Short-term Results of Laparoscopic Transabdominal Preperitoneal Inguinal Hernioplasty in a Developing Country
Tanweer Karim, Vivek K Katiyar, Rabishankar Singh, Subhajeet Dey
Citation Information :
Karim T, Katiyar VK, Singh R, Dey S. Short-term Results of Laparoscopic Transabdominal Preperitoneal Inguinal Hernioplasty in a Developing Country. World J Lap Surg 2017; 10 (3):83-86.
Introduction: Inguinal hernias have plagued mankind for its upright gait since evolution. Around 16% of the patients presenting to surgery outpatient department have inguinal hernias. Various procedures like the use of patients' own tissues or prosthetic meshes have been used in the past to repair inguinal hernia with varying degrees of success. Laparoscopic hernioplasty is the latest technique with several advantages over open procedures like reduced postoperative pain and shorter recovery period. However, steeper learning curve and cost of the procedure have been cited as limiting factor.
Aim: To study the outcome of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair in terms of operating time, postoperative pain, wound complications, and recurrence.
Materials and methods: This is an analysis of patients that underwent TAPP inguinal hernia repair, from January 2013 to May 2015. Case records of 90 patients between 18 and 60 years that underwent TAPP by a single surgical team were followed prospectively. Data regarding operative time, complications, immediate postoperative pain, chronic groin pain, recurrence, and sensory disturbance were recorded and evaluated.
Results: All the patients were males aged from 18 to 60 years. Mean operative time was 60 minutes (40–120 minutes). Postoperative pain as assessed by visual analog scale (VAS) 6 hours after has been low (mean: 2). Chronic pain occurred in 2 patients (2.22%), but that has not affected routine work or mobility.
Conclusion: Short-term results of TAPP hernia repair using mesh demonstrated to be an effective and safe procedure with low prevalence of chronic pain that was generally of a mild, infrequent nature. Intraoperative bleeding and use of postoperative analgesia were considerably less. There was no incidence of early recurrence. Learning curve is not so steep as claimed, and considering advantages, the cost of the procedure should not be a limiting factor even in a developing country.
Patino, JF. A history of the treatment of hernia. In: Nyhus LM, Condon RE, editors. Hernia. 4th ed. Philadelphia (PA): JB Lippincott Company; 1995. pp. 3-15.
Horeyseck G, Roland F, Rolfes N. ‘Tension-free’ repair of inguinal hernia: laparoscopic (TAPP) versus open (Lichtenstein) repair. Chirurg 1996 Oct;67(10):1036-1040.
Wellwood J, Sculpher MJ, Stoker D, Nicholls GJ, Geddes C, Whitehead A. Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost. BMJ 1998 Jul;317(7151):103-110.
Wauschkuhn CA, Schwarz J, Boekeler U, Bittner R. Laparoscopic inguinal hernia repair: gold standard in bilateral hernia repair? Results of more than 2800 patients in comparison to literature. Surg Endosc 2010 Dec;24(12): 3026-3030.
Schumpelick V, Treutner KH, Arlt G. Inguinal hernia repair in adults. Lancet 1994 Aug;344(8919):375-379.
Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin North Am 2003 Oct;83(5):1045-1051, v-vi.
Vale L, Ludbrook A, Grant A. Assessing the costs and consequences of laparoscopic vs. open methods of groin hernia repair: a systematic review. Surg Endosc 2003 Jun;17(6): 844-849.
Feliu X, Claveria R, Besora P, Camps J, Fernández-Sallent E, Viñas X. Bilateral inguinal hernia repair: laparoscopic or open approach? Hernia 2011 Feb;15(1):15-18.
Tanphiphat C, Tanprayoon T, Sangsubhan C, Chatamra K. Laparoscopic vs open inguinal hernia repair. A randomized, controlled trial. Surg Endosc 1998 Jun;12(6):846-851.
Yang C, Zhang H, Pu J, Mei H, Zheng L, Tong Q. Laparoscopic vs open herniorrhaphy in the management of pediatric inguinal hernia: a systemic review and meta-analysis. J Pediatr Surg 2011 Sep;46(9):1824-1834.
