Background: Rates of preterm delivery, a major proximate cause of perinatal morbidity and mortality, have been increasing. Prenatal alcohol exposure has been implicated in preterm delivery, although results have been inconsistent due to inadequate control for confounding factors, insufficient power, unreliable and inaccurate assessment of both exposure and gestational age, and lack of stratification of prematurity into severity levels. The purpose of this study was to examine the relation between maternal alcohol, cocaine and cigarette use during pregnancy, and extreme and mild preterm birth. Methods: Three thousand one hundred thirty consecutive gravidas were followed prospectively for antenatal substance use and had ultrasound confirmed pregnancy dating. Results: Alcohol and cocaine, but not cigarette use, were associated with increased risk of extreme preterm delivery after control for potential confounders. For every unit increase in alcohol exposure, risk of extreme preterm delivery increased significantly [odds ratio (OR) 34.8]. Furthermore, in women aged 30+, alcohol exposure was associated with mild prematurity. Abstention from alcohol while continuing to use cocaine and tobacco was related to a decrease in extreme prematurity of 41%. Conclusions: The risk of extreme preterm delivery associated with alcohol use is substantial and similar in magnitude to other well-recognized risks. Increased accuracy in identifying exposure and the use of ultrasound to confirm gestational age dating likely contributed to the findings of the current study. These findings suggest that eliminating pregnancy alcohol use might substantially reduce the risk of preterm delivery.

O presente estudo tem como objetivo descrever a mortalidade fetal e pósnatal em gestações gemelares monocoriônicas monoamnióticas, e analisar fatores preditores do número de crianças vivas no momento da alta hospitalar. Realizado de forma retrospectiva, envolveu pacientes com gestações gemelares monocoriônicas monoamnióticas, com ambos os fetos vivos no primeiro atendimento realizado no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, no período de 2004 a 2014. Para a análise da proporção de crianças vivas, de acordo com os subgrupos estudados, foi utilizado o teste chi-quadrado. Regressão ordinal multivariada foi utilizada para investigar os fatores preditores associados. O nível de significância estatística adotado foi de 0,05. Foram incluídas 39 gestantes com idade média de 27,3 + 6,3 anos. Destas, 17 (43,6%) eram nulíparas e 8 (20,5%) apresentavam algum antecedente clínico prévio à gestação. O primeiro exame ultrassonográfico ocorreu em idade gestacional média de 21,7 ± 6,2 semanas (intervalo: 12,7 - 36,1). A incidência de complicações obstétricas e/ou clínicas na gestação foi de 28,2% (n=11), e de intercorrências fetais, 30,7% (n=12), dentre as quais: malformações (n=7), alteração da vitalidade fetal (n=1), feto acárdico (n=2), síndrome da transfusão feto fetal (n=1) e infecção congênita (n=1). O óbito intrauterino ocorreu em 12,8% (n=5) das gestações. A idade gestacional média do parto foi de 32,7 ± 3,7 semanas, e 94,7% foram cesáreas. O peso médio dos nascidos vivos foi de 1832 ± 591 g, com discordância média de peso ao nascer de 7,5 ± 7,2%; 4 (5,9%) fetos apresentavam restrição de crescimento. Excluindo um caso que evoluiu para abortamento, a taxa de óbitos fetais foi de 9,2% (7/76; IC95% 3,8 - 18,1) e o coeficiente de mortalidade até a alta hospitalar foi de 17,9% (12/67, IC95%: 9,6 - 29,2), sendo a mortalidade global de 25% (19/76; IC95% 15,8 - 36,3). A mortalidade no subgrupo sem malformações foi de 16,7% (10/60; IC95% 8,3 - 28,5). O tempo médio de internação das crianças, que foram de alta vivas, foi de 18,1 ± 20,5 dias. Foram fatores significativos para predição do número de crianças vivas: presença de intercorrência fetal (OR 29,3, IC95%: 4,1 - 210; p=0,001) e idade gestacional do parto (OR 0,64, IC95%: 0,49 - 0,83; p=0,001) / The present study, involving monochorionic monoamniotic twin pregnacies, examines fetal e post natal mortality, and investigates predictors of the number of children alive at hospital discharge. It is a retrospective study involving monochorionic monoamniotic twin pregnancies with two live fetuses at the first ultrasound scan at the Department of Obstetrics and Gynecology, São Paulo University Medical School Hospital, between 2004 and 2014. Chi-square test was used for comparison of subgroups according to the number of children alive at hospital discharge. Prediction analysis was performed with multivariate ordinal regression. Significance level was set at 0,05. The study population included 39 women, with mean maternal age of 27,3 ± 6,3 years, 17 (43,6%) were nulliparous and 8 (20,5%) presented a previous disease. The first ultrasound examination was performed at 21,7 ± 6,2 weeks (range: 12,7 - 36,1). The incidence of obstetric and/or clinical complications during pregnancy was 28,2% (n=11), and fetal complications occurred in 30,7% (n=12), including: major fetal abnormalities (n=7), fetal distress (n=1), acardic twin (n=2), twin-to-twin transfusion syndrome (n=1) and congenital infection (n=1). Stillbirth occurred in 5 (12,8%) pregnancies. Mean gestational age at delivery was 32,7 ± 3,7 weeks, and 94,7% were cesarean. The average birthweight was 1832 ± 591g and mean birth weight discordance was 7,5% ± 7,2; 4 (5,9%) neonates were growth restricted. The rate of stillbirth was 9,2% (7/76; 95%CI 3,8 - 18,1) and death before hospital discharge coefficient was 17,9% (12/67, 95%CI 9,6 - 29,2). Overall mortality rate was 25% (19/76; 95%CI 15,8 - 36,3). In the subgroup without fetal structural defects, mortality was 16,7% (10/60; 95%CI 8,3 - 28,5). Mean length of hospital stay was 18,1 ± 20,5 days amongst children that were discharged alive. The number of children alive at hospital discharge was correlated with the occurrence of fetal complications (OR 29,3, 95%CI 4,1 - 210; p=0,001) and gestational age at delivery (OR 0,64, 95%CI 0,49 - 0,83; p=0,001)

