Maternal mortality and COVID-19.

OBJECTIVE: The aim of this study was to collect and analyze data from different sources to have a general overview of COVID-19-related maternal deaths in Brazil, as well as to compare data with worldwide reports. STUDY DESIGN: We systematically searched data about COVID-19 maternal deaths from the Brazilian Ministry of Health surveillance system, State Departments of Health epidemiological reports, and media coverage. Data about timing of symptom onset and death (pregnancy or postpartum), gestational age, mode of birth, maternal age, comorbidities and/or risk factors, date of death, and place of death were retrieved when available. RESULTS: We identified 20 COVID-19-related maternal deaths, age range 20-43 years. Symptoms onset was reported as on pregnancy for 12 cases, postpartum for 3 cases, and during the cesarean section for 1 case (missing data for 4). In 16 cases, death occurred in the postpartum period. At least one comorbidity or risk factor was present in 11 cases (missing data for 4). Asthma was the most common risk factor (5/11). Ten cases occurred in the Northeast region, and nine cases occurred in the Southeast region (5 of them in São Paulo, the first epicenter of COVID-19 in the country). CONCLUSIONS: To the best of our knowledge, this is the largest available series of maternal deaths due to COVID-19. Barriers to access healthcare, differences in pandemic containment measures in the country and high prevalence of concomitant risk factors for COVID-19 severe disease may play a role in the observed disparity compared to worldwide reports on maternal outcomes.

A Novel Radiologic Finding to Predict Ophthalmic Abnormalities in Children With Congenital Zika Syndrome.

BACKGROUND: The Zika virus (ZIKV) epidemic had devastating consequences in Brazil. We investigated whether a radiologic finding (ie, infratentorial abnormalities) was associated with sight-threatening defects in children born with congenital Zika syndrome (CZS). We also investigated whether ophthalmic abnormalities correlated with head circumference (HC) and gestational age of infection. METHODS: Cross-sectional evaluation based upon a previous cohort from March 2016 to December 2018, in Paraíba, Brazil. The study population was comprised of children born to mothers with laboratory-confirmed ZIKV infection during pregnancy (ZIKV reverse transcriptase polymerase chain reaction [RT-PCR]+) and children born with clinical and radiologic features of CZS. RESULTS: A total of 75 infants had complete data. All 75 had brain calcifications. Microcephaly was present in 53 (71%) of them. Infratentorial abnormalities were present in 17 infants (22.7%). Ophthalmic abnormalities were seen in 16 of the 17 children (94%) with infratentorial abnormalities, while 28% of children without infratentorial abnormalities had ophthalmic findings (odds ratio [OR]: 42.0; 95% confidence interval [CI]: 5.1-342.9). Similar associations were observed when macular chorioretinal atrophy and optic nerve abnormalities were analyzed individually (OR: 23.7; 95% CI: 6.0-93.3 and OR: 11.5; 95% CI: 3.3-40.0, respectively). Infratentorial abnormalities were more frequently associated with ophthalmic abnormalities (94%) than microcephaly (43.4%) (P < .001). Mean HC was statistically different between groups with and without ophthalmic abnormalities (P = .01). A statistically significant difference in gestational age between both groups was not noted (P = .12). CONCLUSIONS: In children with CZS, the presence of infratentorial abnormalities is a significant predictor of ophthalmic abnormalities. All neonates whose mothers had ZIKV exposure during pregnancy should have an ophthalmologic examination.

Wide dispersion of B chromosomes in Rhammatocerus brasiliensis (Orthoptera, Acrididae).

