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BACKGROUND: The effectiveness of Toxoplasma gondii (Tg) screening during pregnancy in areas with a low prevalence of the infection is debated. We investigate the Tg serological status, the rate of primary infection in a cohort of pregnant women and the rate of congenital toxoplasmosis among their infants during a 3-year period in an urban area with low Tg prevalence. METHODS: Demographic and Tg serological data for all pregnant women delivering from January 2009 to December 2011 were collected. All pregnant women with primary Tg infection during pregnancy and their infants were included in the study. RESULTS: In early pregnancy, 10,347 women underwent prenatal screening and 2308 (22.3%) had anti-Tg. The seroprevalence among non-native women was significantly higher than that among native women [32.8% vs. 19.1%, relative risk: 1.71, P < 0.001]. The incidence rate of primary Tg infection during pregnancy was 0.77%. Immigrant women were more likely to be infected during pregnancy than Italian women (relative risk: 4.88, P < 0.001). Tg infection was more frequent in women coming from Africa, Asia, Eastern Europe and South America. The CT incidence rate was 0.06%. All congenitally infected infants were born to immigrant mothers. CONCLUSIONS: Tg infection during pregnancy and congenital disease are more frequent in non-native mothers and their infants. Measures to prevent Tg exposition must be carefully explained to pregnant women, with a focus on specific habits in non-native women. Prenatal screening is still effective to select women for prenatal therapy aiming to decrease vertical transmission and to identify foetuses/newborns with congenital disease that could benefit from pre/postnatal antiparasitic therapy.

Human cytomegalovirus (CMV) is the most common cause of intrauterine infection, occurring in 0.2% to 2.2% of all live births, and congenital infection is a common cause of sensorineural hearing loss and mental retardation. Transmission to fetus may occur through primary or secondary maternal infection with a probability of 30% to 40%, intrauterine transmission following primary infection during pregnancy compared with 0.5% to 2.2 % following secondary infection. Approximately 10-15% of congenitally infected babies are symptomatic at birth and these infants have a perinatal mortality rate of around 10% with 70-80% of surviving babies presenting major neurological sequelae. Despite infection, 85-90% of babies have no symptoms at birth however 8-15% of them will suffer from psychomotor and sensory-neural disabilities. The management of congenital CMV infections varies considerably in different centers and often there are unequal methods used between practitioners, which can lead to substantial discrepancies between the indications suggested by the literature and what is actually performed. A multidisciplinary group of 30 experts and/or qualified representatives of the six Italian Scientific Societies of Clinical Microbiologists (AMCLI), Gynaecology and Obstetrics (SIGO), Sexually Transmitted Diseases (SIMaST), Infectious and Tropical Diseases (SIMIT), Neonatology (SIN) and Pediatrics (SIP) developed evidence and expert opinion-20 based consensus guidelines on CMV congenital infection management including mechanism of pathogenesis, clinical and epidemiological aspects, prevention, diagnostics, and treatments. Each section used a scoring system to rate the quality of evidence on which recommendations are based.The document was prepared, discussed and validated by multidisciplinary committee through a consensus conference

