Objectives. - To investigate the determinants of Group B streptococcus (GBS) maternal colonization, as well as factors associated with its vertical transmission.Patients and methods. - Case-control study on all singletons pregnancies delivered beyond at least 24 weeks of amenorrhoea in Southern Reunion maternities for which GBS screening was known. Multiple logistic regression analysis using 2004-2007 dataset of South Reunion birth registers.Results. - Out of 17,430 women delivered between 1st January 2004 and 31st December 2007, 2911 (16.7%) carried GBS. In a model adjusted on antenatal care, risk groups for GBS carriage were the women indigenous from another island of the Indian Ocean than Reunion (OR: 1.29, CI95%: 1.05-1.57) and obese women (body mass index >= 30, OR: 1.19, CI95%: 1.03-1.18). Protective factors included birthplace in mainland France (OR: 0.82, CI95%: 0.69-0.97) and underweight (OR: 0.81; CI95%: 0.69-0. 95). In a model controlling for a composite obstetrical variable delineating the protective roles of C-section and antibioprophylaxis as well as the putative role of meconium-stained fluids (thin, thick or fetid), all previously found in our setting, three key factors were independently associated with GBS vertical mother-to-child transmission: obesity (OR: 1.48, CI95%: 1.05-2.09), fetal tachycardia (OR: 4.92, CI95%: 2.79-8.68) and late preterm birth (35 to 36 wks, OR: 2.14, CI95%: 1.32-3.45).Conclusion. - These findings strengthen the putative roles of corpulence and ethnicity in GBS acquisition previously found in the United States, while confirming an authentic role of obesity in its vertical transmission, independently of other classical cofactors lighted by our study. (C) 2011 Elsevier Masson SAS. All rights reserved.

PURPOSE:Since February 2005, an outbreak of Chikungunya virus (CHIKV) infections occurred in Reunion Island. It is transmitted by the Aedes albopictus mosquito. Neonatal cases observations suggest possible fetal transmission during pregnancy. MATERIAL [corrected] AND METHODS. Observations made in 160 pregnant mothers infected by CHIKV between June 1, 2005 and February 28, 2006, in the south of Reunion island were recorded.RESULTS:Three of nine miscarriages before 22 weeks of gestation could be attributed to the virus. 3,829 births took place during this time. Among the 151 infected women, 118 were viremia negative at delivery, and none of the newborns showed any damage. Among the 33 with positive viremia at delivery, 16 newborns (48.5%) presented neonatal Chikungunya.DISCUSSION:Though fetal contamination risks appear to be rare before 22 weeks of gestation, they are potentially dangerous. After 22 weeks gestation, newborns infection occurs if the mother is viremia positive at delivery. Transplacental transmission is suspected, but the pathogenic mechanism remains unknown.

L’île de la Réunion connaît depuis février 2005 une importante épidémie d’infections à virus Chikungunya (CHIKV), transmises par le moustique Aedes albopictus. En raison de la découverte des formes néonatales, il nous est apparu nécessaire d’évaluer les conséquences de l’infection chez la femme enceinte, et notamment le risque de transmission materno-fœtale, jamais décrit à ce jour. Étude de cohorte rétrospective concernant l’issue de 160 grossesses de patientes infectées, dans le sud de la Réunion, entre le 1er juin 2005 et le 28 février 2006. Parmi 9 cas de mort fœtale de moins de 22 SA, l’imputabilité du virus est évoquée dans 3 cas. 3 829 accouchements ont eu lieu pendant cette période. Parmi 151 patientes infectées pendant la grossesse, 118 femmes ont accouché en dehors de la période virémique ; aucun nouveau-né n’a présenté d’atteinte virale. 33 femmes ont accouché en période virémique, 16 nouveau-nés (48,5 %) ont présenté un Chikungunya néonatal. Le risque de contamination fœtale avant 22 SA semble rare, mais grave. Après 22 SA, les cas d’atteintes néonatales sont observés uniquement chez les nouveau-nés des patientes en période virémique. Un passage transplacentaire du virus semble probable. Sa physiopathologie reste inconnue. Since February 2005, an outbreak of Chikungunya virus (CHIKV) infections occurred in Reunion Island. It is transmitted by the Aedes albopictus mosquito. Neonatal cases observations suggest possible fetal transmission during pregnancy. Observations made in 160 pregnant mothers infected by CHIKV between June 1, 2005 and February 28, 2006, in the south of Reunion island were recorded. Three of nine miscarriages before 22 weeks of gestation could be attributed to the virus. 3 829 births took place during this time. Among the 151 infected women, 118 were viremia negative at delivery, and none of the newborns showed any damage. Among the 33 with positive viremia at delivery, 16 newborns (48.5%) presented neonatal Chikungunya. Though fetal contamination risks appear to be rare before 22 weeks of gestation, they are potentially dangerous. After 22 weeks gestation, newborns infection occurs if the mother is viremia positive at delivery. Transplacental transmission is suspected, but the pathogenic mechanism remains unknown.

