Visceral Leishmaniasis in pregnancy and vertical transmission: A systematic literature review on the therapeutic orphans.

BACKGROUND: Reports on the occurrence and outcome of Visceral Leishmaniasis (VL) in pregnant women is rare in published literature. The occurrence of VL in pregnancy is not systematically captured and cases are rarely followed-up to detect consequences of infection and treatment on the pregnant women and foetus. METHODS: A review of all published literature was undertaken to identify cases of VL infections among pregnant women by searching the following database: Ovid MEDLINE; Ovid Embase; Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials; World Health Organization Global Index Medicus: LILACS (Americas); IMSEAR (South-East Asia); IMEMR (Eastern Mediterranean); WPRIM (Western Pacific); ClinicalTrials.gov; and the WHO International Clinical Trials Registry Platform. Selection criteria included any clinical reports describing the disease in pregnancy or vertical transmission of the disease in humans. Articles meeting pre-specified inclusion criteria and non-primary research articles such as textbook, chapters, letters, retrospective case description, or reports of accidental inclusion in trials were also considered. RESULTS: The systematic literature search identified 272 unique articles of which 54 records were included in this review; a further 18 records were identified from additional search of the references of the included studies or from personal communication leading to a total of 72 records (71 case reports/case series; 1 retrospective cohort study; 1926-2020) describing 451 cases of VL in pregnant women. The disease was detected during pregnancy in 398 (88.2%), retrospectively confirmed after giving birth in 52 (11.5%), and the time of identification was not clear in 1 (0.2%). Of the 398 pregnant women whose infection was identified during pregnancy, 346 (86.9%) received a treatment, 3 (0.8%) were untreated, and the treatment status was not clear in the remaining 49 (12.3%). Of 346 pregnant women, Liposomal amphotericin B (L-AmB) was administered in 202 (58.4%) and pentavalent antimony (PA) in 93 (26.9%). Outcomes were reported in 176 pregnant women treated with L-AmB with 4 (2.3%) reports of maternal deaths, 5 (2.8%) miscarriages, and 2 (1.1%) foetal death/stillbirth. For PA, outcomes were reported in 88 of whom 4 (4.5%) died, 24 (27.3%) had spontaneous abortion, 2 (2.3%) had miscarriages. A total of 26 cases of confirmed, probable or suspected cases of vertical transmission were identified with a median detection time of 6 months (range: 0-18 months). CONCLUSIONS: Outcomes of VL treatment during pregnancy is rarely reported and under-researched. The reported articles were mainly case reports and case series and the reported information was often incomplete. From the studies identified, it is difficult to derive a generalisable information on outcomes for pregnant women and babies, although reported data favours the usage of liposomal amphotericin B for the treatment of VL in pregnant women.

Vivax malaria in pregnancy and lactation: a long way to health equity.

BACKGROUND: The Sustainable Development Goals (SDG) call for increased gender equity and reduction in malaria-related mortality and morbidity. Plasmodium vivax infections in pregnancy are associated with maternal anaemia and increased adverse perinatal outcomes. Providing radical cure for women with 8-aminoquinolines (e.g., primaquine) is hindered by gender-specific complexities. CASE PRESENTATION: A symptomatic episode of vivax malaria at 18 weeks of gestation in a primigravid woman was associated with maternal anaemia, a recurrent asymptomatic P. vivax episode, severe intra-uterine growth restriction with no other identifiable cause and induction to reduce the risk of stillbirth. At 5 months postpartum a qualitative glucose-6-phosphate dehydrogenase (G6PD) point-of-care test was normal and radical cure with primaquine was prescribed to the mother. A 33% fractional decrease in haematocrit on day 7 of primaquine led to further testing which showed intermediate phenotypic G6PD activity; the G6PD genotype could not be identified. Her infant daughter was well throughout maternal treatment and found to be heterozygous for Mahidol variant. CONCLUSION: Adverse effects of vivax malaria in pregnancy, ineligibility of radical cure for pregnant and postpartum women, and difficulties in diagnosing intermediate levels of G6PD activity multiplied morbidity in this woman. Steps towards meeting the SDG include prevention of malaria in pregnancy, reducing unnecessary exclusion of women from radical cure, and accessible quantitative G6PD screening in P. vivax-endemic settings.