McCormack K, Scott NW, Go PM, Ross S, Grant AM, EU Hernia Trialists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2003;1:CD001785.
EU Hernia Trialists Collaboration. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000 Jul;87(7):860-867.
Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R, Dunlop D, Gibbs J. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004 Apr;350(18): 1819-1827.
The MRC laparoscopic groin hernia trial group. Laparoscopic versus open repair of groin hernia: a randomised comparison. Lancet 1999 Jul;354(9174):185-190.
Memon MA, Cooper NJ, Memon B, Memon MI, Abrams KR. Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair. Br J Surg 2003 Dec;90(12):1479-1492.
Fujita F, Lahmann B, Otsuka K, Lyass S, Hiatt JR, Phillips EH. Quantification of pain and satisfaction following laparoscopic and open hernia repair. Arch Surg 2004 Jun;139(6):596-600, discussion 600-602.
Karthikesalingam A, Markar SR, Holt PJ, Praseedom RK. Meta-analysis of randomized controlled trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia. Br J Surg 2010 Jan;97(1):4-11.
Hamza Y, Gabr E, Hammadi H, Khalil R. Four Arm RCT Comparing Open and Laparoscopic Hernia Repair. Int J Surg 2010;8(1):25-28.
Leibl BJ, Jäger C, Kraft B, Kraft K, Schwarz J, Ulrich M, Bittner R. Laparoscopic Hernia Repair–TAPP or/and TEP. Langenbeck's Archives of Surgery 2005 Feb;390(2):77-82.
Felix EL, Michas CA, Gonzalez MH Jr. Laparoscopic hernioplasty: TAPP vs TEP. Surg Endosac 1995 Sep;9(9):984-989.
Swanstorm LL. Laparoscopic Herniorrhaphy: Surg Clin North Am 1996 Jun;76(3):483-491.
Eklund A, Montgomery A, Bergkvist L, Rudberg C, Swedish Multicentre Trial of Inguinal Hernia Repair by Laparoscopy (SMIL) study group. Chronic pain 5 years after randomized comparison of laparoscopic and Lichtenstein inguinal hernia repair. Br J Surg 2010 Apr;97(4):600-608.
Bignell M, Partridge G, Mahon D, Rhodes M. Prospective randomized trial of laparoscopic (trans-abdominal pre-peritoneal-TAPP) versus open (mesh) repair for bilateral and recurrent inguinal hernia: incidence of chronic groin pain and impact on quality of life: results of 10 year follow-up. Hernia 2012 Dec;16(6):635-640.
Liem MS, van Duyn EB, van der Graaf Y, van Vroonhoven TJ; Coala Trial Group. Recurrences after conventional anterior and laparoscopic inguinal hernia repair: a randomized comparison. Ann Surg 2003;237(1):136-141.
McCormack K, Wake B, Perez J, Fraser C, Cook J, McIntosh E. Laparoscopic surgery for inguinal hernia repair: systematic review of effectiveness and economic evaluation. Health Technol Assess 2005 Apr;9(14):1-203, iii-iv.
Picot J, Jones J, Colquit JL, Gospodarevskaya E, Loveman E, Baxter L, Clegg AJ. The clinical effectiveness and cost effectiveness of bariatric (weight loss) surgery for morbid obesity: a systematic review and economic evaluation. Health Technol Assess 2009 Sep;13(41):1-190.
Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA 2003 Jan;289(2):187-193.
Yanovski SZ. Overweight, obesity, and health risk: National Task Force on the Prevention and Treatment of Obesity. Arch Intern Med 2000 Apr;160(7):898-904.
Franco JVA, Ruiz PA, Palermo M, Gagner M. A review of studies comparing three laparoscopic procedures in bariatric surgery: sleeve gastrectomy, roux-en-y gastric bypass and adjustable gastric banding. Obesity Surgery 2011;21(9):1458-1468.
Karlsson J, Taft C, Rydén A, Sjöström L, Sullivan M. Ten-year trends in health-related quality of life after surgical and conventional treatment for severe obesity: the SOS intervention study. Int J Obes 2007 Aug;31(8):1248-1261.