A 74-year-old woman (43 kg, 139 cm) was admitted to the Montreal Heart Institute for unstable angina. She had had left carotid endarterectomy 4 years earlier and was awaiting surgery for right carotid occlusive disease in another hospital. An unstable angina syndrome developed for which she was referred to our center. A coronary angiogram revealed a proximal occlusion of the left anterior descending artery, severe stenosis of the left circumflex artery with poor runoff, and a 70% stenosis of the dominant right coronary artery. Left ventricular contraction was within normal limits at echocardiography. She was scheduled for a double coronary artery bypass of the left anterior descending and right coronary arteries without extracorporeal bypass to minimize the risk of stroke. Anesthesia was induced with sufentanil, midazolam, and pancuronium. The blood pressure was 180/75 mm Hg and the central venous pressure, 5 mm Hg. Catheterization (Swan-Ganz catheter, Baxter Healthcare Corp, Edwards Division, Santa Ana, Calif) showed a normal pulmonary artery pressure (19/9 mm Hg) and cardiac output was 2.4 L/min (cardiac index: 1.9 L · min–1 · m–2). The initial blood gas values were within normal limits. Concomitantly to sternotomy and the beginning of the internal thoracic artery dissection, a right lower thigh incision was performed for endoscopic saphenectomy (Vasoview, Uniport Endoscopic Vessel Harvesting System, Origin Medsystems, Inc, a subsidiary of Eli Lilly and Company, Indianapolis, Ind). After identification of the internal saphenous vein and insertion of a port, a seal was achieved at the level of the knee incision and carbon dioxide insufflation was initiated at a flow of 2 L/min to obtain a pressure of 15 mm Hg. The saphenous vein was dissected up to the level of the femoral crux. During isolation of branches, 1 small collateral vein was torn off near the crux, 8 minutes after the start of the endoscopic dissection. Simultaneously, systemic blood pressure suddenly fell to 55 mm Hg systolic (Fig 1, A ), followed by ischemic changes (depression of the ST segment in leads DII and V5 , Fig 1, B ). Capnography showed an immediate rise of end-tidal carbon dioxide to 48mmHg (Fig 1, D ). Carbon dioxide insufflation was immediately discontinued and the internal thoracic artery retractor was taken down to rule out any cardiac compression, but there was no improvement in the hemodynamic status. A sternal retractor was put in and cardiac dissection was begun as the extracorporeal circuit was primed. One hundred micrograms of phenylephrine hydrochloride (Neo-Synephrine) was administered and a perfusion of norepinephrine was started. The blood gas sample drawn during the hypotensive episode showed respiratory acidosis with a pH of 7.27 and a PCO 2 level of 64 mm Hg. There were no changes in ventilation pressures and the arterial oxygen saturation was 100%. Pulmonary artery pressure rose to a level of 60mmHg systolic with a central venous pressure of 19 mm Hg (Fig 1, C ). Ventilatory rate and tidal volume were increased with an inspired oxygen fraction of 100%. Ischemic changes regressed as the blood pressure was restored. The total duration of hypotension was 4 minutes. After hemodynamic stabilization without further need for inotropic support, the harvesting of the left internal thoracic artery was resumed and the saphenous vein was taken out by the bridging technique. The 2 bypasses were completed uneventfully off-pump with mechanical stabilization. The patient was extubated 12 hours after the operation with no evidence of neurologic deficit or elevation of serum creatine kinase MB levels. The patient was discharged on postoperative day 6 without complications. The internal saphenous vein used for coronary artery bypass is usually harvested by the open technique, allowing direct visualization. Many potential complications may occur with the traditional technique, including dehiscence, skin necrosis, or wound infection. These complications are increased in the case of obesity, diabetes mellitus, and peripheral vascular disease. To reduce these complications and to improve the functional result and, to a lesser degree, the cosmetic appearance, new techniques are now available with the current trend of minimally invasive coronary surgery. These include the classic bridging technique, the tunneling technique, and endoscopic harvesting with or without gas insufflation. Serious venous gas embolism, a rare complication of endoscopic procedures with an incidence of about 1 in 7500 cases in laparoscopic surgery,1Herron DM Vernon JK Gryska PV Reines HD Venous gas embolism during endoscopy.Surg Endosc. 