Improved perinatal care during the last few years has led to higher survival rates for preterm infants. However, with higher survival rates, the number of children demonstrating long-term health disorders that result in a poorer quality of life is increasing. The most common complications in those preterm children include motion disorders, vision and hearing impairment, mental disorders, and chronic lung disease. Intrauterine infection may cause foetal infection and inflammation thus inducing the inflammatory response in foetus, defined by foetal inflammatory response syndrome (FIRS). FIRS may cause a heavy damage in foetus and newborns as well as later disorders in the infant organism, such as cerebral palsy and chronic lung disease. Speaking about researches proving relation of the perinatal inflammatory response and psychomotor development in a preterm newborn, these are few. The foetal inflammatory response syndrome is a problem that has not been examined yet in Lithuania. Researches of cytokines in umbilical cord blood to make prognoses on the health and psychomotor development in a premature infant has not been performed either. Hopefully, the study results will allow a more detail explanation of the reasons for preterm delivery, better understanding of health disorders in premature infants and prognosis of the process of a child development. The aim of the study was to evaluate the importance of FIRS for the early and later adaptation of premature infants and for... [to full text] / Dėl pagerėjusios perinatalinės priežiūros per pastaruosius metus neišnešiotų naujagimių išgyvenamumas labai pagerėjo. Tačiau, kai neišnešiotų naujagimių išgyvena vis daugiau, daugėja ir vaikų, kuriems augant, išryškėja ilgalaikiai sveikatos sutrikimai, pabloginantys jų gyvenimo kokybę. Nurodoma, kad dažniausia neišnešioto naujagimio gimimo priežastis yra intrauterinė infekcija, kuri progresuodama gali inicijuoti vaisiaus uždegiminio atsako sindromą, kurio metu vaisiuje suintensyvėja uždegiminių citokinų IL-1, IL-6, IL-8, TNF-α, augimo veiksnių gamyba. Šio sindromo pasekmė - sunkūs vaisiaus ir naujagimio pažeidimai bei vėlesni liekamieji kūdikio sveikatos sutrikimai, tokie kaip cerebrinis paralyžius ir lėtinė plaučių liga. Tyrimų, kurie rodytų perinatalinio uždegimo ir neišnešioto naujagimio psichomotorinės raidos sąsajas nėra daug. Ryšys tarp vaisiaus uždegimo ir neišnešiotų naujagimių retinopatijos atrastas neseniai, tad tyrimų šia kryptimi atlikta taip pat nedaug. Ryšys tarp perinatalinio uždegimo ir grėsmingų naujagimystės komplikacijų leidžia daryti prielaidą, kad neišnešioto naujagimio ankstyvas sveikatos vertinimas ir gyvenimo kokybės prognozė yra labai svarbūs, norint kuo anksčiau pradėti tikslinį gydymą bei ankstyvą vaiko raidos korekciją. Šio darbo tikslas buvo įvertinti vaisiaus uždegiminio atsako sindromo įtaką neišnešioto naujagimio sveikatai ir psichomotorinei raidai iki 1 metų koreguoto amžiaus. Tyrimo objektą sudarė virkštelės kraujo citokinų IL-6, bTNF-α... [toliau žr. visą tekstą]

Dėl pagerėjusios perinatalinės priežiūros per pastaruosius metus neišnešiotų naujagimių išgyvenamumas labai pagerėjo. Tačiau, kai neišnešiotų naujagimių išgyvena vis daugiau, daugėja ir vaikų, kuriems augant, išryškėja ilgalaikiai sveikatos sutrikimai, pabloginantys jų gyvenimo kokybę. Nurodoma, kad dažniausia neišnešioto naujagimio gimimo priežastis yra intrauterinė infekcija, kuri progresuodama gali inicijuoti vaisiaus uždegiminio atsako sindromą, kurio metu vaisiuje suintensyvėja uždegiminių citokinų IL-1, IL-6, IL-8, TNF-α, augimo veiksnių gamyba. Šio sindromo pasekmė - sunkūs vaisiaus ir naujagimio pažeidimai bei vėlesni liekamieji kūdikio sveikatos sutrikimai, tokie kaip cerebrinis paralyžius ir lėtinė plaučių liga. Tyrimų, kurie rodytų perinatalinio uždegimo ir neišnešioto naujagimio psichomotorinės raidos sąsajas nėra daug. Ryšys tarp vaisiaus uždegimo ir neišnešiotų naujagimių retinopatijos atrastas neseniai, tad tyrimų šia kryptimi atlikta taip pat nedaug. Ryšys tarp perinatalinio uždegimo ir grėsmingų naujagimystės komplikacijų leidžia daryti prielaidą, kad neišnešioto naujagimio ankstyvas sveikatos vertinimas ir gyvenimo kokybės prognozė yra labai svarbūs, norint kuo anksčiau pradėti tikslinį gydymą bei ankstyvą vaiko raidos korekciją. Šio darbo tikslas buvo įvertinti vaisiaus uždegiminio atsako sindromo įtaką neišnešioto naujagimio sveikatai ir psichomotorinei raidai iki 1 metų koreguoto amžiaus. Tyrimo objektą sudarė virkštelės kraujo citokinų IL-6, bTNF-α... [toliau žr. visą tekstą] / Improved perinatal care during the last few years has led to higher survival rates for preterm infants. However, with higher survival rates, the number of