Effects of challenge dose and inoculation route of the virulent Neospora caninum Nc-Spain7 isolate in pregnant cattle at mid-gestation.

Parameters such as pathogen dose and inoculation route are paramount in animal models when studying disease pathogenesis. Here, clinical findings, including foetal mortality, parasite transmission rates and lesion severity, and immune responses were evaluated in Asturiana pregnant heifers at day 110 of gestation challenged with a virulent (Nc-Spain7) Neospora caninum isolate. Four different doses of parasite tachyzoites were inoculated intravenously (IV1, 107 parasites, n = 6; IV2, 105, n = 6; IV3, 103, n = 6; and IV4, 102, n = 5), and the subcutaneous (SC) inoculation route was also assessed for the dose of 105 tachyzoites (SC, n = 6). In addition, a control group (n = 4 pregnant heifers) was evaluated. Foetal death was observed in all infected groups from 25 to 62 days post-infection, varying with the dose (IV1:4/6, IV2:3/6; IV4:2/5, IV3:1/6), and was three times less frequently associated with the SC route than IV inoculation (1/6 vs. 3/6). A dose-dependent effect for parasite loads in placental and foetal brain tissues was also detected. After SC challenge, a reduced number of tachyzoites were able to reach foetal brain tissues, and no lesions were observed. In calves, specific IgG responses in precolostral sera were mainly associated with high-dose groups (IV1 [100.0%] and IV2 [66.7%]), and cerebral parasite DNA detection was scarce (3/18). In dams, IFN-γ production and the dynamics of anti-N. caninum IgG antibodies varied with the dose, and the cell-mediated immune response was also found to be route-dependent. Our results confirm the influence of parasite dose and inoculation route on the outcome and dynamics of bovine neosporosis at mid-gestation.

Intermittent Preventive Treatment (IPT): Its Role in Averting Disease-Induced Mortality in Children and in Promoting the Spread of Antimalarial Drug Resistance.

We develop an age-structured ODE model to investigate the role of intermittent preventive treatment (IPT) in averting malaria-induced mortality in children, and its related cost in promoting the spread of antimalarial drug resistance. IPT, a malaria control strategy in which a full curative dose of an antimalarial medication is administered to vulnerable asymptomatic individuals at specified intervals, has been shown to reduce malaria transmission and deaths in children and pregnant women. However, it can also promote drug resistance spread. Our mathematical model is used to explore IPT effects on drug resistance and deaths averted in holoendemic malaria regions. The model includes drug-sensitive and drug-resistant strains as well as human hosts and mosquitoes. The basic reproduction, and invasion reproduction numbers for both strains are derived. Numerical simulations show the individual and combined effects of IPT and treatment of symptomatic infections on the prevalence of both strains and the number of lives saved. Our results suggest that while IPT can indeed save lives, particularly in high transmission regions, certain combinations of drugs used for IPT and to treat symptomatic infection may result in more deaths when resistant parasite strains are circulating. Moreover, the half-lives of the treatment and IPT drugs used play an important role in the extent to which IPT may influence spread of the resistant strain. A sensitivity analysis indicates the model outcomes are most sensitive to the reduction factor of transmission for the resistant strain, rate of immunity loss, and the natural clearance rate of sensitive infections.

[Study on prevalence and vertical transmission rate of Toxoplasma gondii infections among parturient women in Wuhu City].

