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Ben Schwartz is Associate Editor, Contemporary OB/GYN.
New interim guidance from The Centers for Disease Control and Prevention (CDC) emphasizes the need for standard screening and monitoring of infants with possible congenital Zika virus infection plus hearing screening and specific testing and evaluation in three clinical scenarios. Plus: Are at-risk women commonly tested for rectal gonorrhea, chlamydia? Also: According to a study, ovarian cancer may originate in fallopian tubes.
New interim guidance from The Centers for Disease Control and Prevention (CDC) emphasizes the need for standard screening and monitoring of infants with possible congenital Zika virus infection plus hearing screening and specific testing and evaluation in three clinical scenarios. The recommendations were published in MMWR and are based on available data on Zika virus infection and interpretation of individual expert opinion collected during a Forum on the Diagnosis, Evaluation and Management of Zika Virus Infection Among Infants held by CDC in August in collaboration with the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.
The guidance follows publication of clinical data on: (1) eye findings in infants without microcephaly or other brain anomalies whose mothers have laboratory evidence of Zika; (2) later development of microcephaly in infants born with normal head circumferences; development of hydrocephalus in infants born with microcephaly; (3) abnormalities on sleep electroencephalogram (EEG) in some infants with microcephaly who did not have recognized seizures; and (4) diaphragmatic paralysis in infants born with microcephaly and arthrogryposis.
For infants with clinical findings consistent with congenital Zika syndrome born to mothers with possible Zika virus exposure in pregnancy, CDC recommends a standard evaluation at birth plus a head ultrasound and a comprehensive ophthalmologic exam. The latter should be performed by age 1 month by an ophthalmologist experienced in assessment of and intervention in infants. For newborns who pass a hearing screening using only otoacoustic emissions methodology, a referral should be made for an automated auditory brain stem response (ABR) test by age 1 month. Referrals to a developmental specialist and early intervention services programs also are recommended.
The CDC report said that for infants with clinical findings consistent with congenital Zika syndrome, consultations also should be considered with:
For infants without clinical findings consistent with congenital Zika syndromeborn to mothers with laboratory evidence of possible Zika virus infection during pregnancy, CDC recommends the following:
For infants with no clinical evidence of Zika Syndrome born to mothers with laboratory evidence of possible Zika virus infection during pregnancy, a diagnostic ABR at 4 to 6 months or behavioral audiology at 9 months is no longer recommended if the initial hearing screening was passed by automated ABR because of absence of data suggesting delayed-onset
Are at-risk women commonly tested for rectal gonorrhea, chlamydia?
According to a study published in Clinical Infectious Diseases, fewer than 0.1% of women who undergo genital testing for gonorrhea and chlamydia undergo rectal testing for these disorders. While the Centers for Disease Control and Prevention (CDC) guidelines do not currently recommend rectal screening for gonorrhea and chlamydia in women who engage in anal intercourse, the authors note that those sexual transmitted infection (STIs)s often are missed due to infrequent testing and follow-ups, which suggests a need for increased testing and education.
The study’s authors used data from a large US commercial laboratory of women aged 15-60 years who were screened for chlamydia and gonorrhea between November 2012 and September 2015. Of 5499 women who were given rectal chlamydia and gonorrhea tests, positive results were found 10.8% of the time. Approximately 80% of the patients who received the rectal test were also given genital chlamydia and gonorrhea tests the same day. The authors found that rectal chlamydia or gonorrhea infection was associated with genital chlamydia or gonorrhea, but 46.5% of such STIs would not have been identified with genital testing alone. Among women with rectal chlamydia or gonorrhea infection, only 20.0% had a recommended repeat rectal test, and of those who had the repeat test, 17.7% were positive.
While testing women for rectal chlamydia and gonorrhea was infrequent, positive rectal tests were often found in women who had negative genital tests. The authors recommend that extragenital chlamydia and gonorrhea testing in at-risk women be increased. They also recommend educating women and healthcare providers about the risks of anal sex and developing a reminder system to prompt physicians to perform follow-up testing at all anatomic sites in women who had a positive genital test.
Study: Ovarian cancer may originate in fallopian tubes
A study published in Nature Communications suggests that high-grade serous ovarian carcinoma (HGSOC) may originate in the fallopian tubes before metastasizing to the patient’s ovaries on average 6.5 years later. The authors performed whole-exome sequence and copy number analyses of laser capture microdissected fallopian tube lesions, ovarian cancers, and metastases. They found that single cell layers of cancer (p53 signatures) and serous tubal intraepithelial carcinomas (STICs) are precursors of ovarian cancer.
The researchers collected tissue samples containing normal cells, ovarian cancers, metastases that had spread elsewhere, and small cancers from the fallopian tubes. These samples came from five women who had been diagnosed with HGSOC. In addition to these samples, the researchers also collected tissue samples from STIC lesions and normal cells from four women who had undergone prophylactic removal of their ovaries and fallopian tubes due to hereditary mutations in the BRCA gene. By staining the small cancers to highlight the cells containing mistakes in the p53 gene, the researchers were able to perform whole-exome genome sequencing on all of the samples. This helped separate the normal genes from cancer-linked DNA errors and helped identify altered DNA in a particular chromosome.
All nine patients showed evidence of identical lost regions of chromosome 17, where the cancer-linked p53 gene is located. This loss is included in the early-stage STIC lesions, which the authors believe suggests that the p53 gene is an early step in ovarian cancer development. The researchers then used multiple statistical models that took the patients’ age at diagnosis into account to determine the amount of time it took for the cancers to form. Their results indicate that ovarian cancers developed from STIC lesions within an average of 6.5 years among the patients analyzed. But once the cancer had reached the ovaries, the disease metastasized rapidly, within 2 years on average. The authors noted that their findings indicate that removal of the fallopian tubes rather than the ovaries in BRCA carriers and non-carriers may be curative as it would eliminate the precursors of ovarian cancer.
The study authors recognized that there were limitations to the study. The study needs to be performed with a larger subject pool to determine whether or not the findings are replicable. In addition, the analysis was limited to ovarian cancers where STICs and other concomitant lesions were identified, which may not be representative of all HGOCs. The precise timing of when potentially malignant cells travel from the fallopian tubes into the ovary is unknown so removal of the tubes may not provide the best risk-reduction. While more research is needed, the researchers hope their findings can eventually be used to help diagnose and treat ovarian cancer much earlier.