infection during pregnancy.ppt

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Perinatal infections account for 2% - 3% of

birth defects which arise form a spectrum oforganisms & have varying modes of

transmission .

Not all birth defects are routinely screened

for during prenatal care, but all birth defectsdo pose a risk to the fetus or neonate .

The variation in residual status of the

mother after primary infection should be

noticed .Caesarian section delivery is

recommended only for mothers who have

active genital lesions at the time of delivery.


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mostly viral

previously known as ( TORCH)infections: Toxoplasmosis, Other(syphilis), Rubella, CMV, Herpes( andHepatitis), the first four are acquired

antenately, herpes and hepatitis usuallyperinately.

The term TORCH is now obsolete asother agents are important ( e.g. HIV).

Most fetuses if infected during the firsttrimester will suffer from a syndrome ofcongenital malformation.


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RUBELLA: ( German Measles).

The fetus is most at risk in the first 16 weeksgestation. Causative Organism: Rubella virus ( togaviruses

RNA). Route of Infection : via respiration as the virus is

concentrated in the nasopharyngeal secretions. Incubation Period: 14-21 days. Symptoms: Mild pyrexia, arthralgia, rash which

persists for a week and always affecting the face,lymphadenopathy in the postauricular, deep cervicaland suboccipital L.N. precedes the appearance of

the rash and persists for 3 weeks. Risk of fetal transmission:-50-60% of fetuses are affected if maternal primaryinfection is in the first month of gestation.-22% in the second month, 6-10% in the third tofourth month.


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Gestational age in weeks Fetal infection %

< 11 90 %

11-12 30 %

13-14 20 %

15-16 10 %

> 16 5 %

Despite of availability of effective vaccines up

to 20% of women of child bearing age dontpossess rubella antibody.

Risk of Fetal infection %


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The congenital rubella syndrome includes:

a-Neuropathic changes:

1.microcephaly.2.mental& motor retardation.

3.meningoencephalitis

4.cerebral palsy.

5.cerebral calcification

b-Cardiovascular lesions:1.persistent ducats arteiosis

2.pulmonary artery stenosis

3.atrioventricular septal defects

c-Ocular defects:

1.cataract

2.microphthalmia

3.retinal changes, retinitis

4.blindness


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The congenital rubella syndrome

includes:d- Inner ear problems

1.sensorineural

e- Symmetric intrauterine growth

retardation.F- Other:

1.purpura

2.jaundice

3.hepatosplenomegaly

4.thrombocytopenia


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Routine antenatal screening:

vaccination( avoid pregnancy for 3 months). Maternal screening: routine rubella IgG

in the first trimester, if infectionsuspected perform rubella IgM.

Prevention:- vaccination before or after pregnancy

( not during).- in acute infection: droplet precautions.

- in neonatal infection: contactprecautions.


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CYTOMEGALOVIRUS (CMV) in UK CMV is commoner cause of cong.

Retardations than rubella.

Infects 50%to 60% of women ofchildbearing age.

Causative agent: CMV (Herpes virusDNA).

Maternal symptoms : usually mild orasymptomatic, fever with/withoutlymphadenopathy, sore throat.


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Transmission:

direct: person to person contact ( saliva, milk,urine, semen, tears, stools, blood, cervical andvag. Secretion.).

indirect: contaminated fomites.

in primary CMV infection , 30-40% of fetuses

will be infected, 2-4% of them will developsevere malformations at birth.

in recurrent CMV infections ( about 1% offetuses will be infected and the rest will appearnormal at birth, but later in life, they may suffer

from delayed speech and learning difficultiesdue to cerebral calcification and sensorineuralhearing loss. And small group will havechorioretinitis.


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Complications of fetal CMV infection

include:1. micro-& hydrocephaly

2. chorioretinitis

3. cerebral calcification

4. mental retardation5. heart block

6. petechiae

Maternal screening: not recommended.

Prevention: hand washing( especiallyafter changing diapers).


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TOXOPLASMOSIS

Causative agent: by protozoan toxoplasmagondi. Risk of fetal infection:

First Trimester - 15 % ( less incidence of fetalinfection but serious disease is most common ).Second Trimester - 25 % .

Third Trimester - 65 % ( but almost 90% ofnewborns are without clinical signs of disease ). 40% of fetuses are affected if the mother has the

illness. the earlier in pregnancy the more damage. Maternal symptoms: usually asymptomatic,

fever, rash & eosinophelia If symptomatic( theCNS prognosis is poor).


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Maternal screening: not recommended,

if infection suspected( toxoplasma IgG,IgM, and repeat test every 10 weeksthrough pregnancy.

