the latest buzz about zika virus in pregnancy21/03/2018 1 the latest “buzz” about zika virus in...
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21/03/2018
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The Latest “Buzz” about Zika Virus in Pregnancy
Dr. Verena Kuret
Maternal‐Fetal Medicine Specialist, Calgary AB
ACFP 63rd Annual Scientific Assembly
Faculty/Presenter Disclosure
• Faculty/Presenter: Dr. Verena Kuret
• Relationships with commercial interests:
Grants/Research Support: Not Applicable
Speakers Bureau/Honoraria: Not Applicable
Consulting Fees: Not applicable
Other: This presentation has received support from the Alberta College of Family Physicians in the form of a speaker fee and/or expenses.
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ACFP 63rd ASADisclosure of Commercial Support
This program has received financial support in the form of sponsorship from:
• Potential for conflict(s) of interest: Those speakers/faculty who have made COI disclosure are noted in the 63rd ASA Program and on the Salon A/B slide scroll.
Mitigating Potential Bias
• ACFP: → The ACFP’s Sponsorship Guidelines apply to ASA Sponsorship. The ACFP abides by the College of
Family Physicians of Canada’s Understanding Mainpro+ Certification Guidelines, the Canadian Medical Association’s Policy Guidelines for Physicians in Interactions With Industry and the Innovative Medicines Canada Code of Ethical Practices (2016). As a non‐profit organization, the ACFP complies with Canada Revenue Agency regulations. When deliberating acceptance of sponsorship, the ACFP considers and accepts sponsorship only from those whose products, services, policies, and values align with the ACFP vision, values, goals, and strategies priorities.
• ASA Planning Committee: → Consideration was given by the 63rd ASA Planning Committee to identify when Planning
Committee members’ and speakers’ personal or professional interests may compete with or have actual, potential, or apparent influence over program content.
→ Material/Learning Objectives and/or session description were developed and reviewed by a Planning Committee composed of experts/family physicians responsible for overseeing the program’s needs assessment and subsequent content development to ensure accuracy and fair balance.
→ The 63rd ASA Planning Committee reviewed Sponsorship Agreements to identify any actual, potential or apparent influence over the program.
→ Information/recommendations in the program are evidence‐ and/or guidelines‐based, and opinions of the independent speakers will be identified as such.
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Objectives
• How to diagnose Zika virus
• When to screen for Zika virus
• What to do once Zika virus is diagnosed
• Awareness of resources
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Transmission
• Mosquito bite
• Perinatal (trans‐placental) transmission
• Sexual transmission
• Blood transfusion
• Organ donation
Travel and Conception
• AVOID TRAVEL!
– Pregnant women and their partners
– Couples planning conception
• Couples seeking pregnancy who have travelled to active transmission area
– Wait 2 months for female traveler
– Wait 6 months for male partners
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Sexual Transmission
• ZIKV detected in semen >90 days
• Detected in all bodily fluids
• Condoms (or barrier contraceptive) or abstinence recommended during pregnancy
If they must travel…
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Zika Virus Infection
• Incubation period 3‐12 days
• 80% of infected people are asymptomatic
• Guillain‐Barre Syndrome
• Meningoencephalitis
• Acute myelitis
• Acute disseminated encephalomyelitis
• Congenital Zika Syndrome
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Congenital Zika Syndrome (CZS)
• Severe microcephaly
• Brain anomalies
• Ocular findings
• Congenital contractures /Arthrogryposis
• Neurological impairments
Congenital Zika Syndrome (CZS)
• Congenital Zika infection reported in all 3 trimesters
• Greatest risk with infection in first & second trimester
• Similar rates of infants born with CZS regardless of maternal symptoms
M. Johansson et al, Zika and the Risk of Microcephaly, New Engl J Med: May 25, 2016N Rodrigues Faria et al; Science 15 Apr 2016: Vol. 352, Issue 6283, pp. 345‐349C Moore et al, Characterizing the pattern of anomalies in congenital Zika syndrome for pediatric
clinicians; JAMA Pediatr. 2017;171(3):288‐295
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What to ask the patient
• Have you travelled outside of Canada recently?
• Where did you go?
• What were the exact dates?
• Did you or your partner get any mosquito bites?
• Did you or your partner have symptoms?
Testing:
• SYMPTOMATIC PATIENT (pregnant or non‐pregnant)
Molecular Testing:
Blood ZIKV RT‐PCR up to 14 days after symptom onset
Urine ZIKV RT‐PCR up to 14 days after symptom onset
Serology:
Blood ZIKV serology (IgM and IgG), ideally more than 7 days after symptom onset (Lab will add dengue and chikungunya serology)
Convalescent blood at least 14 days later
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Testing
• ASYMPTOMATIC PREGNANT FEMALE within 14 DAYS of potential exposure
• “G1P0 patient @ 19 wks, just returned from 10 days
in Mexico Feb 17 – 27, 2018”
Blood & Urine ZIKV RT‐PCR within 14 days of exposure
Serology for ZIKV (IgM and IgG) collected 2 weeks after exposure
Convalescent blood at least 14 days later
Testing
• ASYMPTOMATIC PREGNANT FEMALE more than 14 DAYS after potential exposure
• “G2P1 @ 10 weeks’ who visited family in El Salvador
for 6 weeks Oct – Nov 2017. Her husband travelled
with her”
Serology for ZIKV (IgM and IgG)
Convalescent blood sample at least 14 days later
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Who CAN’T get testing…
• Asymptomatic male travellers
• Asymptomatic non‐pregnant female travellers
MFM Ultrasound and Consult
• Fetal assessment recommended for all exposed in pregnancy
– 19 – 20 weeks’ gestation or third trimester
• ~4 weeks after return of travel
• Individualize!
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Pediatric Follow up
• Thorough newborn assessment prior to discharge
• Routine well‐child visits
• Standard hearing and vision tests for first 2‐3 years of life
Positive ZIKV in Pregnancy
• Positive IgM or IgG ZIKV PRNT
• Serial fetal surveillance with ultrasound
• Amniocentesis for confirmation of fetal infection
• Neonatology consultation
• Cord blood, cord tissue, placental tissue testing at delivery
• Newborn assessment/testing and close surveillance
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Take Home Messages
• Pregnant patient’s or couples wanting to conceive should NOT travel to areas with ZIKV risk
• Wait 2 or 6 months to conceive after exposure
• IgM & IgG serology now available
• Testing can be completed > 12 weeks from travel exposure
• Ultrasound best completed at 19 – 20 weeks’ gestation or later
Resources
• Alberta Health – ZIKV. – www.health.alberta.ca/health‐info/zika‐virus.html
• Center for Disease Control (CDC) – www.cdc.gov/zika/
• Public Health Agency of Canada – ZIKV. – www.Canada.ca/zika‐virus
• Pan American Health Organization (PHAC)– www.paho.org/hq/index.php?option=com_content&view=article&id=11585&Itemid=41688&lang=en
• World Health Organization. – www.who.int/topics/zika/en/
• Society of Obstetrics & Gynecology (SOGC)– https://sogc.org
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Thank you!
• MFM on call (Southern Alberta)
Adolfo Valle for NPR
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