OBJECTIVE: To investigate the prevalence and vertical transmission rate of Toxoplasma gondii infections among in parturient women in Wuhu City, so as to provide reference for the prevention and control of toxoplasmosis among pregnant women in the city. METHODS: Parturient women's venous blood samples and neonatal heel blood samples were collected in Wuhu City and prepared into filter-paper blood samples. The prevalence and vertical transmission rate of T. gondii infections were detected using the loop -mediated isothermal amplification (LAMP) assay among the parturient women. RESULTS: There were three positive samples detected in the 475 filter-paper blood samples from the parturient women, with a mean positive rate of 0.63%. The prevalence of T. gondii infection was 0 in pregnant women at ages of < 20 years (0/5) and at an advanced maternal age (0/24), while the prevalence was 0.67% (3/446) in pregnant women at an appropriate maternal age. T. gondii infection was detected in 2 filter-paper blood samples from newborns, with a vertical transmission rate of 66.67%. CONCLUSIONS: There is T. gondii infection in the parturient women and a high vertical transmission rate of T. gondii infection is detected in Wuhu City. The awareness of the potential risk factors of toxoplasmosis should be improved among pregnant women to prevent the damages of toxoplasmosis to humans.

The impact of malaria parasites on the placenta and perinatal outcome at Korle Bu teaching hospital, Accra, Ghana: a case control study

Objective: Malaria remains a complex and overwhelming health problem affecting vulnerable groups such as pregnant women and their infants in Ghana. Malaria during pregnancy does not only pose a threat to the mother but can cause serious structural damages to the placenta and subsequently affect the pregnancy outcome. The aim of the study was to investigate the impact of Plasmodium parasites on the placenta and perinatal outcome of women delivering at Korle Bu Teaching Hospital. A better understanding of the impact of malaria parasites on the placenta morphology and prenatal outcome is crucial for better management of pregnant women and their babies. Methods: The study involved testing blood collected from postpartum placentas and examining the placental tissue for Plasmodium parasites, after which they were classified as study group (Plasmodium positive) or control (Plasmodium negative). The patients in the study group with similar gestational and maternal age were matched with patients from the control group. The morphological characteristics of the placenta and the perinatal outcome of the two patient groups were compared using an unpaired t-test. Results: Sixteen (16, 13.6%) out of 118 women tested positive for Plasmodium parasites on the maternal side of the placenta by both rapid diagnostic test and microscopy and /or tested positive for malarial parasite during pregnancy, whiles the rest (102, 86.4%) had no history of malaria in the index pregnancy and tested negative. The mean placenta weight was significantly reduced in the study group (difference: -102.0g; 95% Confidence Interval [CI]: 424.4g, 486.6g) who delivered during early term (p=0.02). Patients in the study group, who delivered during late term, had a significantly reduced mean placenta diameter (difference: -2.5cm; 95% CI: 20.0cm, 21.4cm) (p=0.003) and delivered infants with lower mean birth weight (difference: - 0.693kg; 95 CI: 3.268kg, 3.475kg) (p<0.001). Conclusion: Malaria during pregnancy does not only pose a threat to the mother but to the fetus and our results add evidence that malaria parasites cause alterations to certain morphological characteristics of the placenta which subsequently affect the birth weight as the pregnancy progresses to late term

Congenital Chagas Disease in the United States: Cost Savings through Maternal Screening.

Chagas disease, caused by Trypanosoma cruzi, is transmitted by insect vectors through transfusions, transplants, insect feces in food, and from mother to child during gestation. Congenital infection could perpetuate Chagas disease indefinitely, even in countries without vector transmission. An estimated 30% of infected persons will develop lifelong, potentially fatal, cardiac or digestive complications. Treatment of infants with benznidazole is highly efficacious in eliminating infection. This work evaluates the costs of maternal screening and infant testing and treatment of Chagas disease in the United States. We constructed a decision-analytic model to find the lower cost option, comparing costs of testing and treatment, as needed, for mothers and infants with the lifetime societal costs without testing and the consequent morbidity and mortality due to lack of treatment or late treatment. We found that maternal screening, infant testing, and treatment of Chagas disease in the United States are cost saving for all rates of congenital transmission greater than 0.001% and all levels of maternal prevalence above 0.06% compared with no screening program. Newly approved diagnostics make universal screening cost saving with maternal prevalence as low as 0.008%. The present value of lifetime societal savings due to screening and treatment is about $634 million saved for every birth year cohort. The benefits of universal screening for T. cruzi as part of routine prenatal testing far outweigh the program costs for all U.S. births.