Background. Human cytomegalovirus (HCMV) is a major cause of congenital infection as well as sensorineural hearing loss and neurodevelopmental delay. Prenatal diagnosis is based mainly on the detection of HCMV infection in amniotic fluid and on ultrasound (US) examination. The major limitation of these techniques is that US identifies prenatally only up to 15-20% of infected babies and positive results of amniotic fluids tests do not discriminate between the infants who will have symptoms at birth and those who will not. Objectives. The aims of this study are to evaluate the usefulness of fetal cerebral magnetic resonance (MR) and biological parameters in fetal blood when a high HCMV load is detected in amniotic fluid. The results of MR and fetal blood testing were correlated with the fetal histological examination or neonatal outcome. Methods. We enrolled 17 women at 20-21 weeks gestation with documented intrauterine transmission of HCMV (amniotic fluid with a viral load more than 10^5 copies/ml) with or without abnormal ultrasound findings. All pregnant women performed cerebral MR at 21 weeks gestation. Twelve women elected to terminate the pregnancy and fetal blood was collected from the umbilical cord. Immunological, haematological, biochemical and virological examinations were performed in fetal blood. HCMV antigen expression and inflammatory response were studied in all fetal tissues including inner ears using immunohistochemical staining procedures. Five pregnancies continued up to term and fetal MR was repeated at 32 weeks of gestation. Results. We found no evidence of brain HCMV infection by immunohistochemistry in 4 out of 12 foetuses and US and MR brain imaging were both normal in these cases. Eight fetal brains were HCMV positive and a brain histological damage was observed. Among these, 4 HCMV positive inner ears were observed. Viral infection always involved the stria vascularis, the most vascularised area of the cochlea, and less the Reissner's membrane, the Organ of Corti and the vestibular apparatus. Considering the 8 fetuses with histological brain damage, US was pathological in 4 cases (50%) and MR imaging only in 3 (38%). The most prevalent finding were periventricular hyperechogenicity (US) and microcephaly (MR). In fetal blood only platelet count and the % of natural killer cells were associated significantly .

Each year approximately 1–7% of pregnant women acquire a primary cytomegalovirus (CMV) infection. Of these, about 30–40% transmit infection to their fetuses. Up until some years ago it was not possible to precisely define the maternal immune status through laboratory testing. Recent development of advanced serological tests now allow us to identify, among pregnant women with suspected CMV, those with primary infection who are therefore at higher risk of transmitting CMV to their fetus. Given the high risk of mother–fetus transmission and fetal damage, prenatal diagnosis is recommended, between 20-21 weeks’ gestation, to women with primary CMV infection contracted in the first half of pregnancy and/or in case of fetal abnormalities suggestive of infection. CMV-DNA detection in amniotic fluid (AF) distinguish uninfected from infected fetuses in primarily infected mothers (positive predictive value =100%). However it is still very difficult to determine which are the infected foetuses at higher risk of developing severe CMV disease. In this work we studied a cohort of 790 pregnancies at risk of in utero CMV transmission; 796 amniotic fluid (AF) samples were tested by real time PCR assay (qPCR) and virus isolation. AF samples were collected at 20-21 weeks' gestation and at least 6-8 weeks after the onset of maternal CMV infection. Outcome was fully documented in 714 newborns and 82 foetuses. A total of 108 newborns were CMV infected; 25 were 119 symptomatic and 83 asymptomatic. Comparing symptomatic and asymptomatic newborns, the mean viral load in AF was significantly higher in symptomatic newborns (mean values 2x10^6 vs 9.4x10^5, P=0.009). The 82 infected foetuses were divided in two groups: those with histological damage in the brain and in 2 or more organs and those with histological damage in only 2 or more organs. When qPCR disclosed more than 10^6 copies/mL of AF, 62.5% of foetuses had disseminated infection and brain damage compared to 29.4% of foetuses with disseminated infection alone. Although the highest median values of CMV-DNA in AF tend to indicate an increased risk of severe infection, high viral loads may be associated with symptomatic or asymptomatic congenital infections leading to the conclusion that a correlation between a high CMV load in AF and foetal/neonatal compromission is uncertain. Recent studies suggest that the determination of multiple markers (haematological, biochemical and virological markers) in foetal blood following virus detection in AF, is predictive of perinatal outcome of CMV infected foetuses. However our results do not completely confirm this. Therefore, one of the major limitations of CMV prenatal diagnosis is that we are not able to discriminate between infants who will or will not have symptoms at birth. Prognosis factors for CMV disease are still being researched. In this regards, we found interesting results studying the HLA-G antigen, which is a tolerogenic HLA-Ib molecule expressed during pregnancy. HLA-G expression is modified by CMV infection, with functional consequences in immuno-regulation. Data indicates that this molecule could be a biomarker of both maternal and foetal infection and leading to disease progression

