Varicela durante gestaçäo: relato de 13 casos e revisäo da literatura recente / Varicella during pregnancy: report of 13 cases and review of the recent literature

A ocorrência da varicela durante a gestaçäo é baixa, mas sua história natural näo é bem definida e há dúvidas se a varicela na grávida é mais grave que nos demais adultos. Na tentativa de esclarecer estes aspectos, foi feita uma análise retrospectiva de 34 casos de varicelas internados no Hospital das Clinicas da FMUSP de 1976 a 1986: 13 gestantes e 21 adultos imunocompetentes, sendo 11 do sexo masculino e 10 do sexo feminino. A média de idade entre as gestantes foi de 21,4% e entre os adultos 24,6% anos para os pacientes de sexo feminino e 25,9% anos para os pacientes do sexo masculino. Neste grupo dez pacientes apresentaram complicaçöes (47,6%) e no grupo de gestantes somente quatro (30,7%). Três gestantes tiveram pneumonite (23%) e entre as mulheres näo gest antes quatro apresentaram pneumonite (36,3%). As três mulheres grávidas com pneumonite apresentaram insuficiência respiratória versus nenhum caso de insuficiência respiratória entre os adultos imunocompetentes. Conclue-se que a ocorrência de complicaçöes na mulher grávida com varicela foi semelhante a do adulto em geral, na casuística estudada. O curso clínico da pneumonite, entretanto, foi mais grave na gestante.

Prematurity: infection as an etiologic factor.

Preterm delivery accounts for a substantial percentage of perinatal mortality and morbidity. A large body of evidence suggests that perinatal infections may play an etiologic role in preterm rupture of membranes and preterm labor. The interaction between a patient's vaginal flora and her local defense mechanisms (antibacterial activity of amniotic fluid and cervical mucus) may help determine who delivers prematurely. The evidence implicating infection as a cause of labor is reviewed, and the organisms which may be responsible are identified. Potential avenues of investigation and intervention are outlined which would delineate the role of infections in preterm delivery and lead to a means of preventing some preterm deliveries caused by infection.

Listeriosis and borreliosis as causes of antepartum fever.

Fever of unknown origin in the pregnant woman presents special diagnostic, therapeutic, and obstetric problems. Two such clinically ill, febrile third-trimester patients, one presenting with maternal septicemia and transplacental fetal listeriosis and the other with borreliosis, are discussed. Although the neonatal outcome in such infections historically is poor, the infants of these mothers survived. It is suggested that special diagnostic procedures, timely administration of parenteral antibiotics, and vigilant antepartum testing be considered in all similar pregnant patients.

Listeria monocytogenes. An important pathogen in premature labor and intrauterine fetal sepsis.

Listeria monocytogenes is a rare complication of pregnancy. Maternal listeriosis often causes premature labor and congenital infections. High perinatal morbidity and mortality rates are associated with this disease. Two cases of fetal perinatal infections, complications and management are discussed.

Anaemia, malaria and sickle cell disease.

Serious defects in the living conditions of the vast majority of people in the tropics, rather than racial factors, are the underlying reasons why anaemia is common, why malaria is rampant and why the complications of sickle cell disease are so serious. Mass illiteracy, poor environmental hygiene and widespread poverty with all their implications explain why malaria eradication programmes have so far failed in tropical Africa and why basic health-care schemes have been difficult to establish. Pregnant women are very vulnerable to the effects of anaemia, malaria and sickle cell disease. However, appropriate use of folic acid and iron supplements as well as malarial chemosuppression succeeds in maintaining haemoglobin concentrations at reasonable levels during pregnancy. If, for whatever reason, the haemoglobin level falls to under 4.4 g/dl or the haematocrit value is 0.14 or less, anaemia becomes an obstetric emergency. Both maternal and fetal mortality rise sharply, maternal death being due to anaemic heart failure, fulminating bacterial infection and shock from even small loss at delivery or abortion. With the haemoglobin concentration as low as 4.4 g/dl, blood transfusion greatly improves maternal but not necessarily fetal prognosis. Additional cause of morbidity in sickle cell disease is painful crises, the control of which remains largely unsatisfactory. Now that sickle cell disease can be diagnosed early in intrauterine life the idea of aborting the affected fetuses as a means of controlling or reducing sickle cell disease is well within the means of developed countries, but it is a line of approach which developing countries cannot afford at present.

Premature rupture of the membranes and ascending infection.

The association of premature rupture of the membranes (PROM) and ascending infection was investigated in 15 women. Bacteriological, histological and immunofluorescence methods were used to study infection at various levels in the birth canal. In most of the women the membranes as well as the placentae showed heavy bacterial invasion. Bacterial distribution within the membranes showed a choriodecidual preponderance. Ascending infection appears to follow the choriodecidual route and may be a primary pathogenetic event in many instances of PROM. The anaerobe Bacteroides fragilis, which is very infrequently isolated in normal pregnant women, was found in five out of 15 women. Two infants had congenital pneumonia caused by group B streptococci and Haemophilus influenzae respectively. The neonatal outcome with PROM may be influenced by the efficiency of the individual defence mechanisms including the antimicrobial capacity of amniotic fluid.

Estrogen excretion in pregnant women with leprosy: evidence of diminished fetoplacental function.

Estrogen excretion was assayed in 64 women with leprosy and 15 healthy control women. The mean estrogen excretion was lower in women with leprosy than in controls and the incidence of subnormal estrogen values was higher in the leprosy patients than in the controls. There was an association between infant birth weight and frequency of subnormal estrogen excretion. These features were most marked in women with lepromatous leprosy and are further evidence of diminished fetoplacental function in women with leprosy.

Infectious disease and perinatal morbidity.

Excess perinatal morbidity and mortality continue to be major problems in developed and developing nations. Most perinatal deaths occur in infants born weighing less than 2500 g. Large expenditures of time, equipment, and personnel have led to striking reductions in neonatal mortality. However, rates of prematurity have not declined. Exploration of proven causes of prematurity and low birth weight suggests a role for infection that has hitherto not received sufficient attention. Women with symptomatic pyelonephritis, even when treated promptly, experience an excess of prematurity and perinatal death, and their children have lowered intelligence scores and neurologic scores. Women with asymptomatic bacteriuria experience higher rates of low birth weight and perinatal mortality, as well as symptomatic pyelonephritis, and these are preventable by screening and treatment during pregnancy. Recent evidence also suggests that genital mycoplasmas (Ureaplasma urealyticum and Mycoplasma hominis) are a cause of prematurity and that treatment of women colonized with these organisms results in significant reduction in prematurity rates.

Rubella retinopathy and subretinal neovascularization.

A case of rubella retinopathy associated with macular scarring from subretinal neovascularization is presented. Ophthalmoscopic findings included diffuse mottling of the retinal pigment epithelium throughout the macula and into the postequatorial areas, atrophic "rings" around both optic discs, and a solid white and slightly raised macular cicatrix in the right eye. The patient has been followed for three years; her visual acuity remains at 20/20 and there has been no change in the appearance of her retinae. Rubella retinopathy should be considered in the differential diagnosis of young patients with subretinal neovascularization.

Rubella and virus induced cataracts.

Gregg's discovery is acknowledged. The effects of the rubella virus on the lens is discussed, including virus persistence in the lens, post-natal development and post-natal spontaneous absorption of cataract. The effect of herpes simplex, herpes zoster, cytomegalic inclusion disease echovirus and smallpox on the lens are described.