The grasshopper Rhammatocerus brasiliensis shows polymorphism of B chromosomes, but the magnitude of B-chromosome occurrence and the factors that may contribute to their dispersion in the species remain unknown thus far. The present study analyzed the occurrence and dispersion of B chromosomes in R. brasiliensis individuals from 21 populations widely distributed in the Brazilian Northeast. The genetic connectivity between 10 populations was verified through analysis of ISSR markers from 200 individuals. Of the 21 populations, 19 presented individuals with one B chromosome, three with two, and one with three B chromosomes. The B chromosome is of medium size and constitutive heterochromatin (CH) located in the pericentromeric region. A variant B chromosome was observed in three populations, similar in size to that of chromosome X, gap and CH, and located in the terminal region. B chromosome frequencies in different populations varied from 0% to 18,8%, mean 8,5%. The wide distribution of the B chromosome is likely a consequence of the positive gene flow among the analyzed populations. B-chromosome occurrence in populations of R. brasiliensis possibly follows the population genetic structure of the species and, owing to the existence of a variant, its origin may not be recent.

Occurrence of Harmful Cyanobacteria in Drinking Water from a Severely Drought-Impacted Semi-arid Region.

Harmful cyanobacterial blooms have become increasingly common in freshwater ecosystems in recent decades, mainly due to eutrophication and climate change. Water becomes unreliable for human consumption. Here, we report a comprehensive study carried out to investigate the water quality of several Campina Grande reservoirs. Our approach included metagenomics, microbial abundance quantification, ELISA test for three cyanotoxins (microcystin, nodularins, and cylindrospermopsin), and in vivo ecotoxicological tests with zebrafish embryos. Cytometry analysis showed high cyanobacterial abundance, while metagenomics identified an average of 10.6% of cyanobacterial sequences, and demonstrated the presence of Microcystis, Cylindrospermopsis, and toxin coding genes in all ponds. Zebrafish embryos reared with pond water had high mortality and diverse malformations. Among the ponds analyzed, Araçagi showed the highest lethality (an average of 62.9 ± 0.8%), followed by Boqueirão (lethality average of 62.5 ± 0.8%). Here, we demonstrate that water from ponds undergoing extremely drought conditions have an abundance of potentially harmful cyanobacteria and their toxins. Our findings are consistent with a scenario in which polluted drinking water poses a great risk to human health.

Occurrence of Harmful Cyanobacteria in Drinking Water from a Severely Drought-Impacted Semi-arid Region

Harmful cyanobacterial blooms have become increasingly common in freshwater ecosystems in recent decades, mainly due to eutrophication and climate change. Water becomes unreliable for human consumption. Here, we report a comprehensive study carried out to investigate the water quality of several Campina Grande reservoirs. Our approach included metagenomics, microbial abundance quantification, ELISA test for three cyanotoxins (microcystin, nodularins, and cylindrospermopsin), and in vivo ecotoxicological tests with zebrafish embryos. Cytometry analysis showed high cyanobacterial abundance, while metagenomics identified an average of 10.6% of cyanobacterial sequences, and demonstrated the presence of Microcystis, Cylindrospermopsis, and toxin coding genes in all ponds. Zebrafish embryos reared with pond water had high mortality and diverse malformations. Among the ponds analyzed, Aracagi showed the highest lethality (an average of 62.9 +/- 0.8%), followed by Boqueirao (lethality average of 62.5 +/- 0.8%). Here, we demonstrate that water from ponds undergoing extremely drought conditions have an abundance of potentially harmful cyanobacteria and their toxins. Our findings are consistent with a scenario in which polluted drinking water poses a great risk to human health.

Occurrence of harmful cyanobacteria in drinking water from a severely drought-impacted semi-arid region

Harmful cyanobacterial blooms have become increasingly common in freshwater ecosystems in recent decades, mainly due to eutrophication and climate change. Water becomes unreliable for human consumption. Here, we report a comprehensive study carried out to investigate the water quality of several Campina Grande reservoirs. Our approach included metagenomics, microbial abundance quantification, ELISA test for three cyanotoxins (microcystin, nodularins, and cylindrospermopsin), and in vivo ecotoxicological tests with zebrafish embryos. Cytometry analysis showed high cyanobacterial abundance, while metagenomics identified an average of 10.6% of cyanobacterial sequences, and demonstrated the presence of Microcystis, Cylindrospermopsis, and toxin coding genes in all ponds. Zebrafish embryos reared with pond water had high mortality and diverse malformations. Among the ponds analyzed, Aracagi showed the highest lethality (an average of 62.9 +/- 0.8%), followed by Boqueirao (lethality average of 62.5 +/- 0.8%). Here, we demonstrate that water from ponds undergoing extremely drought conditions have an abundance of potentially harmful cyanobacteria and their toxins. Our findings are consistent with a scenario in which polluted drinking water poses a great risk to human health.

