respectively). All IAs were susceptible towards alterations in T4 binding proteins during pregnancy. CONCLUSION: We proved that IAs may give a FT4 pattern during pregnancy similar to that obtained by ED ID-MS.

Hearing loss in children with congenital cytomegalovirus infection in relation to the maternal trimester in which the maternal primary infection occurred.

OBJECTIVES: The purpose of this work was to study the relation between maternal trimester of primary infection with cytomegalovirus and the occurrence of sensorineural hearing loss in the congenitally infected offspring. PATIENTS AND METHODS: Thirty-four consecutive live-born children diagnosed with a congenital cytomegalovirus infection after maternal primary cytomegalovirus infections were included in the study. Five were lost for follow-up, and 1 died. Of the remaining 28 congenitally infected children, an estimation of the maternal trimester in which cytomegalovirus primary infection occurred was performed. All of the children were investigated for potential sensorineural hearing loss. RESULTS: Five of the maternal infections occurred in the first trimester, 12 in the second trimester, and 11 in the third trimester of pregnancy. Sensorineural hearing loss was detected in 4 (80%) of the 5 congenitally infected children who were infected after a primary maternal infection in the first trimester of pregnancy and in 1 (8%) of the 12 children when the maternal infection occurred in the second trimester of pregnancy. No sensorineural hearing loss was detected after primary maternal infection occurring in the third trimester. Fluctuation and improvement of sensorineural hearing loss were seen regardless the trimester of pregnancy during which maternal primary infection occurred. Progression of sensorineural hearing loss occurred in 2 children born after a maternal primary infection of the first trimester. CONCLUSIONS: Hearing loss seemed more common in infants with congenital cytomegalovirus infection who were born to women who experienced a primary cytomegalovirus infection in the first trimester of pregnancy than when infection took place later in pregnancy.

A serologic strategy for detecting neonates at risk for congenital cytomegalovirus infection.

OBJECTIVES: To evaluate the feasibility of a serologic screening program in pregnant women to detect neonates at risk for a congenital cytomegalovirus infection. STUDY DESIGN: Unselected mother-infant pairs (n = 7140) were studied. In the mother, serologic screening consisted of the testing for cytomegalovirus antibodies at the first prenatal visit and at birth. In the neonate, cytomegalovirus urine culture was performed to diagnose congenital infection. RESULTS: Serologic screening showed evidence of past infection in 3850 women (53.9%); 192 (2.7%) women had both immunoglobulin (Ig)G and IgM antibodies when first tested during pregnancy. Seroconversion was detected in 44 seronegative women (1.4%). Forty-four congenital infections were diagnosed (0.62%): 8 in women with past infections, 22 in women who seroconverted, and 14 in women who initially had positive IgM antibodies. CONCLUSIONS: Screening at the first prenatal visit and at birth defines two major risk groups for congenital cytomegalovirus infection: women with seroconversion during pregnancy and women with IgM antibodies in their first prenatal serum sample (0.6% and 2.7%, respectively, of the pregnant population). In these selected babies (3.3% of the study group), cytomegalovirus urine culture should be performed. This type of screening allows the detection of 82% of all congenital cytomegalovirus infections.

Prevention of toxoplasmosis during pregnancy--an epidemiologic survey over 22 consecutive years.

BACKGROUND: Prevention of congenital toxoplasmosis is most often based on the results of a serological screening program in pregnant women followed by prenatal and postnatal treatment of women and their newborns when infection is already established during pregnancy or on cord blood (secondary prevention). Little effort has been made to study primary prevention of toxoplasmosis during pregnancy. OBJECTIVE: To assess the possibilities of two different programs aimed at preventing the acquisition of toxoplasmosis during pregnancy. METHODS: During the first study period (1979-1982) the natural incidence of toxoplasmosis in pregnancy was studied in 2986 pregnant women. In the second study period (1983-1990) the incidence of toxoplasmosis was studied in 8300 women. During this period, seronegative women received a written list of recommendations on how to avoid a toxoplasma infection during pregnancy. In the third study period (1991-2001) the incidence of toxoplasmosis was studied in 16,541 women. During this period, the prevention campaign consisted of a leaflet explaining a) toxoplasmosis as a disease and b) what measures should be taken to avoid toxoplasmosis during pregnancy. The third part of the campaign involved a reiteration of these recommendations during antenatal classes held around mid-gestation. The impact of the two prevention programs was studied by measuring the seroconversion rate in seronegative women. RESULTS: Twenty of 1403 seronegative women in the first period (1.43%), 19 of 3605 women in the second period (0.53%) and 8 of 8492 in the third period (0.09%) seroconverted during pregnancy. The first prevention campaign reduced the seroconversion rate by 63% (p<0.05 OR 2.729 95% CI 1.452-5.084). The second prevention program resulted in a reduction rate of 92% compared to the seroconversion rate in the first period (p<0.0001 OR 15.34 95% CI 6.741-34.89). CONCLUSION: Promotion of simple measures is very effective in the prevention of toxoplasmosis during pregnancy. Primary prevention should not only be based on education about preventive measures given by physicians, but these guidelines should be reiterated during antenatal classes and leaflets distributed containing written recommendations on the nature of the disease and its avoidance.