Genital herpes is a common sexually transmitted infection. In reproductive age it involves the additional risk of vertical transmission to the neonate. Rates of transmission are affected by the viral type and whether the infection around delivery is primary or recurrent. Neonatal herpes is a rare but very severe complication of genital herpes infection and is caused by contact with infected genital secretions at the time of labor. Maternal acquisition of herpes simplex virus (HSV) in the third trimester of pregnancy carries the highest risk of neonatal transmission. Prevention of neonatal herpes depends on preventing acquisition of genital HSV infection during late pregnancy and avoiding exposure of the infant to herpetic lesions during delivery. Uninfected woman should be counselled about the need of avoiding sexual contact during the third trimester. Elective caesarean section before the onset of labor is the choice mode of delivery for women with genital lesions or with prodromal symptoms near the term, even if it offers only a partial protection against neonatal infection. Antiviral suppressive therapy is used from 36 weeks of gestation until delivery in pregnant women with recurrences to prevent genital lesions at the time of labor so reducing the need of caesarean sections. Currently, routine maternal serologic screening is not yet recommended. Because most mothers of infants who acquire neonatal herpes lack histories of clinically evident genital herpes, researchers should focus on the recognition of asymptomatic primary genital HSV infections.

Objective: The aim was to determine the outcome of pregnancies complicated by maternal Parvovirus B19 (B19) infection. Method: Among 175 pregnant women referred to our clinic because of suspicion of a B19 infection, 63 with confirmed laboratory diagnosis of acute/recent B19 infection were followed up by ultrasound and Doppler measurement of the middle cerebral artery peak systolic velocity. Results: The vertical transmission rate was 31.7% (20/63). Of the 20 infected, 8 had hydrops, 1 had signs suggestive of meconium peritonitis and 1 had an isolated hydrothorax. Three fetuses presenting with hydrops were treated with intrauterine blood transfusion. Two of them died while the last showed resolution of anemia. Among the five untreated hydropic fetuses, one presented with mild signs that resolved spontaneously, two died at 16 and 17 weeks of gestation and two had also cardiomegaly and the parents opted for elective termination of pregnancy. All the anemic fetuses had middle cerebral artery peak systolic velocity values more than 1.8 multiples of the median. No stillbirth occurred. Conclusions: The outcome of uncomplicated cases with B19 infection is good. In the presence of hydrops prognosis was very poor. It seems therefore logical to attempt to pick up this ominous signs early. © 2012 John Wiley & Sons, Ltd.

SUMMARYWe assessed recent trends in hepatitis C virus (HCV) prevalence in pregnant women with HIV using data from a large national study. Based on 1240 pregnancies, we observed a 3·4-fold decline in HCV seroprevalence in pregnant women with HIV between 2001 (29·3%) and 2008 (8·6%). This decline was the net result of two components: a progressively declining HCV seroprevalence in non-African women (from 35·7% in 2001 to 16·7% in 2008), sustained by a parallel reduction in history of injecting drug use (IDU) in this population, and a significantly growing presence (from 21·2% in 2001 to 48·6% in 2008) of women of African origin, at very low risk of being HCV-infected [average HCV prevalence 1%, adjusted odds ratio (aOR) for HCV 0·09, 95% CI 0·03–0·29]. Previous IDU was the stronger determinant of HCV co-infection in pregnant women with HIV (aOR 30·9, 95% CI 18·8–51·1). The observed trend is expected to translate into a reduced number of cases of vertical HCV transmission.