The spectrum of neuropathological changes associated with congenital Zika virus infection.

A major concern associated with ZIKV infection is the increased incidence of microcephaly with frequent calcifications in infants born from infected mothers. To date, postmortem analysis of the central nervous system (CNS) in congenital infection is limited to individual reports or small series. We report a comprehensive neuropathological study in ten newborn babies infected with ZIKV during pregnancy, including the spinal cords and dorsal root ganglia (DRG), and also muscle, pituitaries, eye, systemic organs, and placentas. Using in situ hybridization (ISH) and electron microscopy, we investigated the role of direct viral infection in the pathogenesis of the lesions. Nine women had Zika symptoms between the 4th and 18th and one in the 28th gestational week. Two babies were born at 32, one at 34 and 36 weeks each and six at term. The cephalic perimeter was reduced in four, and normal or enlarged in six patients, although the brain weights were lower than expected. All had arthrogryposis, except the patient infected at 28 weeks gestation. We defined three patterns of CNS lesions, with different patterns of destructive, calcification, hypoplasia, and migration disturbances. Ventriculomegaly was severe in the first pattern due to midbrain damage with aqueduct stenosis/distortion. The second pattern had small brains and mild/moderate (ex-vacuo) ventriculomegaly. The third pattern, a well-formed brain with mild calcification, coincided with late infection. The absence of descending fibres resulted in hypoplastic basis pontis, pyramids, and cortico-spinal tracts. Spinal motor cell loss explained the intrauterine akinesia, arthrogryposis, and neurogenic muscle atrophy. DRG, dorsal nerve roots, and columns were normal. Lympho-histiocytic inflammation was mild. ISH showed meningeal, germinal matrix, and neocortical infection, consistent with neural progenitors death leading to proliferation and migration disorders. A secondary ischemic process may explain the destructive lesions. In conclusion, we characterized the destructive and malformative consequences of ZIKV in the nervous system, as reflected in the topography and severity of lesions, anatomic localization of the virus, and timing of infection during gestation. Our findings indicate a developmental vulnerability of the immature CNS, and shed light on possible mechanisms of brain injury of this newly recognized public health threat.

Immune activation in amniotic fluid from Zika virus-associated microcephaly.

Recent advances in the understanding of neuropathogenesis associated with Zika virus (ZIKV) infection has led to descriptions of neonatal microcephaly cases. However, none of these reports have evaluated the humoral response during ZIKV infection. We report here polyfunctional immune activation associated with increased interferon-gamma-inducible protein 10, interleukin (IL)-6, IL-8, vascular endothelial growth factor (VEGF), monocyte chemoattractive protein 1 (MCP-1), and granulocyte colony-stimulating factor (G-CSF) levels in the amniotic fluid of ZIKV-positive pregnant women with neonatal microcephaly. These cytokines have been associated not only with neuronal damage, but also with differentiation and proliferation of neural progenitor cells. Our results suggested that the immune activation caused by ZIKV infection in the uterine environment could also interfere with fetal development. ANN NEUROL 2017;81:152-156.

Detection and sequencing of Zika virus from amniotic fluid of fetuses with microcephaly in Brazil: a case study.