First Toxoplasma gondii isolate from an aborted foetus of European bison (Bison bonasus bonasus L.).

The study was performed on a male European bison (Bison bonasus bonasus L.) foetus spontaneously aborted at the fourth or fifth month of pregnancy in the Bialowieza Forest. Serum samples from the foetus and mother revealed the presence of antibodies against T. gondii (S/P% = 88% and 75%, respectively). Mobile extracellular tachyzoites were first observed in a Vero cell culture, 110 days following inoculation of brain homogenate. PCR amplification with TGR1E1 and TGR1E2 primers confirmed the presence of T. gondii DNA, which was classified as Type I by PCR-RFLP genotyping. The sequences of 18S ribosomal RNA (18S rRNA) and 5.8S ribosomal RNA (5.8S rRNA) genes; internal transcribed spacer 1 (ITS1) and internal transcribed spacer 2 (ITS2), obtained from T. gondii isolate, have been deposited in GenBank (accession number KX459518.1). This is the first in vitro isolation and molecular identification of T. gondii from an aborted European bison foetus. The origin of this protozoan isolate indicates that the species is a significant threat to the European bison conservation program implemented in the Bialowieza Forest.

Foetal death in naive heifers inoculated with Neospora caninum isolate Nc-Spain7 at 110 days of pregnancy.

Neospora caninum infection is a leading cause of abortion in cattle worldwide. The pathogenesis of bovine neosporosis, particularly during the second term of gestation when most abortions occur in naturally infected dams, is poorly understood. In the present study foetal death was observed in 3 of 6 experimentally infected dams at 110 days of gestation after 6 weeks of experimental period. All experimental heifers were febrile between 3 and 5 days post infection (dpi). Inoculated dams seroconverted by 3-4 weeks post-infection with higher mean antibody titres in aborting dams compared to non-aborting heifers, although not significantly (p > 0.05). Neospora caninum DNA was detected in all infected foetuses and placentas, and three infected foetuses also had N. caninum antibodies. The parasite burden was higher in the brain of dead/aborted foetuses than in live foetuses. Interestingly, high IFN-γ production was detected in foetal fluids of a dead foetus found upon euthanasia of its dam, while no IFN-γ was observed in amniotic, allantoic and/or foetal fluids in the three infected foetuses that were alive upon maternal euthanasia. The present study confirms that the infection of dams on gestation day 110 with 10(7) tachyzoites of the Nc-Spain7 isolate causes abortion. The fact that some infected dams aborted and some did not is relevant to the understanding of N. caninum pathogenesis of abortion in naturally infected cows.

The triple threat of pregnancy, HIV infection and malaria: reported causes of maternal mortality in two nationwide health facility assessments in Mozambique, 2007 and 2012.