Background In developed countries the rate of vertical transmission of HIV has dramatically declined after the introduction of a combination of measures represented by antiretroviral treatment before and at delivery, elective caesarean section and elimination of breastfeeding. Such measures are strongly effective and COULD reduced vertical transmission in many cases close to 0%. However, they can only be applied if the woman with HIV infection is aware of being infected: although HIV testing is always recommended during pre-conception counselling, many pregnancies are not preceded by a counselling visit, and a substantial proportion of pregnancies are not planned at all; so it is not uncommon to have a first assessment for HIV and other infections once pregnancy is already established. National data about pregnancies of HIV-infected women reported rate of 26.6% pregnancies characterized by a previously undetected HIV infection. The objectives of the present study were to assess the rate of women arriving at the time of delivery with unknown HIV status and to register the timing of availability laboratory results of the screening, in order to detect the possibility of a dismissed diagnosis before delivery. Material and Methods Data were collected by informatics consultation of clinical documentation of pregnant women delivering at the S. Orsola Hospital, where more than 3000 deliveries take place every year. We evaluated deliveries occurred during 4 sample-monthes in the years 2008-2009. We registered the effective annotation in the patients charts of HIV testing occurred during pregnancy, determined by a review of prenatal care records, which women submit ad admission and we evaluated the timing of availability of laboratory results (enzyme immunoassay) versus timing of delivery, were testing was performed at admission in women with no documented HIV testing records. Results: HIV status was present in 1136 (99.5%) charts of 1142 women at delivery: in 1002 cases (87.7%) HIV testing was performed during pregnancy and it was absent in the remain 134 (11.7%) women, so laboratory analysis (EIA) was performed. Laboratory results were available prior to delivery in 74 cases (55.2% of women tested at admission), on useful time to carry out all known strategies to prevent vertical transmission of HIV infection. In 28 cases (20.8%) serological diagnosis was received after delivery, but on time for an eventually promptly starting of antiretroviral prophylaxis on the newborn. The receipt of test results after 12 hours from delivery occurred in 32 cases (23.9%) and they were very late to enactment the necessary prevention strategies. Conclusion We found an important percentage of pregnant women reach to delivery without a HIV screening performed during pregnancy. This underline the necessary close surveillance that nurses, midwives and obstetrician must keep and the importance of HIV testing suggestion during pregnancy in order to achieve a timely HIV assessment, performed in the early stages of pregnancy. The attention of maternity hospital personnel, registering prenatal records, show crucial importance for a complete preventive intervention against HIV transmission to the newborn. Our study emphasizes the importance of a promptly HIV testing results and suggest the possibility of presence of rapid testing in delivery rooms, in order to carry out the prevention strategies soon as possible during labour in positive cases. We want to underline the recent up-date of international guidelines, where HIV testing is simplified adopting an opt-out approach and the abolition of a specific written informed consent in order to permit a major efficiency of pre-natal care ad an better manage of high risk pregnancies.

Objective: The administration of highly active antiretroviral therapy (HAART) to HIV-infected pregnant women raised the question of the association with adverse pregnancy outcomes. There is limited information regarding use of HAART during pregnancy in resource-constrained settings, where an increasing number of women need HAART administration. Our aim was to explore the association between HAART administration and adverse pregnancy outcomes and low birth weight (LBW)in a resource-limited setting. Methods: A retrospective cohort of HIV-infected pregnant women enrolled in the programme of Prevention of Mother-to- Child Transmission between 2003 and 2007 in Ouagadougou, Burkina Faso, was considered. Age, CD4+ T lymphocyte count, type and timing of antiretroviral drugs administration, pregnancy outcome, paediatric infection and birth weight were evaluated. Data were analysed using univariate analysis and binary logistic regression. Results: 678 HIV-infected were enrolled: 395 women received prophylactic regimen and 283 HAART regimen (115 started prior to conception, 168 started after the first trimester). Statistical analysis raised CD4+ T cell count

