Download Intrauterine fetal infection

Perinatal Infections
Fetal Infection
Nabeel Bondagji
Consultant perinatologist
KFSH&RC Jeddah
Infections
Toxoplasmosis
Rubella
Varicella
Parvovirus
CMV
HIV
Syphilis
Introduction
3% of the perinatal mortalities are
related to (fetal infection)
Fetus can be affected at any gestational
age
Most severe affection occurs in the first
trimester
Most of the fetal infections are
preventable
Red indicates the most vulnerable period of development. (Moore 143).
•First Trimester
Organogenesis
Growth restriction
•Second and Third Trimester
Neuological Impairment
Growth restriction
Think of fetal infection
 I.U.G.R
 Hepatic Calcification
 Intracrainal Calcification
 Hydrocephally, Microcephally
 Ascits
 Pericardial,Pleural Effusion
 Non Immune Hydrops Fetalis
Toxoplasmosis
- Toxoplasmon gondii (intracellular
parasite)
Trans-placental affect the placenta fetus
Transmission Rate
- 10 –15% 1st trimester
- 25%
2nd trimester
- 60%
3rd trimester
Toxoplasmosis
Toxoplasmosis
- Incidence of congenital toxoplasmosis
- 0.07 – 0.5 : 1000 London
- 2 : 1000 Brussels
- 3.22 : 1000 Paris
Risks to the Fetus
1st Trimester
- 55 – 85% will show sequilie
- Chrioretinitis severe impairment of vision
- Hearing loss
- Mental Retardation
- Ascits
- Periventirecular Calcification
- Hydrocephally
Toxoplasmonsis
Ultra Sound
- Intracranial, hepatic, calcification
- Ascitis
- Hepatosplenomegally
- Microcephally
- I.U.G.R
Diagnosis Fetal Blood Sampling
- IgM
- PCR
- Culture
Toxoplasmosis
Treatment
- Reduce risk of transmission
Spiramycin
- If fetal infection documented
- Pyrimethamine
- Sulfadiazine….. Folic acid
Pyron F, Wallonlion C, Goner P,
Cochrane Database Review
January 2005
Objective
To assess whether treatment of
toxoplasmosis reduces the risk of
congenital toxoplasmosis
Selection Criteria
RCT
- Antibiotics
- No treatment
Proven Infection
Look, outcome of the children
3332 Papers identified
NO Trial fulfill the criteria
Conclusion
We do not know whether antibiotics
Treatment reduces the congenital
transmission or not.
Screening is Expensive
Screening is not recommended in
countries where screening and
treatment is not routine.
Toxoplasmosis
Prevention to Toxoplasmosis: Advice to
Pregnant Women whose Serological Tests are
Negative.
Cook meat at 60oC + (Industrial deepfreezing also seems to destroy parasites
efficiently).
 When handling raw meat, do not touch
eyes or mouth.

Cont..
Prevention of
Toxoplasmosis
-
-
-
Carefully wash hands after handling raw meat,
dirt, or vegetables soiled by dirt.
Wash fruit and vegetables before eating
Wear gloves when gardening
Avoid all contacts with things that may have
been contaminated by cat feces
If the cat’s litter has to be changed, put on
gloves and disinfect often with boiling water.
Rubella German
Measles
Rubella
- 3rd Disease
RNA Virus
- Respiratory secretions
- 2 – 3 weeks I.P.
Rubella
- 0.5 – 2% Non Immune
- 0.2 – 0.5 Congenital Rubella
Syndrome
Risk of Transmission
- 8 – 12 weeks
90%
-12 – 16 weeks 50%
- 16 – 20 weeks 17%
Rubella
Ultra Sound - I.U.G.R.
- Hepto-splenomegally
Congenital Rubella syndrome
- Eye
Cataract, Retinopathy
Microphthalmia, glaucoma
- Ear
Deafness
-Heart PDA
Rubella
Diagnosis
 IgM
RUBELLA
Prevention
 Active immunization by vaccination is
the only efficient way of preventing
congenital rubella.
Varicella Zoster Virus DNA Herpes
- Chickenpox
- Herpes Zoster
- Incidence in pregnancy 0.4 – 0.7 : 1000
Maternal
- Pneumonia increase mortality
Fetal Congenital Varicella Syndrome in 1st tri
mester
- Skin Scar, Limb Hyproplasia
- Chrioretinitis, Microcephally
Varicella
Neonatal Infection
Increase in Mortality
- 5 days before delivery – 48 hours post
partum
- Avoid delivery if possible in this period
Diagnosis
Viral Culture
- PCR
Presence of infection does not
predicate the severity of the disease
VARICELLA
Prevention
 Passive immunization is currently available
and should be administered within 24-72
hours to sero-negative pregnant patients who
have been exposed to varicella.
Varicella
Treatment
- Oral cyclovir to improve sysmatic I.V. to treat
pneumonia
- Safe in Pregnancy
- Does not prevent or decrease the fetal effect
- VZIG to be given to the neonate 5 days
before delivery – 2 days postpartum
Varicella
Screening
- Not Recommended
Parvovirus B.19 the fifth
disease
Infectious period 5 – 10 days after exposure
Mode of transmission
- Transplacental 33% transmission risk
- Fetal effect – abortion <20 weeks
- Hydrops fetalis 18% of all non immune
Intrauterine fetal
infection
 Fetal effect of B19 :
- A symptomatic
- IUGR
- Congenital anomalies
- Hydrops fetalis
- IUFD
 Parvovirus B 19
pathogenesis:
a) Anemia
b) Fetal myocardium and hepatic affection
c) Vasculitis
Diagnosis
Parpovirus
- ELISA
-Western blot test
IGM Diagnosis of Primary Infection
Elect Microscopy
- Direct Visualization of the virus or viral
particles
Parvovirus
Fetal Diagnosis
- PCR in A.F., Placenta & Blood
Ultra Sound
- Hydropy Fetalis
Parvovirus
Prognosis and therapy
Survivor recovers normal
Fetal Therapy
Intravascualr Intrauterine Blood
Transfusion
CMV
DNA Herpes Virus
Most common perinatal infection
0.2 – 2% of all newborns
Leading cause of hearing loss
Mode of transmission
Contact with infected
-Blood
-Urine
-Salvia
-Sexual contact
CMV
I.P 28 – 60 days
Viremia 2 – 3 weeks
Maternal effect –
Asympathic, mild fever, malaise &
myalgia
Primary infection
0.7 – 4%
Recurrent infection
13.5%
Epidimulogical Facts
Primary Infection
-Risk of Transmission 30 – 40%
-10% Seguilie of the infected
-30% Prenatal Mortality
-Of the survivor 80%will have
neurological damage
Recurrent Infection
Transmission 0.1 – 2% Mostly a
symptomatic most of the sequilie occurs
as hearing loss
Diagnosis
CMV
Diagnosis Culture or PCR
– blood, urine & salvia
IgG Serial Measurements 3 – 4 weeks
Diagnosis either by seroconversion
Or increase titer by more than 4 folds
-1 : 4 – 1: 16
-1 : 16 – 1 : 256
IGM is not reliable as it may be negative
even in the right phase and may persist
for months after infections
Diagnosis
Fetal Diagnosis Ultra Sound System
- Intracrainal or hepatic calcification
- Echogenic bowel
- Ascits
A.F.
- Culture
- PCR
CMV
Treatment
- Not available
- Neonatal therapy ganciclovir may
decrease neonatal infections
Vaccine
- May Reactivate A previous infection
CMV
Screening
Not Recommended
Human immunodeficiency
virus (HIV) Infection
This is the major cause of congenital
infection in the developing world.
Over one million children had been
infected from their mother by the end
of 1998.
Mother  child