children demonstrating long-term health disorders that result in a poorer quality of life is increasing. The most common complications in those preterm children include motion disorders, vision and hearing impairment, mental disorders, and chronic lung disease. Intrauterine infection may cause foetal infection and inflammation thus inducing the inflammatory response in foetus, defined by foetal inflammatory response syndrome (FIRS). FIRS may cause a heavy damage in foetus and newborns as well as later disorders in the infant organism, such as cerebral palsy and chronic lung disease. Speaking about researches proving relation of the perinatal inflammatory response and psychomotor development in a preterm newborn, these are few. The foetal inflammatory response syndrome is a problem that has not been examined yet in Lithuania. Researches of cytokines in umbilical cord blood to make prognoses on the health and psychomotor development in a premature infant has not been performed either. Hopefully, the study results will allow a more detail explanation of the reasons for preterm delivery, better understanding of health disorders in premature infants and prognosis of the process of a child development. The aim of the study was to evaluate the importance of FIRS for the early and later adaptation of premature infants and for... [to full text]

Orientador: Márcia Guimarães da Silva / Resumo: Introdução: A infecção da cavidade amniótica e inflamação são associadas com o parto pré-termo espontâneo. Em geral, essas infecções são polibacterianas e causadas principalmente pela ascensão bacteriana do trato genital inferior. Dessa forma, a invasão microbiana da cavidade amniótica e o risco do parto pré-termo estão frequentemente relacionados à colonização vaginal por diferentes espécies bacterianas, incluindo aquelas de difícil cultivo, como micoplasmas genitais. Ureaplasma urealyticum e Mycoplasma hominis são as principais bactérias isoladas no líquido amniótico de gestações complicadas por parto pré-termo com membranas íntegras ou na presença de rotura prematura de membranas pré-termo. Além dos micoplasmas genitais, Gardnerella vaginalis merece destaque por ser a principal bactéria do core patológico da vaginose bacteriana e por estar associada ao risco de parto pré-termo. Dessa forma, considerando que a infecção da cavidade amniótica é de natureza polibacteriana, mimetizar esse cenário em membranas fetais in vitro se torna ferramenta importante para melhor entendimento dos mecanismos envolvidos no parto pré-termo. Objetivo: Avaliar a modulação da resposta imune induzida pela interação entre micoplasmas genitais e G. vaginalis nas membranas corioamnióticas in vitro. Material e Métodos: Para a estimulação da cultura in vitro, foram coletadas 8 membranas corioamnióticas de gestantes que tiveram a resolução da gestação por cesárea eletiva de termo (≥ 37 semanas de gestaç... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: The intraamniotic infection and inflammation are associated with spontaneous preterm birth (PTB). In general, such infections are polybacterial and caused mainly by ascending bacteria from the lower genital tract. Thus, the microbial invasion of the amniotic cavity (MIAC) and risk of preterm birth is often cervicovaginal colonizers such as genital mycoplasmas, in which Mycoplasma hominis (MH) and Ureaplasma urealyticum (UU) are the most commonly isolated bacteria in the amniotic fluid in both PTB with intact membranes and in preterm premature rupture of membranes (pPROM). In addition, Gardnerella vaginalis, the main microorganism of the pathological core of bacterial vaginosis is also closely associated with the risk of preterm birth. Thus, considering that the infection of the amniotic cavity is polybacterial, mimic this scenario in fetal membranes in vitro becomes an important tool for a better understanding of the mechanisms that trigger preterm delivery. Objective: To evaluate the modulation of the immune response induced by the interaction between genital mycoplasmas and G. vaginalis in chorioamniotic membranes in vitro. Material and methods: For the in vitro culture stimulation, 8 chorioamniotic membranes of pregnant women in term elective cesarean section (≥ 37 weeks gestation) were collected, in the absence of labor and/or premature rupture of membranes. Chorioamniotic membrane cultures were stimulated with 106 or 103UFC of heat inactivated bacterial sus... (Complete abstract click electronic access below) / Doutor

Doctor Pharmaceuticae - Dpharm / The use of efavirenz (EFV) in the first trimester of pregnancy remains controversial. In South Africa, the use of EFV-containing antiretroviral therapy (ART) as part of a Fixed Dose Combination (FDC) during the first trimester of pregnancy started in April, 2013. Literature to date has reported conflicting outcomes following the use of EFV-containing ART during the first trimester of pregnancy. The objectives of the study were to determine the prevalence of adverse pregnancy outcomes among HIV-positive pregnant women treated with EFV-containing ART and compare these results with those of pregnant women treated with NVP-containing ART and HIV-negative pregnant women in resource-limited settings. In addition, the study also aimed to determine the effect of the time of initiation of ART on the prevalence of adverse pregnancy outcomes.