Wang, Y, Beydoun, MA. The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev 2007;29:6-28.
Health Implications of Obesity. National Institute of Health consensus development conference statement. Ann Inter Med 1985 Dec;103(6 (Pt 2)):1073-1077.
Frachetti, KJ, Goldfine, AB. Bariatric surgery for diabetes management. Curr Opin Endocrinol Diabetes Obes 2009 Apr;16(2):119-124.
Fritscher LG, Canani S, Mottin CC, Fritscher CC, Berleze D, Chapman K, Chatkin JM. Bariatric surgery in the treatment of obstructive sleep apnea in morbidly obese patients. Respiration 2007;74(6):647-652.
Shields M, Carroll MD, Ogden CL. Adult obesity prevalence in Canada and the United States. NCHS Data Brief 2011 Mar;(56):1-8.
Sjostrom, L., Peltonen, M., Jacobson, P. et al, Bariatric surgery and long-term cardiovascular events. JAMA. 2012;307: 56-65.
Adams TD, Davidson LE, Litwin SE, Kolotkin RL, La Monte MJ, Pendleton RC, Strong MB, Vinik R, Wanner NA, Hopkins PN, et al. Health benefits of gastric bypass surgery after 6 years. JAMA 2012 Sep;308(11):1122-1131.
Flum DR, Belle SH, King WC, Wahed AS, Berk P, Chapman W, Pories W, Courcoulas A, McCloskey C, Mitchell J, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 2009 Jul;361(5):445-454.
Castillo OA, Vitagliano G, Díaz M, Sánchez-Salas R. Port-site metastasis after laparoscopic partial nephrectomy: case report and literature review. J Endourol 2007 Apr;21(4): 404-407.
Manabe D, Saika T, Ebara S, Uehara S, Nagai A, Fujita R, Irie S, Yamada D, Tsushima T, Nasu Y, et al.; Okayama Urological Research Group, Okayama, Japan. Comparative study of oncologic outcome of laparoscopic nephroureterectomy and standard nephroureterectomy for upper urinary tract transitional cell carcinoma. Urology 2007 Mar;69(3):457-461.
Dhobada S, Patankar S, Gorde V. Port-site metastasis after laparoscopic radical nephrectomy for renal-cell carcinoma: case report. J Endourol 2006 Feb;20(2):119-122.
Kobori Y, Shigehara K, Amano T, Takemae K. [Port site metastasis of primary adenocarcinoma of the renal pelvis after a laparoscopic nephrectomy: a case report]. Hinyokika Kiyo 2005 Feb;51(2):105-108.
El-Tabey NA, Shoma AM. Port site metastases after robot assisted laparoscopic radical cystectomy. Urology 2005 Nov;66(5):1110.
Porpiglia F, Fiori C, Bovio S, Destefanis P, Alì A, Terrone C, Fontana D, Scarpa RM, Tempia A, Terzolo M. Bilateral adrenalectomy for Cushing's syndrome: a comparison between laparoscopy and open surgery. J Endocrinol Invest 2004 Jul-Aug;27(7):654-658.
Chueh S-CJ, Tsaia I-D, Laia M-K. Solitary port-site metastasis after laparoscopic bilateral nephroureterectomy for transitional cell carcinoma in a renal transplant recipient. Transplant Proc 2004 Nov;36(9):2697-2698.
Naderi N, Nieuwenhuijzen JA, Bex A, Kooistra A, Horenblas S. Port site metastasis after laparoscopic nephro-ureterectomy for transitional cell carcinoma. Eur Urol 2004 Oct;46(4): 440-441.
Iwamura M, Tsumura H, Matsuda D, Kurosaka S, Yoshida K, Baba S. Port site recurrence of renal cell carcinoma following retroperitoneoscopic radical nephrectomy with manual extraction without using entrapment sac or wound protector. J Urol 2004 Mar;171(3):1234-1235.
Matsui Y, Ohara H, Ichioka K, Terada N, Yoshimura K, Terai A. Abdominal wall metastasis after retroperitoneoscopic assisted total nephroureterectomy for renal pelvic cancer. J Urol 2004 Feb;171(2 Pt 1):793.
