Perinatal infection

By Dr MOHAMED KHALIL MD MRCOG

Are pregnant women immuno- compromised?

For which infections should pregnant women be screened?

HIV

Syphilis

GBS

Rubella

Cytomegalovirus?

Toxoplasma?

Bacterial vaganosis?

Why are infections in pregnancy important?

Maternal ---fetal morbidity --mortality

Early onset infection/ septicemia

Late onset disease/meningitis

What neonatal conditions are caused by Group B streptococcus ?

How can they be prevented?

Screening for all pregnant women at 35-37

ttt +ve women/penicillin, vancomycin, cefazolin

Identifying women with risk factors eg PTL <37 wks, SROM>18hs, intrapartum fever>38c,

previous affected child, GBS bacteruria

Which common genital infections are implicated in preterm birth?

Bacterial vaganosis/Bad odor, PH>4.5 ,KOH, Clue cell ,

Metronidazol/ Clindamycin/ safe in pregnancy

Human Parvovirus ,

Cytomegalovirus

Toxoplasma

What are examples of infections with minimal maternal effects but the potential for significant fetal

compromise?

Usually asymptomatic in adult

Maternal infection diagnosed by igG, igM

Fetal anaemia, none immune hydrops/ death

Fetal anaemia can be diagnosed by DOPPLER of MCA------MCAPSV

Intrauterine transfusion may be necessary if MCPSV > 1.5 MOM

What maternal and fetal effects are caused by parvovirus ? =fifth disease

Usually asymptomatic in adult

Fetus could have CNS abnormalities, IUGR/IUFD

The gold standard for the diagnosis of fetal CMV infection is the amniotic fluid CMV nucleic acid amplification testing

How does cytomegalovirus affect the fetus?

NO

Should pregnant women be screened for antibodies to cytomegalovirus?

What is toxoplasma/mode of transmission?

Parasite Ingestion of infected meat/ exposure to

infected cat feces Infection in early pregnancy/ less incidence

of fetal infection but it will be serious Infection in late pregnancy /higher incidence of fetal infection

ToxoplasmosisToxoplasmosis

The reported overall risk of congenital toxoplasmosis ranges from 18% to 44% .

 The risk is low in early pregnancy (7-15 weeks) at 6% to 26% but with severe damage to the

fetus .

And rising to 32% to 93% at 29 to 34 weeks of gestation with less fetal damage

Subclinical disease

Acute toxoplasma infection can be indicated if maternal serum shows igG+, igM+, igG avidity index low

IUGR, IUFD

Multiple systems affection, CNS

Scan---calcification—brain--liver

Antiparasite therapy can prevent fetal sequel

What is the significance of toxoplasmosis in pregnancy?

Does maternal varicella infection pose risks during pregnancy? What about herpes zoster?

Acute varicella infection=chicken poxReactivation=shingles=zoster

Chicken pox----maternal pneumonia/ death

Time of fetal infection if infection happen ( ) 13-20wk mainly skeletal deformities, skin, CNS, Eyes defects

Infection after 20 wks--- congenital zoster syndrome is uncommon

Vaccination is contraindicated during pregnancy

VZIG to susceptible individuals

Can varicella-zoster infection be prevented by VZIG?

How does infection with human immunodeficiency virus (HIV) impact pregnancy?

Maternal concern is to control the diseasePregnancy does not worsen the disease in mother

Vertical transmission 50% occur during labour10-20% with breast feeding

Can anti-retroviral therapy( AZT) be safely used in pregnancy?

Safety concern need to be balanced against the potential benefit to mother and baby

Antiretroviral reduces viral load

What steps can be taken to reduce the risk of vertical transmission ?

Antiretroviral during antepartum period

Cesarean section even with ROM

No breast feeding

The risk is 15-25% without prevention versus <5% with preventive measures

Should pregnant women be routinely screened for HIV infection ?

Yes

What is the significance of rubella in pregnancy?