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Em geral, essas infecções são polibacterianas e causadas principalmente pela ascensão bacteriana do trato genital inferior. Dessa forma, a invasão microbiana da cavidade amniótica e o risco do parto pré-termo estão frequentemente relacionados à colonização vaginal por diferentes espécies bacterianas, incluindo aquelas de difícil cultivo, como micoplasmas genitais. Ureaplasma urealyticum e Mycoplasma hominis são as principais bactérias isoladas no líquido amniótico de gestações complicadas por parto pré-termo com membranas íntegras ou na presença de rotura prematura de membranas pré-termo. Além dos micoplasmas genitais, Gardnerella vaginalis merece destaque por ser a principal bactéria do core patológico da vaginose bacteriana e por estar associada ao risco de parto pré-termo. Dessa forma, considerando que a infecção da cavidade amniótica é de natureza polibacteriana, mimetizar esse cenário em membranas fetais in vitro se torna ferramenta importante para melhor entendimento dos mecanismos envolvidos no parto pré-termo. Objetivo: Avaliar a modulação da resposta imune induzida pela interação entre micoplasmas genitais e G. vaginalis nas membranas corioamnióticas in vitro. Material e Métodos: Para a estimulação da cultura in vitro, foram coletadas 8 membranas corioamnióticas de gestantes que tiveram a resolução da gestação por cesárea eletiva de termo (≥ 37 semanas de gestação), na ausência de trabalho de parto e/ou rotura prematura de membranas. As culturas das membranas corioamnióticas foram estimuladas com 106 ou 103 Unidades Formadoras de Colônias (UFC) de suspensão bacteriana, inativada pelo calor, diluída em meio de cultura de tecidos com U. urealyticum, M. hominis e G. vaginalis isolados ou em combinação. Amostras de membranas corioamnióticas, apenas com o meio de cultura, sem estímulo bacteriano foram usadas como controle negativo. Como controle positivo foi utilizado o lipopolissacarídeo (LPS) de Escherichia coli. Os sobrenadantes obtidos das culturas de membranas corioamnióticas, após 24 horas de estimulação bacteriana, foram avaliados pela tecnologia Luminex® xMAPTM utilizando um painel para as seguintes citocinas e receptores: IL-1β, IL-4, IL-6, IL-8, IL-10, IL-13, TNF-α, GM-CSF, sIL-1R1, sIL-1R2, sIL-6R, sTNF-R1, sTNF-R2. Além disso, pela técnica de ELISA foi avaliado o receptor solúvel sgp130, e por imunohistoquímica, a imunomarcação dos receptores de membrana mIL-6R e gp130 nas células coriônicas e no epitélio amniótico. A análise estatística para os dados de citocinas e receptores solúveis foi feita utilizando modelos de feitos mistos lineares usando a biblioteca Ime4 da linguagem de programação R. Os dados de imunohistoquímica foram avaliadas usando a análise de variância unidirecional (ANOVA) seguida pelo teste de Tukey, em que, o valor de p <0,05 foi considerado estatisticamente significante. O software empregados nessas análises foi o GraphPad Prism (GraphPad Software Inc., San Diego, CA, EUA). Resultados: A estimulação das membranas por micoplasmas genitais não aumentou a produção de citocinas pró-inflamatórias (IL-1β, IL-8, TNF-α, GM-CSF), exceto a estimulação com U. urealyticum que aumentou os níveis de IL-8. No entanto, a estimulação com U. urealyticum e M. hominis aumentaram significativamente os níveis de IL-10 e IL-13. A estimulação das membranas corioamnióticas por G. vaginalis isoladamente ou em combinação com micoplasmas genitais resultou em aumento de citocinas pró e anti-inflamatórias (IL-1β, IL-6, IL-8, IL-10, IL-13, TNF-α, GM-CSF). Quanto a produção de IL-6, todos os grupos aumentaram significativamente com relação ao controle não estimulado, com exceção ao estímulo com M. hominis isolado. Já os níveis de sIL-6R aumentaram significativamente somente com estímulo por U. urealyticum isolado ou em combinação com M. hominis. Além disso, o receptor solúvel sgp130 se apresentou em níveis elevados em todos os tratamentos, com exceção do tratamento com G. vaginalis isolada ou na combinação das três espécies bacterianas em cargas iguais. A análise imunohistoquímica mostrou maior imunorreatividade do receptor de membrana mIL-6R apenas nas células do âmnio na presença de LPS e G. vaginalis em comparação com o controle (p <0,0001), mas não para os grupos de M. hominis, U. urealitycum e estimulações polibacterianas. Além disso, o gp130 aumentou estatisticamente nas células do âmnio e cório estimuladas com LPS, G. vaginalis e todos os tratamento polibacterianos. Conclusões: Membranas corioamnióticas