BACKGROUND: The paper's primary purpose is to determine changes in magnitude and causes of institutional maternal mortality in Mozambique. We also describe shifts in the location of institutional deaths and changes in availability of prevention and treatment measures for malaria and HIV infection. METHODS: Two national cross-sectional assessments of health facilities with childbirth services were conducted in 2007 and 2012. Each collected retrospective data on deliveries and maternal deaths and their causes. In 2007, 2,199 cases of maternal deaths were documented over a 12 month period; in 2012, 459 cases were identified over a three month period. In 2007, data collection also included reviews of maternal deaths when records were available (n = 712). RESULTS: Institutional maternal mortality declined from 541 to 284/100,000 births from 2007 to 2012. The rate of decline among women dying of direct causes was 66% compared to 26% among women dying of indirect causes. Cause-specific mortality ratios fell for all direct causes. Patterns among indirect causes were less conclusive given differences in cause-of-death recording. In absolute numbers, the combination of antepartum and postpartum hemorrhage was the leading direct cause of death each year and HIV and malaria the main non-obstetric causes. Based on maternal death reviews, evidence of HIV infection, malaria or anemia was found in more than 40% of maternal deaths due to abortion, ectopic pregnancy and sepsis. Almost half (49%) of all institutional maternal deaths took place in the largest hospitals in 2007 while in 2012, only 24% occurred in these hospitals. The availability of antiretrovirals and antimalarials increased in all types of facilities, but increases were most dramatic in health centers. CONCLUSIONS: The rate at which women died of direct causes in Mozambique's health facilities appears to have declined significantly. Despite a clear improvement in access to antiretrovirals and antimalarials, especially at lower levels of health care, malaria, HIV, and anemia continue to exact a heavy toll on child-bearing women. Going forward, efforts to end preventable maternal and newborn deaths must maximize the use of antenatal care that includes integrated preventive/treatment options for HIV infection, malaria and anemia.

Apoptosis and cell proliferation in the mouse model of embryonic death induced by Tritrichomonas foetus infection.

Bovine tritrichomonosis is a sexually transmitted disease caused by the protozoon Tritrichomonas foetus and characterised by embryonic-death and abortion. During pregnancy, the processes of cell proliferation and death play a crucial role for blastocyst implantation and the subsequent maintenance of early pregnancy, and their misbalance may lead to the abortion. In this study, we aimed to investigate whether cell proliferation and death may be altered during tritrichomonosis. For this purpose, we used pregnant BALB/c mice as an alternative experimental animal model that has successfully reproduced the infection. We analysed the immunohistochemical expression of active caspase-3 and proliferating cell nuclear (PCNA) antigens in the endometrium of infected mice. We found an increase in the number of caspase-3 positive cells in infected mice that were not pregnant at the necropsy. Besides, the number of positive proliferating cells increased in the uterine luminal epithelium of infected animals killed at 5-7 days post coitum (dpc). Pregnant infected mice killed at 8-11 dpc showed higher proliferation than control animals. We suggest that the cytopathic effect induced by T. foetus in the uteri of infected mice may induce the apoptosis of the epithelial cells and, as a result, promote a compensatory proliferative response. The information described here will be helpful to further study the pathogenesis of the bovine tritrichomonosis.

Evolution of malaria in pregnancy control: Jhpiego's 10-year contribution.

Malaria continues to be a life-threatening illness throughout Sub-Saharan Africa, with pregnant women and children being particularly vulnerable and an estimated 10 000 women and 200 000 newborns dying each year as a result of malaria in pregnancy (MIP). Since 2004, WHO has supported a three-pronged MIP approach: (1) intermittent preventive treatment with sulfadoxine-pyrimethamine; (2) use of insecticide-treated bed nets; and (3) effective case management. The present article identifies benchmarks in Jhpiego's 10-plus years of MIP experience at the regional and national levels that have contributed to its global MIP leadership and aligned programs and policies with global approaches toward malaria elimination. As countries continue to develop and expand MIP programming, support will continue to be essential in the following eight MIP program areas: integration, policy, capacity development, community engagement, quality assurance, commodities, monitoring and evaluation, and financing.

Serious and fatal illness associated with falciparum and vivax malaria among patients admitted to hospital at West Sumba in eastern Indonesia.