BACKGROUND: The incidence of microcephaly in Brazil in 2015 was 20 times higher than in previous years. Congenital microcephaly is associated with genetic factors and several causative agents. Epidemiological data suggest that microcephaly cases in Brazil might be associated with the introduction of Zika virus. We aimed to detect and sequence the Zika virus genome in amniotic fluid samples of two pregnant women in Brazil whose fetuses were diagnosed with microcephaly. METHODS: In this case study, amniotic fluid samples from two pregnant women from the state of Paraíba in Brazil whose fetuses had been diagnosed with microcephaly were obtained, on the recommendation of the Brazilian health authorities, by ultrasound-guided transabdominal amniocentesis at 28 weeks' gestation. The women had presented at 18 weeks' and 10 weeks' gestation, respectively, with clinical manifestations that could have been symptoms of Zika virus infection, including fever, myalgia, and rash. After the amniotic fluid samples were centrifuged, DNA and RNA were extracted from the purified virus particles before the viral genome was identified by quantitative reverse transcription PCR and viral metagenomic next-generation sequencing. Phylogenetic reconstruction and investigation of recombination events were done by comparing the Brazilian Zika virus genome with sequences from other Zika strains and from flaviviruses that occur in similar regions in Brazil. FINDINGS: We detected the Zika virus genome in the amniotic fluid of both pregnant women. The virus was not detected in their urine or serum. Tests for dengue virus, chikungunya virus, Toxoplasma gondii, rubella virus, cytomegalovirus, herpes simplex virus, HIV, Treponema pallidum, and parvovirus B19 were all negative. After sequencing of the complete genome of the Brazilian Zika virus isolated from patient 1, phylogenetic analyses showed that the virus shares 97-100% of its genomic identity with lineages isolated during an outbreak in French Polynesia in 2013, and that in both envelope and NS5 genomic regions, it clustered with sequences from North and South America, southeast Asia, and the Pacific. After assessing the possibility of recombination events between the Zika virus and other flaviviruses, we ruled out the hypothesis that the Brazilian Zika virus genome is a recombinant strain with other mosquito-borne flaviviruses. INTERPRETATION: These findings strengthen the putative association between Zika virus and cases of microcephaly in neonates in Brazil. Moreover, our results suggest that the virus can cross the placental barrier. As a result, Zika virus should be considered as a potential infectious agent for human fetuses. Pathogenesis studies that confirm the tropism of Zika virus for neuronal cells are warranted. FUNDING: Consellho Nacional de Desenvolvimento e Pesquisa (CNPq), Fundação de Amparo a Pesquisa do Estado do Rio de Janeiro (FAPERJ).

Effect of a physical exercise program during pregnancy on uteroplacental and fetal blood flow and fetal growth: a randomized controlled trial.

OBJECTIVE: To estimate the effect of supervised physical exercise on maternal physical fitness, fetoplacental blood flow, and fetal growth. METHODS: This was a randomized controlled trial comparing three groups of pregnant women. Groups were as follows: exercise initiated at 13 weeks (group A); exercise initiated at 20 weeks (group B); and a control group (no supervised exercise; group C). The women in groups A and B walked at moderate intensity three times weekly. Physical fitness level was evaluated at weeks 13, 20, and 28. Fetal growth and uteroplacental blood flow were evaluated monthly. Birth weight was registered. Analysis of variance for repeat measures was used for outcomes evaluated throughout pregnancy. Risk ratio was used as a measure of the relative risk of preeclampsia, fetal growth restriction, macrosomia, small-for-gestational-age newborns, and large-for-gestational-age newborns. RESULTS: All the women analyzed completed more than 85% of the program. According to the evaluation conducted at week 28, physical fitness improved, with mean maximal oxygen consumptions (VO2max) of 27.3±4.3 (group A), 28±3.3 (group B), and 25.5±3.8 (group C; P=.03). Mean birth weights were 3,279±453 g (group A), 3,285±477 g (group B), and 3,378±593 g (group C; P=.53), with no difference in the frequency of large for gestational age or small for gestational age. No association was found between the practice of physical activity and the variables investigated (preeclampsia, fetal weight, blood pressure, and pulsatility index of the uterine, umbilical, and middle cerebral arteries). CONCLUSION: Moderate-intensity walking improved the physical fitness level of healthy, pregnant, previously sedentary women without affecting fetoplacental blood flow or fetal growth. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00641550. LEVEL OF EVIDENCE: II.

Combined spinal-epidural anesthesia and non-pharmacological methods of pain relief during normal childbirth and maternal satisfaction: a randomized clinical trial.