in vitro produzem perfil distinto de citocinas e receptores pró e anti-inflamatórios em resposta à estimulação por micoplasmas genitais e G. vaginalis isolados ou em combinação. G. vaginalis estimula resposta pró-inflamatória nas membranas fetais in vitro, que após 24 horas é regulada pela atividade anti-inflamatória da IL-6 através da via de sinalização clássica. Micoplasmas genitais induzem controle da resposta inflamatória pela produção de IL-13, IL-10 e sTNF-R2 favorecendo sua sobrevivência na cavidade amniótica. Além disso, o aumento de IL-6 por si só pode não ser indicativo de qualquer função, uma vez que a sua atividade é controlada por diferentes receptores de membrana e solúveis, sendo que sua produção pelas membranas fetais não deve ser mediador funcional das vias indutoras de trabalho de parto. A tentativa de correlacionar o risco de desfecho gestacional adverso baseado exclusivamente nos níveis de IL-6 em fluidos biológicos, sem considerar os receptores de IL-6, podem ser ineficazes. / Introduction: The intraamniotic infection and inflammation are associated with spontaneous preterm birth (PTB). In general, such infections are polybacterial and caused mainly by ascending bacteria from the lower genital tract. Thus, the microbial invasion of the amniotic cavity (MIAC) and risk of preterm birth is often cervicovaginal colonizers such as genital mycoplasmas, in which Mycoplasma hominis (MH) and Ureaplasma urealyticum (UU) are the most commonly isolated bacteria in the amniotic fluid in both PTB with intact membranes and in preterm premature rupture of membranes (pPROM). In addition, Gardnerella vaginalis, the main microorganism of the pathological core of bacterial vaginosis is also closely associated with the risk of preterm birth. Thus, considering that the infection of the amniotic cavity is polybacterial, mimic this scenario in fetal membranes in vitro becomes an important tool for a better understanding of the mechanisms that trigger preterm delivery. Objective: To evaluate the modulation of the immune response induced by the interaction between genital mycoplasmas and G. vaginalis in chorioamniotic membranes in vitro. Material and methods: For the in vitro culture stimulation, 8 chorioamniotic membranes of pregnant women in term elective cesarean section (≥ 37 weeks gestation) were collected, in the absence of labor and/or premature rupture of membranes. Chorioamniotic membrane cultures were stimulated with 106 or 103UFC of heat inactivated bacterial suspension diluted in tissue culture medium with U. Urealyticum, M. hominis and G. vaginalis alone or in combination. Unstimulated samples were used as control in which was included only culture media without bacteria, and as positive control was used Lipopolysaccharide (LPS) from Escherichia coli. The supernatants obtained from the chorioamnionic membrane cultures after 24 hours were evaluated by Luminex xMAP technology using a panel for the following cytokines and receptors: IL-1β, IL-4, IL-6, IL-8, IL-10, IL-13, TNF-α, GM-CSF, sIL-1R1, sIL-1R2, sIL-6R, sTNF-R1, sTNF-R2. In addition, the soluble receptor sgp130 was evaluated by the ELISA technique, and by immunohistochemistry we identified membrane receptors, mIL-6R and gp130, in the amnion and chorion cells. Statistical analysis for cytokine and soluble receptors data were performed using linear mixed-effects models using the lme4 library of the R statistical language. Immunohistochemistry data were evaluated using one-way (ANOVA) followed by Tukey's test, in which the value of p <0.05 was considered statistically significant and the software used was GraphPad Prism (GraphPad Software Inc., San Diego, CA, EUA). Results: The stimulation of genital mycoplasmas did not increase the proinflammatory cytokines (IL-1β, IL-8, TNF-α, GM-CSF), except U. urealyticum that increased IL-8 levels. However, U. urealyticum and M. hominis significantly increased IL-10 and IL-13 levels. G. vaginalis alone or in combination with genital mycoplasmas showed an increased pro- and anti-inflammatory cytokines (IL-1β, IL-6, IL-8, IL-10, IL-13, TNF-α, GM-CSF). Considering the IL-6 production, all groups increased significantly compared to the control, except M. hominis isolated. Moreover, sIL-6R levels increased significantly only in the presence of U. urealyticum alone or in combination with M. hominis. In addition, the soluble sgp130 receptor was elevated in all treatments, except for the treatment with G. vaginalis alone or in combination of the three bacteria in