Download Perinatal Infectious Diseases

Perinatal Infectious
Diseases
Dr. Hazem Al-Mandeel
Perinatal Infections
• Accounts for 2-3% of birth defects
• Few infectious organisms are cost-effective to
screen for prenatally (Rubella, Cytomegalovirus,
Syphilis, HBV ± HCV, ?HIV)
• Important perinatal infections include:
Toxoplasmosis, Rubella infection, CMV
infection, genital herpes infection, Syphilis, HBV
infection, HIV infection, group B streptococcus
infection
Toxoplasmosis
• Parasitic infection cause by Toxoplasma gondii
• One of the common infections worldwide (0.1%)
• Infection leads to lifelong immunity (10-40%
+ve)
• Risk of fetal infection depends on trimester
• Consequences: classic triad hydrocephalus,
intracranial calcifications, and chorioretinitis
• 25% of infected fetuses are symptomatic (mental
retardation, seizure, CNS, &
hepatosplenomegally
Toxoplasmosis
• Dx: rarely made clinically
• Maternal infection cause mononucleosis-like
syndrome (check Ab’s IgM & IgG)
• Fetal testing by either blood or placenta culture
• Treatment: pyrimethamine + sulfadiazine +
folinic acid
• Route of Delivery: vaginal
• Prevention: avoiding cat litter/feces, wearing
gloves when gardening, and avoid ingestion of
unpasturized milk or raw meat
Rubella (German Measles)
• Viral infection caused by RNA virus and causes
lifelong immunity
• Disease of childhood and transmitted by
respiratory route (highly contagious)
• The period of infectivity is 7 days before the rash
to 5 days after the rash appears
• 85% of the general population is seropositive
• 75% of infected patients become clinically ill
Rubella (German Measles)
• Risk of fetal infection affected by GA
• Consequences:
1. Spontaneous abortion
2. IUGR
3. Congenital heart disease
4.CNS (deafness, cataracts, retinopathy,
microcephaly, calcifications, mental retardation)
5. Hepatosplenomegally
6.Thrombocytopenic purpura
Rubella (German Measles)
• Dx: maternal testing (IgM & IgG) and fetal
testing (IgM in umbilical blood or IgG in infant’s
blood after 5 months)
• Treatment: none; mother can deliver vaginally
• Prevention: screen all pregnant women in 1st
visit; avoid exposure during pregnancy;
vaccination of seronegative women in postpartum
period and contraception for 3 months
Cytomegalovirus (CMV)
• Caused by DNA herpes virus
• One of the most common congenital viral
syndrome
• Transmitted via exposure to infected blood, other
body fluid, or organ transplantation
• 50% of pregnant women are seropositive
Cytomegalovirus (CMV)
• Risk of fetal infection: 50% in all trimesters
with 1ry infection and < 1% with recurrent one
• Dx:
a) Symptomatic infection appears as a
mononucleosis-like syndrome with hepatitis
(rarely seen)
b) Asymptomatic infection is more common
Cytomegalovirus (CMV)
• Dx: viral culture of amniotic fluid, urine, or
other body fluid. Maternal and fetal Ab’s testing
• Treatment: if active  ganciclovir
• Route of delivery: vaginal
• Prevention: counseling the mother to avoid
blood transfusion in pregnancy and in using
universal protection measures at work
Herpes Simplex Virus (HSV)
• HSV-II causes 90%, HSV-I causes 10% (protect)
• Most contagious STD and most common cause
genital ulcer
• HSV-II accounts for 70% & HSV-I for 30%
• 50% of pregnant women are seropositive
• Types of genital herpes infections:
- Primary
- Recurrent
Herpes Simplex Virus (HSV)
• Dx: culture from ulcer or smear or ELISA
• Significance:
- 1ry infection: spontaneous abortion, IUGR,
IUFD, & preterm labour. No malformation
syndrome. Neonatal attack rate 50%, mortality
50%, and permanent sequelae 50%
- Recurrent infection: no intrauterine risks.
Neonatal attack rate 4% by passing vaginally
Herpes Simplex Virus (HSV)
• Treatment: antiviral agents, symptomatic relief,
and abstinence from sexual contact
• Route of delivery: caesarean section if active
genital lesions are present at time of delivery and
no documented fetal infection otherwise
vaginally
• Neonatal management: no need for isolating
the fetus from the mother or stop breastfeeding
unless a lesion is present
Herpes B Virus (HBV) Infection
• Infection caused by DNA hepadenavirus type I
• HBV is endemic in Saudi Arabia
• Transmitted via body fluids. Mother-infant
transmission causes 40% of all chronic infections
• Types of infection:
- Asymptomatic: 75% of all infected patients
- Acute hepatitis: jaundice and liver enzymes
- Chronic hepatitis: in 10% of infected adults and
80% of infected infants
Sequelae of Chronic Hepatitis
• Immunological markers: HBsAg for
screening. Others HBcAg & HBeAg
• Maternal: cirrhosis and hepatocellular
carcinoma
• Fetal: uncommon infection, occurs in third
trimester, can cause premature birth, low birth
weight or neonatal death
• Carrier mothers may transmit infection in 10% if
only HBsAg or 80% if both HBsAg & HBeAg
HBV
• Dx: all pregnant women should be screened for
HBsAg at 1st visit (repeat at 28 wks if high risk)
• Treatment: no specific therapy
• Route of delivery: vaginal
• Prevention: neonates of HBsAg +ve women
should receive HBIg and active vaccine.
Avoid scalp electrode, scalp needles after
delivery, and avoid breastfeeding
Human Immunodeficiency Virus
• Single-stranded RNA virus causes AIDS
• Virus transmitted via sexual contact with infected
partner, blood Tx, transplacental, & needle stick
• 1 in 3 neonates delivered to HIV +ve mothers
• AIDS manifestations
• Dx: ELISA (for screening) and Western Plot
• HIV screening is recommended for all high-risk
mothers
Group B Streptococci (GBS)
•
•
•
•
GBS is part of normal flora in G.I tract
Transmission occurs via colonized birth canal
Vaginal colonization rate is 35% (?lower in S.A)
Risk of transmission from colonized woman to
neonate is 50%, but attack rate is only 1%
• Dx: culture in specific media or rapid assays
(low sensitivity but good specificity)
GBS Clinical Issues
• Obstetric complications: preterm
labour/delivery, PROM, intrapartum or
postpartum infection
• Neonatal complications:
 Early-onset infection: occurs within 48hrs, 50%
mortality. Sepsis, pneumonia, meningitis
 Late-onset infection: occurs after 1st week, 25%
mortality. Meningitis is most common presentation
Prevention of GBS Neonatal
Infection
• Intrapartum antibiotic prophylaxis prevents 70%
of GBS neonatal infection
• Women selection by either screening approach
(all pregnant women at 35-37 wks) or risk factors
• Pen G is the antibiotic of choice
• Others: Ampicillin, Cefalozin, Erythromycin, or
Clindamycin
• Check CDC recommendations
Management of HIV +ve Mother
1.
2.
3.
4.
5.
6.
7.
8.
Maternal counseling
Antiviral prophylaxis with AZT (start at 14wks)
Multidrug antiviral therapy if viral load is high
Treatment for infectious diseases
Maternal vaccination against HBV
Maternal prophylaxis for P. carinii pneumonia
Avoid scalp electrode or instrumental delivery
Mode of delivery (caesarean section is protective)