Saraiva P, Rodrigues H, Rodrigues P. Portsite recurrence after laparoscopic adrenalectomy for metastatic melanoma. Int Braz J Urol 2003 Nov-Dec;29(6):520-521.
Chen YT, Yang SSD, Hsieh CH, Wang CC. Hand port-site metastasis of renal-cell carcinoma following hand-assisted laparoscopic radical nephrectomy: case report. J Endourol 2003 Nov;17(9):771-775.
Wang PH, Yen MS, Juang CM, Chen YJ, Chao HT, Yuan CC. Intraperitoneal cancer spread after laparoscopic cystectomy for mature teratoma with malignant transformation. Eur J Gynaecol Oncol 2002;23(2):131-132.
Castilho LN, Fugita OE, Mitre AI, Arap S. Port site tumor recurrences of renal cell carcinoma after videolaparoscopic radical nephrectomy. J Urol 2001 Feb;165(2):519.
Landman J, Clayman RV. Re: port site tumor recurrences of renal cell carcinoma after videolaparoscopic radical nephrectomy (letter). J Urol 2001 Aug;166(2):629-630.
Andersen JR, Steven K, Smith AD. Implantation metastasis after laparoscopic biopsy of bladder cancer. J Urol 1995 Mar;153(3 Pt 2):1047-1048.
Maciel GA, Soares Junior (Jr), Alves Da Motta EL, Abi Haidar M, De Lima AR, Baracat EC. Nonobese women with polycystic ovary syndrome respond better than obese women to treatment with metformin. Fertil Steril 2004;81:355-60.
Kumari AS, Haq A, Jayasundaram R, Abdel-Wareth LO, Al Haija SA, Alvarez M. Metformin monotherapy in lean women with polycystic ovary syndrome. R & Pro D. Biomed Online 2005;10:100-04.
Crave JC, Fimbel S, Lejeune H, Cugnardey N, Dechaud H, Pugeat M. Effects of diet and metformin administration on sex hormone binding globulin, androgens, and insulin in hirsute and obese women. J Clin Endocrinol Metab 1995;80:2057-62.
Pasquali R, Gambineri A, Biscotti D, Vicennati V, Gagliardi L, Colitta D, Fiorini S, Cognigni GE, Filicori M, Morselli-Labate AM. Effect of long-term treatment with metformin added to hypocaloric diet on body composition, fat distribution, and androgen and insulin levels in abdominally obese women with and without the polycystic ovary syndrome. J Clin Endocrinol Metab 2000;85:2767-74.
Ehrmann DA, Cavaghan MK, Imperial J, Sturis J, Rosenfield RL, Polonsky KS. Effects of metformin on insulin secretion, insulin action, and ovarian steroidogenesis in women with polycystic ovary syndrome. J Clin Endocrinol Metab 1997;82:524-30.
De Leo V, la Marca A, Ditto A, Morgante G, Cianci A. Effects of metformin on gonadotropin-induced ovulation in women with polycystic ovary syndrome. Fertil Steril 1999;72:282-85.
Yarali H, Yildiz B, Demirol A, Zeyneloglu HB, Yigit N, Bukulmez O, Koray Z. Co-administration of metformin during rFSH treatment in patients with clomiphene citrate-resistant polycystic ovarian syndrome: A prospective randomized trial. Hum Reprod 2002;17:289-94.
Palomba S, Falbo A, Orio F (Jr), Manguso F, Russo T, Tolino A, Colao A, Dale B, Zullo F. A randomized controlled trial evaluating metformin pretreatment and coadministration in nonobese insulin-resistant women with polycystic ovary syndrome treated with controlled ovarian hyperstimulation plus timed intercourse or intrauterine insemination. Hum Reprod 2005 Jun 15 (Epub ahead of print).
Stadtmauer LA, Toma SK, Riehl RM, Talbert LM. Metformin treatment of patients with polycystic ovary syndrome undergoing in vitro fertilization improves outcomes and is associated with modulation of the insulin-like growth factors. Fertil Steril 2001;75:505-09.