equal loads. Immunohistochemistry analysis showed greater intensity of mIL-6R only in amnion cells in the presence of LPS and G. vaginalis compared to control (p <0.0001) but not for M. hominis, U. urealitycum and polybacterial treatments. In addition, gp130 increased statistically in amnion cells stimulated with LPS, GV and all polybacterial treatments. Conclusions: Chorioamniotic membranes in vitro produce a distinct cytokine and pro- and anti-inflammatory profile in response to stimulation by genital mycoplasmas and G. vaginalis alone or in combination. G. vaginalis sustain a proinflammatory response in the fetal membranes in vitro, in which after 24 hours is regulated by the anti-inflammatory activity of IL-6 through the classical signaling pathway. While genital mycoplasmas induce a control of the inflammatory response, by the production of anti-inflammatory cytokines (IL-13, IL-10, sTNF-R2), favoring their survival in the amniotic cavity. Furthermore, the increase of IL-6 alone may not be indicative of any function, since its activity is controlled by different membrane and soluble receptors, since its production by fetal membranes could not be a functional mediator of the labor-inducing pathways. In summary, the attempt to correlate the risk of adverse gestational outcome based exclusively on IL-6 levels in biological fluids without considering IL-6 receptors may be ineffective. / CNPq: 140857/2013-3

O presente estudo tem como objetivo descrever a mortalidade fetal e pósnatal em gestações gemelares monocoriônicas monoamnióticas, e analisar fatores preditores do número de crianças vivas no momento da alta hospitalar. Realizado de forma retrospectiva, envolveu pacientes com gestações gemelares monocoriônicas monoamnióticas, com ambos os fetos vivos no primeiro atendimento realizado no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, no período de 2004 a 2014. Para a análise da proporção de crianças vivas, de acordo com os subgrupos estudados, foi utilizado o teste chi-quadrado. Regressão ordinal multivariada foi utilizada para investigar os fatores preditores associados. O nível de significância estatística adotado foi de 0,05. Foram incluídas 39 gestantes com idade média de 27,3 + 6,3 anos. Destas, 17 (43,6%) eram nulíparas e 8 (20,5%) apresentavam algum antecedente clínico prévio à gestação. O primeiro exame ultrassonográfico ocorreu em idade gestacional média de 21,7 ± 6,2 semanas (intervalo: 12,7 - 36,1). A incidência de complicações obstétricas e/ou clínicas na gestação foi de 28,2% (n=11), e de intercorrências fetais, 30,7% (n=12), dentre as quais: malformações (n=7), alteração da vitalidade fetal (n=1), feto acárdico (n=2), síndrome da transfusão feto fetal (n=1) e infecção congênita (n=1). O óbito intrauterino ocorreu em 12,8% (n=5) das gestações. A idade gestacional média do parto foi de 32,7 ± 3,7 semanas, e 94,7% foram cesáreas. O peso médio dos nascidos vivos foi de 1832 ± 591 g, com discordância média de peso ao nascer de 7,5 ± 7,2%; 4 (5,9%) fetos apresentavam restrição de crescimento. Excluindo um caso que evoluiu para abortamento, a taxa de óbitos fetais foi de 9,2% (7/76; IC95% 3,8 - 18,1) e o coeficiente de mortalidade até a alta hospitalar foi de 17,9% (12/67, IC95%: 9,6 - 29,2), sendo a mortalidade global de 25% (19/76; IC95% 15,8 - 36,3). A mortalidade no subgrupo sem malformações foi de 16,7% (10/60; IC95% 8,3 - 28,5). O tempo médio de internação das crianças, que foram de alta vivas, foi de 18,1 ± 20,5 dias. Foram fatores significativos para predição do número de crianças vivas: presença de intercorrência fetal (OR 29,3, IC95%: 4,1 - 210; p=0,001) e idade gestacional do parto (OR 0,64, IC95%: 0,49 - 0,83; p=0,001) / The present study, involving monochorionic monoamniotic twin pregnacies, examines fetal e post natal mortality, and investigates predictors of the number of children alive at hospital discharge. It is a retrospective study involving monochorionic monoamniotic twin pregnancies with two live fetuses at the first ultrasound scan at the Department of Obstetrics and Gynecology, São Paulo University Medical School Hospital, between 2004 and 2014. Chi-square test was used for comparison of subgroups according to the number of children alive at hospital discharge. Prediction analysis was performed with multivariate ordinal regression. Significance level was set at 0,05. The study population included 39 women, with mean maternal age of 27,3 ± 6,3 years, 17 (43,6%) were nulliparous and 8 (20,5%) presented a previous disease. The