Treatment: start spiramycin in infectedmothers to reduce transmission to thefetus.

Prevention:wash hands before eating,

after handling raw meat , after contactwith cat feces, & soil & cook their meatadequately.


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Infection in the pregnancy may result in:

(occur only if there is acute exacerbationduring pregnancy):

1.spontaneous abortion.

2.perinatal death.

3.abnormal growth.4.characteristic triad of fetal anomalies:

a- Chorioretinitis .

b- Hydrocephaly or microcephaly.

c- Cerebral calcification .


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Human ImmunodeficiencyVirus (HIV)

Causative agent:RNA retrovirus.

Fetal transmission : is 25% if themother is infected, reduced to 8% inif the mother is treated withzidovudine and less than 3% with

suppressive triple antiretroviraltherapy.


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Transmission during pregnancy and

Puerperium: majority of infants infected in thirdtrimester or at time of delivery ,verticaltransmission can occur during vaginal delivery , socaesarean section is protective

(up to 50%). premature babies are more at risk of vertical

transmission.

transmission may also occur with breastfeeding.

bottle feeding reduces vertical transmissionpossibly by up to 50%.


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Screening:Routine HIV antibody performed in 1st

trimester). Repeat in 3rd trimester if high risk forHIV.

Serology: IgG & IgM antibodies (false +ve in1.6%).

If HIV positive, consult Infectious Diseases ,andavoid breastfeeding.

transferred maternal antibody persists up to 18months in uninfected infants, so gene amplificationvia polymerase chain reaction can detect neonatalHIV infection.

intrauterine HIV is associated with prematurity andgrowth retardation.


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Clinicalproblems :appear sooner in infected

baby than in adult AIDS (e.g. at aged 6month)

with:

- hepatosplenomegaly - failure to thrive -encephalopathy - recurrent fever -respiratory

diseases (interstitial lymphocyticpneumonitis) - septicemia (salmonella) -pneumocystis

- lymphadenopathy. Death is usually from respiratory failure or

overwhelming infection( 20% at 18 months).


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Most common cause of jaundice duringpregnancy.

HepatitisB transmitted by contaminatedblood ,saliva, breast milk, semen .

VIRAL HIBATITIS


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Hepatitis B DNA virus Complications: may cause Hepatitis ,Cirrhosis and/or liver

cancer (as an adult at age of 30- 40 years) Rate of transmission from mother to fetus :10-20% (if

HBeAg positive -90%) Pregnant women who are infected transmit the virus

transplacentally to the fetus and at birth. Neonatal jaundice :is rare in women with chronic hepatitis or

acquired hepatitis early in pregnancy. The risk is high when infection occurs late in pregnancy. Screening: Routine HBsAg (performed in 1st trimester). Prevention: HBIG (Hepatitis B immune globulin) and HBV

vaccine should be given to baby at birth. If non-immune mother exposed in pregnancy give HBIG and

HBV vaccine.


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Hepatitis C RNA Virus Vertical transmission is low with rate of

approximately 6%. The risk of transmission correlates with HCV viral

titer in the mother .

Complications: Hepatitis, Cirrhosis and/or livercancer (as an adult). Screening: HCV-A B recommended in high risk

pregnant patients:-intravenous drug users ( IVDU ).

-blood transfusion before 1995-undiagnosed hepatitis. Prevention: Avoid high risk behavior,e.g. IVDU

currently no post-exposure prophylaxis available.


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Herpes Simplex (Primary or

Recurrent).

herpes virus family, DNA virus. Primary Fetal loss Congenital Syndrome Recurrent

Mucocutaneous lesions Disseminated disease Encephalitis Transmission occurs at time of delivery in 90-

95% of cases( vaginal delivery).

Neonatal HSV infection affects 1/5000 births (halfof these related to primary infection).*Prevention:If lesions present at time of delivery,recommend caesarean section.

- Daily oral acyclovir can be considered in late thirdtrimester.


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Varicella Zoster Herpes virus family, DNA virus.

If infection occurs in first trimester4.9% risk of congenital varicella .

Congenital Syndrome-Limb hypoplasia

-Ocular abnormalities

-CNS abnormalities ( convulsivedisorders ).

-Dermatomal scarring


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If infections aquired in the last 10

days of pregnancy result in variablysever fetal infections with neonatalmortality as high as 34% .

Perinatal period (neonatal varicella)

-Chicken pox

-Encephalitis

20-40% risk of(neonatal varicella)

infection if mother developsvaricella in peripartum period.


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Serology (IgG and IgM). Screening:Routine screening

generally not recommended.