Records of 3,449 patients admitted to Karitas Hospital at Waitabula in eastern Indonesia with microscopy-confirmed malaria through 2008 and 2009 were systematically reviewed. Falciparum, vivax, and mixed species malaria occurred among 1,541, 1,837, and 71 admissions, respectively. Among these, 400 (26%), 199 (11%), and 15 (21%) had serious illness. Fatalities occurred in 46 (12%), 18 (9%), and 2 (13%) of these patients, respectively. Although patients with a diagnosis of falciparum malaria were more likely to have serious illness compared with those with vivax malaria (odds ratio [OR] = 2.9; 95% confidence interval [CI]: 2.4-3.5), this diagnosis nonetheless was associated with 32% of serious illness and 27% of fatalities. Among the seriously ill with a diagnosis of falciparum or vivax malaria, no significant difference in risk of death occurred (OR = 1.3; 95% CI: 0.7-2.5). Serious and fatal illness was predominantly anemia or altered mental state syndromes among patients with either of the species diagnoses. Plasmodium vivax was associated with a substantial share of the burden of morbidity and mortality caused by malaria in this hypo- to meso-endemic community.

A perspective of the epidemiology of malaria and anaemia and their impact on maternal and perinatal outcomes in Sudan.

INTRODUCTION: Both malaria and anaemia have adverse effects on maternal and perinatal outcomes. Thus there is an urgent need to investigate the co-epidemiology of malaria and anaemia and their combined impact on maternal and perinatal outcomes in the different regions of Sudan. METHODOLOGY: Various cross-sectional and case control studies conducted during the years 2003-2010 to investigate the epidemiology of malaria and anaemia and their impact on maternal and perinatal outcomes in different regions of Sudan were compared. RESULTS: While 13.7% of antenatal attendants in New Halfa had peripheral microscopically detected Plasmodium falciparum malaria, placental malaria (using histological examinations) was prevalent in 32.0-40% and 19.5% of parturient women in New Halfa and Gadarif Hospitals, respectively. Malaria was a risk factor for anaemia in New Halfa and for stillbirths in Omdurman Maternity Hospital. Anaemia was present in 52.5%, 62.6% and 80.2% of pregnant women in Medani, New Halfa, and Gadarif Hospitals, respectively. In Gadarif, 57.3% of pregnant women had a folate deficiency, while 1% had a vitamin B12, deficiency. In Medani, zinc and copper deficiencies were detected in 45.0% and 4% of pregnant women, respectively. Anaemia was a risk factor for low birth weight in Al-Fashir, for fetal anaemia in New Halfa, and for stillbirth in Kassala Hospital. CONCLUSION: More care should be taken to ensure proper nutrition and malaria prevention such as bed nets and intermittent preventive treatments to avoid these diseases and their effects on maternal and perinatal outcomes.

Assessing the burden of pregnancy-associated malaria under changing transmission settings.

BACKGROUND: The clinical presentation of pregnancy-associated malaria, or PAM, depends crucially on the particular epidemiological settings. This can potentially lead to an underestimation of its overall burden on the female population, especially in regions prone to epidemic outbreaks and where malaria transmission is generally low. METHODS: Here, by re-examining historical data, it is demonstrated how excess female mortality can be used to evaluate the burden of PAM. A simple mathematical model is then developed to highlight the contrasting signatures of PAM within the endemicity spectrum and to show how PAM is influenced by the intensity and stability of transmission. RESULTS: Both the data and the model show that maternal malaria has a huge impact on the female population. This is particularly pronounced in low-transmission settings during epidemic outbreaks where excess female mortality/morbidity can by far exceed that of a similar endemic setting. CONCLUSION: The results presented here call for active intervention measures not only in highly endemic regions but also, or in particular, in areas where malaria transmission is low and seasonal.

Maternal and perinatal outcomes of visceral leishmaniasis (kala-azar) treated with sodium stibogluconate in eastern Sudan.

OBJECTIVE: To investigate maternal and perinatal outcomes when pregnant women with visceral leishmaniasis (VL, also known as kala-azar) are treated with the antimonial sodium stibogluconate. METHOD: Forty-two pregnant women with VL were treated with sodium stibogluconate at Gadarif Hospital, Gadarif, Sudan, and mother and child were followed up for 1 year. RESULTS: The treatment began at a mean+/-SD of 24.4+/-9.2 weeks of pregnancy. None of the patients had malaria or HIV. Two (4.7%) who received the treatment in the first trimester had miscarriages; 4 (4.9%) died from hepatic encephalopathy during the second week of treatment; and 2 (4.7%) had preterm deliveries. One of the newborns had a myelomeningocele and died at 2 hours, and the other died from VL at 2 months. CONCLUSION: Preventive measures against VL should be employed in the region, and more research on VL and its treatment during pregnancy is needed.