Stadtmauer LA, Toma SK, Riehl RM, Talbert LM. Impact of metformin therapy on ovarian stimulation and outcome in ‘coasted’ patients with polycystic ovary syndrome undergoing in vitro fertilization. Reprod Biomed Online 2002;5:112-16.
Glueck CJ, Phillips H, Cameron D, Sieve-Smith L, Wang P. Continuing metformin throughout pregnancy in women with polycystic ovary syndrome appears to safely reduce firsttrimester spontaneous abortion: A pilot study. Fertil Steril 2001;75:46-52.
Kocak M, Caliskan E, Simsir C, Haberal A. Metformin therapy improves ovulatory rates, cervical scores, and pregnancy rates in clomiphene citrate-resistant women with polycystic ovary syndrome. Fertil Steril 2002;77:101-06.
Cole PA, Robinson CH. Mechanism and inhibition of cytochrome P-450 aromatase. J Med Chem 1990;33:2933-42.
Akhtar M, Njar VC, Wright JN. Mechanistic studies on aromatase and related C-C bond cleaving P-450 enzymes. J Steroid Biochem Mol Biol 1993;44:375-87.
Palter SF, Tavares AB, Hourvitz A, Veldhuis JD, Adashi EY. Are estrogens of import to primate/human ovarian folliculogenesis? Endocr Rev 2001;22:389-424.
Weil S, Vendola K, Zhou J, Bondy CA. Androgen and follicle stimulating hormone interactions in primate ovarian follicle development. J Clin Endocrinol Metab 1999;84:2951-56.
Vendola KA, Zhou J, Adesanya OO, Weil SJ, Bondy CA. Androgens stimulate early stages of follicular growth in the primate ovary. J Clin Invest 1998;101:2622-29.
Mitwally MF, Casper RF. Aromatase inhibitors for the treatment of infertility. Expert Opin Investig Drugs 2003;12:353-71.
Mitwally MF, Biljan MM, Casper RF. Pregnancy outcome after the use of an aromatase inhibitor for ovarian stimulation. Am J Obstet Gynecol 2005;192:381-86.
Mitwally MFM, Casper RF. The use of aromatase inhibitor for induction of ovulation in cases of clomiphene citrate failure. Curr Opin Obstet Gynecol 2002;14:255-63.
Mitwally MF, Casper RF. Use of an aromatase inhibitor for induction of ovulation in patients with an inadequate response to clomiphene citrate. Fertil Steril 2001;75:305-09.
Sammour A, Bijan MM, Tan SL, Tulandi T. Prospective randomised trial comparing the effects of letrazole (LE) and clomiphene citrate (CC) on follicular development, endometrial thickness and pregnancy rate in patients undergoing superovulation prior to intrauterine insemination (IUI). Fertil Steril 2001;76(Suppl 1):S110.
Mitwally MF, Casper RF. Single-dose administration of an aromatase inhibitor for ovarian stimulation. Fertil Steril 2005;83:229-31.
Fisher SA, Reid RL, Van Vugt DA, Casper RF. A randomized double-blind comparison of the effects of clomiphene citrate and the aromatase inhibitor letrozole on ovulatory function in normal women. Fertil Steril 2002;78:280-85.
Fatemi HM, Kalibianakis E, Tournaye H, Camus M, Van Steirteghem AC, Devroey P. Clomiphene citrate vs letrozole for ovarian stimulation: A pilot study. Reprod Biomed Online 2003;7:543-46.
Hu Y, Cortvrindt R, Smitz J. Effects of aromatase inhibition on in vitro follicle and oocyte development analyzed by early preantral mouse follicle culture. Mol Reprod Dev 2002;61: 549-59.
Shetty G, Krishnamurthy H, Krishnamurthy HN, Bhatnagar S, Moudgal NR. Effect of estrogen deprivation on the reproductive physiology of male and female primates. J Steroid Biochem Mol Biol 1997;61:157-66.
Mitwally MF, Casper RF. Aromatase inhibition reduces gonadotrophin dose required for controlled ovarian stimulation in women with unexplained infertility. Hum Reprod 2003;18:1588-97.
Mitwally MF, Casper RF. Aromatase inhibition improves ovarian response to follicle-stimulating hormone in poor responders. Fertil Steril 2002;77:776-80.