in utero
at birth
breast milk
Organ/tissue donation



Semen
Kidneys
Skin, bone marrow, corneas, heart
valves, tendons, etc.
TO SCREEN OR NOT TO
SCREEN?
The best defense is a strong offense.
The American Academy of Paediatrics
and the ACOG issued a Joint Statement
on HIV Screening in Pregnancy (1999)
(2001).
A pregnant women should receive HIV
counseling as part of their routine ANC.
A pregnant women should have HIV
testing with their consent.
PRE-TEST COUNSELING
Risks of transmission (including Mode)
Risks of perinatal transmission
Potential social and psychological
implication of Positive test.
The availability of Agents that may reduce
the risk of neonatal infection.
Clarify the difference between HIV
infection and disease.
Timing of Perinatal HIV
Transmission
Cases documented intrauterine,
intrapartum, and postpartum by
breastfeeding



In utero
25% 40% of cases
Intrapartum- 60% 75% of cases
Addition risk with breastfeeding
•
•

14% risk with established infection
29% risk with primary infection
Current evidence suggests most transmission
occurs during the intrapartum period
Factors Influencing Perinatal
Transmission
Maternal Factors





HIV-1 RNA levels (viral load)
Low CD4 lymphocyte count
Other infections, Hepatitis C, CMV, bacterial
vaginosis
Maternal infection drug use
Lack of ZDV during pregnancy
Obstetrical Factors



Length of ruptured
membranes/chorioamnionitis
Vaginal delivery
Invasive procedures
Infant Factors
Reducing HIV
Transmission
with Suboptimal
Regimens
Partial ZDV regimens: ( New York cohort)

Transmission rates
• 6.1% with prenatal, intrapartum, and infant
ZDV
• 10% with only intrapartum ZDV
• 9.3% if only infant ZDV started within first
48 hours
• 26.6% with no ZDV
Reducing Intrapartum HIV
Transmission: Studies of
Therapy
Oral Short
ZDV in a Course
non-breastfeeding
population
(Thailand) from 36 weeks and during labor

Transmission rate: 9.4% ZDV vs. 18.9% placebo
PETRA study – intrapartum/postpartum oral
ZDV/3TC in a breast-feeding population
(Uganda, S. Africa, Tanzania)

Transmission rate: 10% ZDV/3TC vs. 17% placebo
HIV Net 012 – intrapartum/postpartum/neonatal
Nevirapine (NVP) vs. short course/neonatal ZDV
in a breast-feeding population (Uganda)

Transmission rate: 12% NVP vs. 21% ZDV
Treatment with zidovudine
appears
to be safe in
pregnancy.
Elective caesarean section may
decrease mother-to-child
transmission.
HIV
Chochrane Database 2002
Objective to assess what intervention
will decrease the risk of mother to
children transmission of HIV
AZT
4 trials decrease 1585 patients
Neviropine compared AZT 626
decrease transmission
C/S one trial 436 patients decrease risk
of transmission
Immunoglbullin
Does not decrease the risk
Conclusion
Zidoridine, Nevirpine
C/S decreases the transmission
significantly.
Syphilis
- T.P.
- Increase HIV
Transmission all through
Manifestation
Ultra Sound
- Thick Placenta
- Hydrops fetalis
- I.U.G.R
- Hydroamnios – Hepato-splenomegaly ……
- Risk of Transmission
- 90% primary
- 50% secondary
- 6 – 14% Latent Syphillis
Diagnosis
Screening Non Specific
 VDAL
 RPR
 Specific
 TPHA
 F.T.A. becomes …..
3 – 4 weeks
Treatment
- Penicillin
- Benzathin Penicillin 2.4 million unit
- Erythpromycine
Thank You..