Placental malaria, maternal HIV infection and infant morbidity.

Co-infection with malaria and HIV in pregnant women is particularly common in sub-Saharan Africa and has serious consequences for both mother and newborn child. Numerous studies have been published on the effects in pregnancy of HIV on malaria infection and on the effects of malaria on HIV infection. The increased prevalence and intensity of parasitaemia (placental and peripheral infection and parasite density) in HIV-infected women is well established. Similarly, malaria infection seems to be associated with higher viral loads. However, there is still uncertainty as to the influence of malaria on the clinical course of HIV infection, mother-to-child transmission of HIV, and the consequences of co-infection on post-neonatal infant morbidity and mortality. These questions require further investigation. In terms of prevention, intermittent preventive treatment with two doses of sulfadoxine-pyrimethamine (SP) has been found less effective in preventing malaria in HIV-infected than uninfected women, and a higher dosage (such as monthly SP) has been recommended. Regarding malaria, there is also a lack of clear recommendations for women taking daily cotrimoxazole prophylaxis, and anti-malarial-anti-retroviral interactions are not well understood. Multi-centre clinical trials should be undertaken to investigate effective, coherent and well-tolerated strategies to prevent malaria in HIV-infected women. Safe alternatives to SP should be identified and evaluated rapidly. Finally, a central pharmaco-vigilance network should be instituted to report adverse effects.

[Deaths due to infectious diseases in women: occurrences in pregnancy and puerperium]. / Mortes por doenças infecciosas em mulheres: ocorrências no ciclo gravídico-puerperal.

OBJECTIVE: To describe deaths due to infectious diseases as an underlying or multiple cause, identifying cases of pre-existent infectious diseases or ones developed during pregnancy; deaths due to an indirect obstetric cause and deaths due to Aids or other infectious diseases during pregnancy or post-partum, however difficult to classify. METHODS: RAMOS methodology was adopted (by investigation in the household and medical records of the deceased, a new death certificate was filled out with the real causes concerning deaths of women from 10 to 49 years of age, residents in Brazilian capital cities,during the first semester of 2002. RESULTS: A total of 7,332 female cases was analyzed, according to underlying and multiple causes of death, of which 917 were due to infectious diseases (mainly Aids and tuberculosis). In 37 cases, the deceased was pregnant or in an 'extended' puerperium (including) post-partum from 43 days up to one year). Of these, 10 were not indirect obstetric deaths, but the underlying cause was an infectious disease and 14 were classified as indirect obstetric deaths. Regarding multiple causes, 791 cases (neither maternal nor infectious disease as underlying cause) generated 1,016 mentions of infectious diseases (1.28 mentions/death). CONCLUSION: As the frequency of maternal deaths is low, investigations on the near miss (severe cases due to complications of pregnancy and puerperium who survived) are recommended, because they occur in larger numbers and are a relevant contribution to studies on maternal mortality.

Mortes por doenças infecciosas em mulheres: ocorrências no ciclo gravídico-puerperal / Deaths due to infectious diseases in women: occurrences in pregnancy and puerperium