Il Citomegalovirus umano (CMV) è uno degli otto virus, appartenenti alla famiglia Herpesviridae, che infetta la specie umana. L’infezione da CMV è endemica ed ubiquitaria e non risente di variazioni stagionali. Nel corso dell’esistenza dal 40 all’80% degli individui nei Paesi industrializzati e la quasi totalità degli individui nei Paesi in via di sviluppo, va incontro ad infezione da CMV che di norma evolve senza sintomi morbosi e si traduce in una infezione latente (1,2). Si ritiene che gli esseri umani siano l’unico reservoir per il CMV umano; la trasmissione avviene per contatto interumano diretto e più raramente indiretto. Le fonti di infezione includono: secrezioni oro-faringee, urina, secrezioni cervicali e vaginali, sperma, latte materno, lacrime, feci, sangue, ect. Nella popolazione adulta, in particolare nelle donne in età feconda, oltre alla via sessuale, il contatto molto stretto e quotidiano con i bambini gioca un ruolo importante per la diffusione dell’infezione (3). CMV è causa di patologie fetali anche gravi se trasmesso in utero, infatti risulta essere la principale causa di infezione congenita nei paesi sviluppati con un’incidenza compresa tra lo 0.3 e il 2% di tutti i nati vivi (4,5). Dei neonati infettati congenitamente solo il 10-15% circa viene alla luce con sintomatologia evidente, in questi pazienti la mortalità perinatale è del 10% ed importanti sequele neurologiche - prevalentemente difetti dello sviluppo psicomotorio e sordità - si osservano in circa il 70-80% di quanti sopravvivono (6). L’ 85-90%, invece, pur essendo infetto, non presenta alla nascita alcuna sintomatologia. Di questi, però, un 8-15% presenterà segni tardivi (6,7). CMV è la più importante causa non genetica di sordità nell’infanzia: più del 50% dei nati con infezione sintomatica e circa il 10% degli asintomatici alla nascita svilupperà sordità neurosensoriale variabile tra forme lievi e profonde, con deterioramento progressivo in circa il 50% dei casi (8). La trasmissione materno-fetale è legata principalmente all’infezione materna primaria che presenta un rischio di trasmissione variabile tra il 24 e il 75% (valore medio 40%) (4,7), percentuali più basse sono osservate nel primo trimestre (~36%) e più alte nel terzo trimestre (~78%) (9). Casi di trasmissione materno-fetale conseguenti ad infezioni non primarie sono stati riportati nello 1-2.2% dei casi, quindi un rischio di trasmissione molto più basso rispetto a quello delle infezioni primarie (7). L’infezione congenita viene acquisita per via transplacentare, cioè dal sangue materno (dai leucociti materni) il virus infetta la placenta, si replica in essa fino ad arrivare a contatto con il circolo fetale. Lo stato sierologico materno è pertanto un fattore fortemente e maggiormente condizionante la possibilità di infezione congenita da CMV. E’ stato stimato che nell’Italia del nord approssimativamente il 30% della popolazione adulta risulta sieronegativa per CMV (10) e di conseguenza circa il 30% delle donne in età feconda sono a rischio di contrarre un’infezione primaria durante la gravidanza. L’entità dei danni feto-neonatali, in particolare le severe compromissioni cerebrali, appaiono correlabili prevalentemente all’epoca gestazionale in cui si verifica la trasmissione verticale: un rischio di prognosi feto-neonatale più grave è principalmente correlabile ad una infezione materna primaria contratta nei primi due trimestri di gravidanza (11). La maggior parte delle infezioni da CMV nelle donne gravide sono asintomatiche anche durante la fase acuta; raramente possono comparire sintomi non specifici e molto modesti, quali febbricola persistente, mialgia, adenomegalia. Le analisi di laboratorio possono evidenziare qualche volta la presenza di linfocitosi atipica e modesto rialzo delle transaminasi. Poiché della maggior parte delle donne lo stato sierologico pregravidico è ignoto e comunque esso non modifica di norma il decorso clinico dell’infezione, solitamente privo ...