Goswami SK, Das T, Chattopadhyay R, Sawhney V, Kumar J, Chaudhury K, Chakravarty BN, Kabir SN. A randomized single blind controlled trial of letrozole as a low-cost IVF protocol in women with poor ovarian response: A preliminary report. Hum Reprod 2004;19:2031-35.
Newkirk KM, Chandler HL, Parent AE, et al. Ultraviolet radiation-induced corneal degeneration in 129 mice. Toxicol Pathol 2007;35:819-26.
Pettenati MJ, Sweatt AJ, Lantz P, et al. The human cornea has a high incidence of acquired chromosome abnormalities. Hum Genet 1997;101:26-29.
Snibson GR. Collagen cross-linking: A new treatment paradigm in corneal disease—a review. Clin Experiment Ophthalmol 2010;38:141-53.
Spoerl E, Raiskup-Wolf F, Kuhlisch E, Pillunat LE. Cigarette smoking is negatively associated with keratoconus. J Refract Surg 2008;24:S737-40.
Rabinowitz YS, Nesburn AB, McDonnell PJ. Videokeratography of the fellow eye in unilateral keratoconus. Ophthalmology 1993;100:181-86.
Goodrich DW, Lee WH. The molecular genetics of retinoblastoma. Cancer Surv 1990;9:529-54.
Moodaley LC, Woodward EG, Liu CS, Buckley RJ. Life expectancy in keratoconus. Br J Ophthalmol 1992;76:590-91.
Honein MA, Dawson AL, Petersen EE, Jones AM, Lee EH, Yazdy MM, Ahmad N, Macdonald J, Evert N, Bingham A, et al. Birth defects among fetuses and infants of US women with evidence of possible Zika virus infection during pregnancy. JAMA 2017 Jan 3;317(1):59-68.
Chervenak FA, Jeanty P, Cantraine F, Chitkara U, Venus I, Berkowitz RL, Hobbins JC. The diagnosis of fetal microcephaly. Am J Obstet Gynecol 1984 Jul 1;149(5):512-517.
Papageorghiou AT, Thilaganathan B, Bilardo CM, Ngu A, Malinger G, Herrera M, Salomon LJ, Riley LE, Copel JA. ISUOG Interim Guidance on ultrasound for Zika virus infection in pregnancy: information for healthcare professionals. Ultrasound Obstet Gynecol 2016 Apr;47(4):530-532.
Chibueze EC, Parsons AJ, Lopes KD, Yo T, Swa T, Nagata C, Horita N, Morisaki N, Balogun OO, Dagvadorj A, et al. Diagnostic accuracy of ultrasound scanning for prenatal microcephaly in the context of Zika virus infection: a systematic review and meta-analysis. Sci Rep 2017 May 23;7(1):2310.
Cordeiro MT. Zika virus: laboratory diagnosis. In: Zika in focus. Springer International Publishing; 2017. pp. 59-62.
Mlakar J, Korva M, Tul N, Popović M, Poljšak-Prijatelj M, Mraz J, Kolenc M, Resman Rus K, Vesnaver Vipotnik T, Fabjan Vodušek V, et al. Zika virus associated with microcephaly. N Engl J Med 2016 Mar 10;374(10):951-958.
Zare Mehrjardi M, Keshavarz E, Poretti A, Hazin AN. Neuroimaging findings of Zika virus infection: a review article. Jpn J Radiol 2016 Dec;34(12):765-770.
Oliveira Melo AS, Malinger G, Ximenes R, Szejnfeld PO, Alves Sampaio S, Bispo de Filippis AM. Zika virus intrauterine infection causes fetal brain abnormality and microcephaly: tip of the iceberg? Ultrasound Obstet Gynecol 2016 Jan;47(1):6-7.
Brasil P, Pereira JP Jr, Moreira ME, Ribeiro Nogueira RM, Damasceno L, Wakimoto M, Rabello RS, Valderramos SG, Halai UA, Salles TS, et al. Zika virus infection in pregnant women in Rio de Janeiro. N Engl J Med 2016 Dec 15;375(24):2321-2334.