OBJETIVO: Descrever os óbitos por doenças infecciosas como causa básica ou múltipla, caracterizando os casos de doença infecciosa preexistente ou desenvolvida na gravidez, aqueles que são mortes maternas por causas obstétricas indiretas e os óbitos por Aids ou outras doenças infecciosas, ocorridos no ciclo gravídico puerperal, havendo dúvidas na classificação. MÉTODOS: Adotou-se a metodologia RAMOS (partindo-se da declaração de óbito -DO- original, dados reais são resgatados por entrevista domiciliar, consultas a prontuários hospitalares e laudos de autopsia; elaborando-se uma nova DO, com as reais causas de morte). População foi constituída pelos óbitos femininos de 10 a 49 anos, de residentes nas capitais brasileiras, do 1º semestre de 2002. As causas foram analisadas em básicas e múltiplas. RESULTADOS: Dos 7.332 óbitos, 917 apresentaram uma doença infecciosa como causa básica (Aids e tuberculose, principalmente). Em 37 casos, a falecida estava no ciclo gravídico puerperal ampliado (englobando, inclusive, mortes ocorridas de 43 dias até um ano pós-parto); 10 não foram classificadas como obstétricas indiretas permanecendo como infecciosas e 14 eram obstétricas indiretas. Quanto às causas múltiplas, para 791 mortes, cujas causas básicas não eram maternas nem infecciosas, houve 1.016 menções de doenças infecciosas (média de 1,28 menção/óbito). CONCLUSÃO: Como o número de mortes maternas é pequeno, recomenda-se, que investigações dos casos graves de complicações da gravidez, parto e puerpério que não faleceram (near-miss) sejam feitas, pois, sendo mais numerosos, representam importante subsídio para estudos da mortalidade materna.

OBJECTIVE: To describe deaths due to infectious diseases as an underlying or multiple cause, identifying cases of pre-existent infectious diseases or ones developed during pregnancy; deaths due to an indirect obstetric cause and deaths due to Aids or other infectious diseases during pregnancy or post-partum, however difficult to classify. METHODS: RAMOS methodology was adopted (by investigation in the household and medical records of the deceased, a new death certificate was filled out with the real causes concerning deaths of women from 10 to 49 years of age, residents in Brazilian capital cities,during the first semester of 2002. RESULTS: A total of 7,332 female cases was analyzed, according to underlying and multiple causes of death, of which 917 were due to infectious diseases (mainly Aids and tuberculosis). In 37 cases, the deceased was pregnant or in an "extended" puerperium (including) post-partum from 43 days up to one year). Of these, 10 were not indirect obstetric deaths, but the underlying cause was an infectious disease and 14 were classified as indirect obstetric deaths. Regarding multiple causes, 791 cases (neither maternal nor infectious disease as underlying cause) generated 1,016 mentions of infectious diseases (1.28 mentions/death). CONCLUSION: As the frequency of maternal deaths is low, investigations on the near miss (severe cases due to complications of pregnancy and puerperium who survived) are recommended, because they occur in larger numbers and are a relevant contribution to studies on maternal mortality.

Impact of placental Plasmodium falciparum malaria on pregnancy and perinatal outcome in sub-Saharan Africa: I: introduction to placental malaria.

Placental malaria is one of the major features of malaria during pregnancy and has been widely used as a standard indicator to characterize malaria infection in epidemiologic investigations. Although pathogenesis of placental malaria is only partially understood, placental sequestration of Plasmodium falciparum results in the accumulation of parasitized erythrocytes in the intervillous space, infiltration by inflammatory cells, and release of pro-inflammatory mediators, which cause pathologic alterations that could impair materno-fetal exchanges, often resulting in adverse pregnancy outcome. In this report, the impact of placental malaria on pregnancy and perinatal outcome is reviewed using data from studies conducted in sub-Saharan Africa. Generally, placental malaria was associated with increased risk of maternal anemia, HIV infection, and maternal mortality, with younger women and primigravidae more likely to be affected. A variety of adverse perinatal outcomes, including low birth weight, preterm delivery, intrauterine growth retardation, reduced fetal anthropometric parameters, fetal anemia, congenital malaria, increased mother-to-child HIV transmission, and perinatal mortality, were associated with placental malaria. There were, however, conflicting reports on whether the risk of these adverse perinatal outcomes associated with placental malaria were statistically significant. There is a clear need to strengthen the malaria prevention and intervention measures for pregnant women in sub-Saharan Africa.