Prevention: If pregnant woman

(with no history of previouschickenpox) is exposed, performSTAT Varicella IgG.

Exposed neonate should receive

VZIG prophylaxis.


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SYPHILIS

Effect of Syphilis on Pregnancy:The more is the duration between infection andconception, the less is the foetal affection.

Abortion: of a dead foetus after the 4thmonth of pregnancy when the spirochetes

can cross the placenta as the cytotrophoblaststarts to disappear.

Repeated late abortions then premature ormature macerated still born then live bornwith congenital syphilis or developing itlater on.

congenital syphilis:-Skin eruption- osteititisof nasal bones saddle nosehepatosplenomegaly-frontal bossing -8thnerve deafness.


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Effect of Pregnancy on Syphilis

Primary lesion which is the sign of earlysyphilis may be masked if infectionoccurs during pregnancy.

Causative agent: Treponema Pallidum

Mode of transmission:-sexual ( most common).

-close contact with open lesions( rare).

-direct blood transfusion.

-cong. Syphilis

Fetal infection is most likely when themother is in the primary or secondarystages.


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Diagnosis

(A) History: of infection, repeated late abortions or maceratedstill birth.

(B) Examination: Signs of primary, secondary or tertiarysyphilis.

(C) Investigations: by serological tests;

(I) Non- specific (non-treponemal ) tests:

Venereal disease research laboratory (VDRL).Rapid plasma reagin (RPR).

(B) Specific (treponemal) tests:

Fluorescent treponemal antibody absorption test (FTA - ABS).

Treponema pallidum immobilization test (TPI).

Non-treponemal test can be positive in other conditions ascollagen diseases , lymphomas, mononucleosis, andfebrile illnesses. So these tests can be performed asscreening tests, if positive a specific (treponemal) test isdone to confirm or refute syphilis.


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Treatment

(A) Mother:Treatment should be started before 16 weeks i.e.

before spirochetes cross the placenta(I ) Penicill in:

Procaine penicillin 600.000 units IM daily for 17

days or - benzathine penicillin (long acting) 2.4million units IM, half the dose in each buttock.This is repeated for 3 courses at 2 weeksinterval.

(I I ) Erythromycin:500 mg/ 6 hours orally for 21 days is given to

patients who are allergic to penicillin.(B) New born:Procaine penicillin 150.000 units IM for 10 days.


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GONORRHEA Causative agent: Neisseria

gonorrhoeae ( gram -ve diplococci).

Symptoms: usually asymptomatic.Mucopurulent endocervical discharge,dysuria, proctitis.

may cause perihepatitis ( Fitz -Hugh-Curtis syndrome).

In infants: it infects conjunctiva(gonococcal ophthalmia neonatorum,

prevented by 1% silver nitrate eyedrops immediately after birth),pharynx, respiratory tract, or analcanal.


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Diagnosis:

gram stain of urethral or endocervicalexudates ( intracellular diplococci).

Culture.

Treatment:

in pregnancy:

Ceftriaxone single i.m. dose.(Rocephine1 gm I.v-I.m)

Or

Spectinomycin 2 gm single i.m. dose +erythromycin 500mg qds/7d.

infants: Benzyl penicillin 30mg/kg stat. (

cephalosporin) + chloramphenicol eyedrops.


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CHLAMYDIA TRACHOMATIS

Associated with: low birth weight, prematurerupture of membrane, fetal death.

Conjunctivitis in 5-14 days after birth.

Complication: Chlamydia pneumonitis,pharyngitis,otitis media.

Treatment:

infant: 1% tetracycline oint, Or drops +erythromycin 10 mg/kg qds PO for 3 weeks.

Parents: erythromycin PO

During pregnancy: erythromycin is used, butAmoxicillin 500mg/8h PO for 1 week is bettertolerated


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Streptococcal infections Group A & B Beta-hemolytic

Streptococci:Are the major causes of perinatal infection . Group B Streptococci which is a normal

constituent of Genital tract in 5 to 25% of

pregnant women has become the mostcommon cause of perinatal infection. Diagnosis: St. infection is suspected in

patients with primaturely rupturedmembranes, septic abortion, endometirtis,chorioamnionitis, or pelvic peritonitis.The diagnosis is established by culturinggroup A or B St. from genital exudates or

blood .


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Life threatening: Puerperal infectionsoccur on occasion in group B St. infectionsparticularly in women with prolongedrupture of membranes, stillbirths & septic

abortions are infrequent complication. 25% of infants: Born to mothers harboring

Beta St. complicated with neonatal sepsisincluding meningitis & Pneumonia.

Penicillin or ampicillin is Drug of choice.


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infection during pregnancy.ppt

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