first ultrasound examination was performed at 21,7 ± 6,2 weeks (range: 12,7 - 36,1). The incidence of obstetric and/or clinical complications during pregnancy was 28,2% (n=11), and fetal complications occurred in 30,7% (n=12), including: major fetal abnormalities (n=7), fetal distress (n=1), acardic twin (n=2), twin-to-twin transfusion syndrome (n=1) and congenital infection (n=1). Stillbirth occurred in 5 (12,8%) pregnancies. Mean gestational age at delivery was 32,7 ± 3,7 weeks, and 94,7% were cesarean. The average birthweight was 1832 ± 591g and mean birth weight discordance was 7,5% ± 7,2; 4 (5,9%) neonates were growth restricted. The rate of stillbirth was 9,2% (7/76; 95%CI 3,8 - 18,1) and death before hospital discharge coefficient was 17,9% (12/67, 95%CI 9,6 - 29,2). Overall mortality rate was 25% (19/76; 95%CI 15,8 - 36,3). In the subgroup without fetal structural defects, mortality was 16,7% (10/60; 95%CI 8,3 - 28,5). Mean length of hospital stay was 18,1 ± 20,5 days amongst children that were discharged alive. The number of children alive at hospital discharge was correlated with the occurrence of fetal complications (OR 29,3, 95%CI 4,1 - 210; p=0,001) and gestational age at delivery (OR 0,64, 95%CI 0,49 - 0,83; p=0,001)

L’objectif était la caractérisation moléculaire de la vaginose bactérienne (VB) et l’identification d’une relation entre anomalies moléculaires de la flore vaginale et prématurité. Nous avons élaboré un outil de quantification par PCR spécifique en temps réel ciblant 8 microorganismes impliqués dans la VB. Seule la combinaison de la quantification d’Atopobium vaginae (108 copies/mL) à celle de Gardnerella vaginalis (109 copies/mL) présentait une sensibilité (95%) et une spécificité (99%) élevées pour le diagnostic de VB. La classification des flores selon la présence d’une VB, d’après les 2 méthodes de référence (critères d’Amsel et score de Nugent), et d’après notre outil moléculaire était concordante dans 94.5% des cas (kappa=0.81, intervalle de confiance [IC] 95%: 0.70-0.81). La discordance portait sur 9 flores intermédiaires (5.5%) dont les concentrations en G. vaginalis et en A. vaginae étaient élevées. De plus, nous avons démontré une étroite corrélation entre l’auto-prélèvement vaginal et le prélèvement réalisé par le médecin pour la quantification microbienne. Cette méthode alternative semble utile pour le suivi des anomalies de la flore vaginale. Nous avons enfin établi un lien entre la composition de la flore vaginale et le risque de prématurité parmi 90 patientes hospitalisées pour une menace d’accouchement prématuré (MAP). L’analyse par courbe de survie montrait un délai raccourci entre le diagnostic de MAP et le terme de l’accouchement en présence de concentrations élevées en A. vaginae ou en G. vaginalis (hasard ratio: 3.3; IC 95%: 1.1-9.5). Notre travail a contribué à améliorer l’analyse de la flore vaginale et à l’évaluation de son lien avec la prématurité. / The aim was the molecular characterization of bacterial vaginosis (BV) and the estimation of the relationship between molecular abnormalities and preterm delivery. A quantitative molecular tool targeting 8 bacterial vaginosis-related microorganisms was developed using specific real-time PCR. Only the combination of the quantification of Atopobium vaginae (108 copies/mL) and Gardnerella vaginalis (109 copies/ml) had an excellent sensitivity (95%) and specificity (99%) for the diagnosis of BV. The categorization of the vaginal flora according to the presence of BV based on the 2 reference methods (Amsel criteria and Nugent score), and our molecular tool was agree in 94.5% of the cases (kappa=0.81, 95% confidence interval [CI] 0.70-0.81). There was disagreement for 9 intermediate floras (5.5%) for which vaginal concentrations of A. vaginae and G. vaginalis were high. We also reported a good agreement for bacterial quantification in self-collected compared with practitioner-collected vaginal swabs. This method provides an alternative to practitioner-collected swabs especially for follow-up. We finally demonstrated a relationship between the high vaginal concentrations of A. vaginae and G. vaginalis and the risk of preterm delivery among 90 women with preterm labor. Survival curves analysis for preterm labor-to-delivery interval showed a significantly shorter interval for high vaginal concentrations of both A. vaginae or G. vaginalis (hazard ratio: 3.3; IC 95%: 1.1-9.5). Our work improved vaginal flora analysis and investigated the relationship with preterm delivery.