Maternal : It cause german measles

100% of infants infected during the first 11 weeks of pregnancy will have rubella defects.

and reduced to 25% at the end of the second trimester .

Sensorineural deafness is the most common single defect,

heart, CNS defect, IUGR ,

preconception vaccination can give protection

Rubella susceptibility screening should be offered early in antenatal care to identify women at risk of contracting rubella infection and to enable vaccination in the postnatal period for the protection of future pregnancies .

6.

What are the fetal effects of congenital syphilis ?Treponema pallidum

Tests of diagnosis VDRL, TPHA, TPI

TPHA false +ve results(pregnancy, malaria, leprosy, glandular fever)

Hydrops, hepatosplenomegally, IUFD,

Congenital syphilis (frontal bossing, high arched palate, hutchington,s teeth, 8th nerve deafness, interstitial keratitis)

Antenatal screening is recommended

Treatment is by penicillin

What are the fetal effects of congenital syphilis? Treponema pallidum

In pregnant women with early untreated syphilis , Mother-to-child transmission of

syphilis in pregnancy is associated with

70% to 100% of infants will be infected ,

41% congenital syphilis (which may cause long-term disability) ,

25% stillbirth

25% preterm birth. [EL = 3]

14% neonatal death,

.

How does herpes simplex virus (HSV) affect pregnancy?

During vaginal delivery

Primary infection

Secondary infection

Neonatal disease ranges from asymptomatic infection to disseminated disease and death

How is transmission of HSV to the fetus/newborn prevented?

by CS if delivery can happen within a month from the primary infection.

Screening for Hepatitis B virus

The prevalence of hepatitis B surface antigen (HBsAg) in pregnant women in the UK range from 0.5% to 1% .

85% of babies born to mothers who are positive for the hepatitis e antigen (eAg) will become HBsAg carriers and

subsequently become chronic carriers ,

Compared with 31% of babies who are born to mothers who are eAg negative (RR2.8, 95% CI 1.69 to 4.47).

Screening for Hepatitis B virus

Mother-to-child transmission of the hepatitis B virus is approximately 95% preventable through administration of vaccine and immunoglobulin to the baby at birth.

Serological screening for hepatitis B virus should be offered to pregnant women so that effective postnatal intervention can be offered to infected women to decrease the risk of mother-to child transmission.

Screening for Hepatitis C virus

Incidence ranges from 0.14 in the West Midlands (95% CI 0.05 to 0.33) to 0.8 in London (95% CI 0.55 to 1.0).

Mother-to-child transmission in the UK is estimated to lie between 3% and 5% .

A higher proportion of infected babies has been observed among those delivered vaginally compared with those delivered by caesarean section but only one study has demonstrated a statistically

significant difference .

Screening for Hepatitis C virus

All infants with HCV-RNA will be negative and lost HCV antibodies by 6 months after birth.

Pregnant women should not be offered routine screening for hepatitis C virus because there is insufficient evidence to support its effectiveness and cost-effectiveness.

HIV

Is a retrovirusAsymptomatic infection has no significant effect on pregnancy complicationDoes not influence the mode of deliveryAbout 15% of babies will remain HIV +ve at 6 months of ageCan be isolated from cervical secretion

abde

All pregnant women are still screened for syphilis

VDRL test is a specific testVDRL remain +ve for evercongenital syphilis causes skeletal damageTtt in early pregnancy will not protect fetusUntreated syphils may result in prematurity

C,e

Which of the following vaccines is recommended to be given during pregnancy?

A- MMR

B- Varicella

C- Influenza

D- All of the above

C

Rubella infection

Rapidly cross the placentaMay lead to fetal cataractMay cause thrombocytopeniaCan be confirmed by fetal blood sample to detect IgG antibodiesCan be confirmed by CV sampling at 10 wk

abce

The following may cross the placenta

Neisseria gonorrhoeaecytomegalovirusHerpes genitalis -------------------- falseparvovirusToxoplasmaSyphilisRubellaHIV