1999; 13: 276-279Crossref PubMed Scopus (32) Google Scholar has not yet been reported in endoscopic saphenectomy. The mechanisms of carbon dioxide embolism usually involve absorption into the circulation, carbon dioxide being highly soluble in blood, or, more seriously, direct entry of gas into the vascular bed generally via an injury to a vessel. This is dependent on the gradient between the central venous pressure and the pressure of insufflation, as demonstrated by Bazin and colleagues2Bazin JE Gillart T Rasson P Conio N Aigouy L Schoeffler P Haemodynamic conditions enhancing gas embolism after venous injury during laparoscopy: a study in pigs.Br J Anaesth. 1997; 78: 570-575Crossref PubMed Scopus (50) Google Scholar during laparoscopy in a porcine model. By extrapolation, one can assume that the mechanism is similar in case of injury to the saphenous vein and in the presence of relative hypovolemia, as in our patient. Similarly, gas embolism has been reported during hysteroscopy with patients in the Trendelenburg position.3Brooks PG Venous air embolism during operative hysteroscopy.J Am Assoc Gynecol Laparosc. 1997; 4: 399-402Abstract Full Text PDF PubMed Scopus (41) Google Scholar This important yet simple factor should be taken into consideration and the operating table should be set in the Fowler position, which facilitates the harvesting of the internal thoracic artery pedicle. Manifestations of carbon dioxide embolism are “gas lock” in the right atrium, pulmonary gas embolism, paradoxic embolism with or without patent foramen ovale with coronary embolism or neurologic disturbances, bradycardia or arrhythmia, cardiovascular collapse resulting from acute reduction in the peripheral resistance, and cardiopulmonary arrest.4Joris JL Anesthetic management of laparoscopy.in: Anesthesia. : Churchill Livingstone, New York1994: 2011-2029Google Scholar The detection of carbon dioxide embolism is based on the widely established end-tidal carbon dioxide monitoring. Indeed, carbon dioxide embolization causes a biphasic change in end-tidal carbon dioxide.4Joris JL Anesthetic management of laparoscopy.in: Anesthesia. : Churchill Livingstone, New York1994: 2011-2029Google Scholar The decrease in end-tidal carbon dioxide is usually encountered in case of embolism, being preceded by an initial increase resulting from pulmonary excretion of carbon dioxide, as in our patient (Fig 1, D ). Transesophageal echocardiography, increasingly used in modern cardiac surgery, is a more sensitive tool for detecting gas bubbles during laparoscopy5Mann C Boccara G Fabre JM Grevy V Colson P The detection of carbon dioxide embolism during laparoscopy in pigs: a comparison of transesophageal Doppler and end-tidal carbon dioxide monitoring.Acta Anaesthesiol Scand. 1997; 41: 281-286Crossref PubMed Scopus (21) Google Scholar and could be used routinely in this clinical setting, allowing in addition the evaluation of regional contraction. Furthermore, clinical evaluation using transesophageal echocardiography is in progress in our center to assess the precise incidence of this phenomenon. We are aware that the majority of episodes are not clinically significant, as demonstrated in a series of laparoscopic cholecystectomies.6Derouin M Couture P Boudreault D Girard D Gravel D Detection of gas embolism by transesophageal echocardiography during laparoscopic cholecystectomy.Anesth Analg. 1996; 82: 119-124PubMed Google Scholar If hypercapnia occurs, the endoscopic procedure insufflation should be immediately suspended and simultaneous compression of the proximal venous axis at the groin should be instituted. Trendelenburg position with tilting of the patient to the left, pharmacologic manipulations, and central venous pressure elevation by volume repletion to restore the hemodynamic status should be implemented promptly and the operation resumed with conversion to the open or bridging technique. In case of a major embolism, aspiration of gas from the right ventricle via the thermodilution catheter or via a direct puncture using a needle may relieve a gas lock in the right ventricle.1Herron DM Vernon JK Gryska PV Reines HD Venous gas embolism during endoscopy.Surg Endosc. 1999; 13: 276-279Crossref PubMed Scopus (32) Google Scholar In refractory cases, cardiopulmonary bypass may be required. In the case reported here, the conjunction of multiple factors, that is, injury to the vein in an elderly woman with low weight and friable tissues, with concomitant hypovolemia in the supine position, enabled gas embolism to occur. No untoward consequences occurred because of vigilant intraoperative monitoring and prompt intervention. Knowledge of the predisposing factors and preventive measures should keep the rate of this complication low and enable patients to have the full benefits of this advance in coronary artery bypass surgery.