Une fraction importante de la population est exposée à la pollution atmosphérique ; ses effets sur la mortalité et la morbidité cardiovasculaire et respiratoire sont connus, et un effet de l'exposition au cours de la grossesse sur le poids de naissance et la croissance fœtale est probable ; un effet sur le risque de naissance prématurée a aussi été suggéré par de nombreuses études, essentiellement en Amérique. En revanche, la capacité des couples à concevoir -fertilité- et les paramètres de la fertilité féminine ont été très peu étudiés en lien avec cette exposition.L’objectif de ce doctorat était de documenter un effet éventuel de la pollution atmosphérique sur la fonction de reproduction humaine et tout particulièrement sur les caractéristiques du cycle menstruel, la probabilité de survenue d’une grossesse (fertilité) et le risque de naissance prématurée.Nous nous sommes appuyés sur une cohorte de couples n’utilisant pas de méthode contraceptive (l’Observatoire de la fertilité en France) et sur treize cohortes de naissances européennes participant au projet ESCAPE (European Study of Cohorts for Air Pollution Effects).Nous avons observé un allongement de la durée de la phase folliculaire du cycle menstruel (période du cycle entre le début des règles et l’ovulation) avec l’exposition de la femme aux particules en suspension dans l’atmosphère (n=158, β=1,6 jour pour une augmentation de la concentration des particules de diamètre aérodynamique inférieur à 10 µm -PM10- de 10 µg/m3 dans le mois précédant le cycle, intervalle de confiance, IC à 95%, 0,3; 2,9). En utilisant deux designs d’étude en parallèle sur la même population, l’approche des durées en cours et l’approche de cohorte prévalente, nous avons mis en évidence une tendance à une diminution de la probabilité de grossesse en association avec l’exposition à la pollution atmosphérique pour la première approche (cohorte prévalente : n=468, risque relatif de grossesse, HR : 0,69 pour une augmentation des PM10 de 10 µg/m3 dans les 70 jours précédant l’inclusion, IC à 95%, 0,43;1,12) ; la tendance était similaire avec l’approche des durées en cours (n=516, durée médiane sans contraception multipliée par 1,29 pour une augmentation des PM10 de 10 µg/m3 dans les 70 jours précédant l’arrêt de la contraception, IC à 95%, 0,97;1,70).Le risque de naissance prématurée, analysé avec un modèle de survie en prenant en compte l’exposition comme une variable dépendant du temps, n’était pas associé à divers polluants atmosphériques dans les cohortes du projet ESCAPE (n=46 791, OR=0,97 pour une augmentation du niveau moyen de PM10 de 10 µg/m3 pendant la grossesse, IC à 95%, 0,87 ;1,07). Nous avons par ailleurs mis en évidence une augmentation du risque de naissance prématurée avec la pression atmosphérique pendant le premier trimestre de grossesse et avec la température moyenne pendant le premier trimestre, au moins dans l’intervalle entre -5°C et 10°C. Nous avons montré qu’une partie de la littérature en faveur d’une association entre particules fines et risque de naissance prématurée pourrait être sujette à un biais causé par des durées de fenêtres d’exposition différentes entre les enfants nés avant terme et ceux nés à terme.Dans l’ensemble, ce travail confirme la nécessité d’utiliser un modèle de survie avec variables dépendant du temps pour étudier le risque de naissance prématurité et appelle à poursuivre les recherches concernant des effets possibles des polluants atmosphériques sur le cycle menstruel et la fertilité, pour lesquels nos travaux font partie des premiers réalisés en population générale. / A large fraction of the population is exposed to atmospheric pollution, which has known effects on cardiovascular and respiratory mortality and morbidity and probable effect on birthweight and fetal growth. So far, the biological aptitude to conceive for couples -fecundity- and the female markers of fecundity have been seldom studied in relation with this environmental exposure.The aim of this PhD was to quantify the possible association between atmospheric pollution and specific health outcomes related to human reproduction: menstrual cycle characteristics, probability of pregnancy and preterm birth risk. We relied on a population of couples not using any contraceptive method (Observatory of Fecundity in France) and on 13 birth cohorts participating in the European Study of Cohorts for Air Pollution Effects.We observed that higher levels of atmospheric pollutants during the 30 days before the start of a menstrual cycle were associated with longer follicular phase (n=158, β=1.6 days per each increase by 10 µg/m3 in particulate matters with an aerodynamical diameter of less than 10 µm -PM10; 95% confidence interval: 0.3;2.9). In the population recruited in OBSEFF study, we observed a trend for an increased time to pregnancy with short-term NO2 and PM10 levels in an original approach relying on two seldom used study designs focusing on a marker of fecundity in parallel: the prevalent cohort approach (n=468, hazard ratio of pregnancy, HR: 0.69 per each increase by 10 µg/m3 in PM10 during the 70 days before the inclusion, with a 95% CI of 0.43;1.12) and the current duration approach (n=516, median current duration of unprotected intercourse multiplied by 1.29 per each increase by 10 µg/m3 in PM10 during the 70 days before the contraception stop, 95% CI: 0.97;1.70). In the cohorts included in ESCAPE, preterm delivery risk studied by a survival model with time-dependent exposures was not associated with atmospheric pollutants levels during pregnancy (n=46,791, OR=0.97 per each increase by 10 µg/m3 in PM10 during the whole pregnancy, 95% CI 0.87;1.7). We observed an increased risk of preterm birth with higher atmospheric pressure during the first trimester of pregnancy and to some extent with temperature between -5°C and 10°C during the first trimester of pregnancy. We additionally showed that using exposure windows with different durations between cases and non-cases is a source of a bias in preterm birth studies that may impact several studies in the literature.This work demonstrated that using a survival model with time-dependent exposures is crucial to study preterm delivery risk. It appeals for additional research on the possible adverse effects of atmospheric pollution on menstrual cycle and fecundity, as our studies are among the first ones conducted in a general population on those topics.