OBJECTIVE: The objective of this study was to compare maternal satisfaction with childbirth according to whether or not combined spinal-epidural anesthesia (CSE) of pain relief was used during labor. METHODS: A randomized, open clinical trial was performed with 70 pregnant women, 35 of whom received CSE anesthesia while 35 received only non-pharmacological forms of pain relief during labor. The variables evaluated were visual analogue scale (VAS) pain score, maternal satisfaction with the technique of pain relief used during childbirth and with delivery, the patient's intention to request the same technique in a subsequent delivery, and loss of control during delivery. RESULTS: VAS pain score decreased significantly in patients receiving CSE during vaginal delivery. Furthermore, maternal satisfaction with the technique of pain relief and with delivery was higher in the CSE group, and around 97% of the patients would repeat the same technique at future deliveries compared to 82.4% of the women in the group using only non-pharmacological methods. With respect to the women's impressions of their control during delivery, approximately half the women in both groups felt that they had lost control at some point during the process. CONCLUSION: The use of CSE was associated with a significant reduction in VAS pain scores during delivery and with greater maternal satisfaction with the pain relief method and with the childbirth process.

Combined spinal-epidural anesthesia and non-pharmacological methods of pain relief during normal childbirth and maternal satisfaction: a randomized clinical trial / Anestesia combinada e métodos não farmacológicos para alívio da dor durante o trabalho de parto e satisfação materna: ensaio clínico randomizado

OBJECTIVE: The objective of this study was to compare maternal satisfaction with childbirth according to whether or not combined spinal-epidural anesthesia (CSE) of pain relief was used during labor. METHODS: A randomized, open clinical trial was performed with 70 pregnant women, 35 of whom received CSE anesthesia while 35 received only non-pharmacological forms of pain relief during labor. The variables evaluated were visual analogue scale (VAS) pain score, maternal satisfaction with the technique of pain relief used during childbirth and with delivery, the patient's intention to request the same technique in a subsequent delivery, and loss of control during delivery. RESULTS: VAS pain score decreased significantly in patients receiving CSE during vaginal delivery. Furthermore, maternal satisfaction with the technique of pain relief and with delivery was higher in the CSE group, and around 97 percent of the patients would repeat the same technique at future deliveries compared to 82.4 percent of the women in the group using only non-pharmacological methods. With respect to the women's impressions of their control during delivery, approximately half the women in both groups felt that they had lost control at some point during the process. CONCLUSION: The use of CSE was associated with a significant reduction in VAS pain scores during delivery and with greater maternal satisfaction with the pain relief method and with the childbirth process.

OBJETIVOS: Comparar a satisfação materna com o processo do nascimento de acordo com a realização ou não de métodos farmacológicos para alívio da dor do trabalho de parto. MÉTODOS: Realizou-se um ensaio clínico randomizado com 70 parturientes, 35 das quais receberam anestesia combinada (raquidiana e peridural associadas) e 35 receberam métodos não farmacológicos para alívio da dor durante o parto vaginal. As variáveis estudadas foram: escores de dor pela Escala Visual Analógica (EVA), satisfação materna com a técnica analgésica e com o parto, desejo de repetir a técnica analgésica em parto posterior e perda do controle sobre o parto. A análise estatística foi realizada no programa Epi-Info 3.5.3, com base na intenção de tratar. RESULTADOS: Pacientes recebendo anestesia combinada (AC) durante o parto vaginal experimentaram uma diminuição significativa dos escores da EVA e maior satisfação materna com a técnica analgésica e com o parto. A maioria das parturientes, cerca de 97 por cento do grupo da anestesia combinada, repetiu a técnica em partos futuros, contra 82,4 por cento do grupo dos métodos não farmacológicos. No que diz respeito ao sentimento de controle do parto, aproximadamente metade das parturientes dos dois grupos sentiu que em algum momento do parto perdeu o controle deste, não havendo diferença significativa entre os grupos. CONCLUSÃO: O uso da AC está associado a uma significante diminuição dos escores da dor durante o parto, e maior satisfação materna com a técnica analgésica e com o parto.