Infections in pregnancy

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Infections in pregnancy

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Infections in pregnancy

  1. 1. Infections in Pregnancy Dr. B. K. Iyer
  2. 2. General Principles <ul><li>Pregnancy does not alter resistance to infection </li></ul><ul><li>Severe infections have greater effects on the fetus </li></ul><ul><li>Maternal antibodies cross the placenta and give passive immunity to the fetus </li></ul><ul><li>Fetus becomes immunologically competent from the 14th week </li></ul>
  3. 3. Fetus and Infection <ul><li>Indirect effect - O2 transport, nutrient exchange </li></ul><ul><li>Direct effect - invasion of placenta and infection of fetus </li></ul><ul><ul><ul><li>Viruses more than bacteria </li></ul></ul></ul><ul><ul><ul><li>rarely effect fetus unless maternal infection is severe </li></ul></ul></ul><ul><ul><ul><ul><li>exception: Rubella, CMV, Herpes Simplex </li></ul></ul></ul></ul>
  4. 4. Fetus and Infection <ul><li>Infections cause </li></ul><ul><li>- miscarriage </li></ul><ul><li>- congenital anomalies </li></ul><ul><li>- fetal hydrops </li></ul><ul><li>- fetal death </li></ul><ul><li>- preterm delivery </li></ul><ul><li>- preterm rupture of the membranes </li></ul>
  5. 5. Viral Diseases <ul><li>Rubella </li></ul><ul><li>Parvovirus </li></ul><ul><li>Cytomegalovirus </li></ul><ul><li>Varicella Zoster </li></ul><ul><li>Herpes </li></ul><ul><li>Hepatitis </li></ul><ul><li>HIV </li></ul><ul><li>Rubeola </li></ul>
  6. 6. Measles (Rubeola) <ul><li>Paramyxovirus </li></ul><ul><li>Incubation - 10-14 days </li></ul><ul><li>Respiratory droplet inoculation </li></ul><ul><li>Fever, rash, cough, rhinorrhea, conjunctivitis and Koplik’s spots </li></ul><ul><li>Pneumonia (2nd bacterial) main cause of death </li></ul><ul><li>Encephalomyolitis, SSPE, Hepatitis </li></ul>
  7. 7. Measles (Rubeola) <ul><li>No increased maternal or fetal deaths </li></ul><ul><li>Risk of preterm delivery </li></ul><ul><li>No specific syndrome </li></ul><ul><li>Neonatal measles and pneumonia if active disease in mother </li></ul><ul><li>Increased PNM in developing countries </li></ul>
  8. 8. Measles (Rubeola) <ul><li>Prevention vaccine (95% recipients protected) </li></ul><ul><li>Treatment antipyrexials </li></ul><ul><li>cough suppresants </li></ul><ul><li>Antibiotics for bacteria </li></ul><ul><li>Suppress uterine contractions </li></ul><ul><li>? Immune serum globulin </li></ul><ul><li>Isolation precautions </li></ul>
  9. 9. Rubella <ul><li>Togavirus (RNA virus) </li></ul><ul><li>Incubation - 14-21 days </li></ul><ul><li>Respiratory droplet inoculation </li></ul><ul><ul><ul><ul><li>only modestly contagious </li></ul></ul></ul></ul><ul><li>Fever, rash (3 days), cough, arthralgias, post auricular and suboccipital lymphadenopathy </li></ul><ul><li>Usually mild, overt clinical symptoms 50-75% of cases </li></ul><ul><li>Encephalitis, bleeding diathesis & arthritis are rare complications </li></ul>
  10. 10. Rubella and the Fetus <ul><li>Purpura, Splenomegaly, jaundice, meningoencephalitis, thrombocytopenia are transient </li></ul><ul><li>Congenital cataracts, Glaucoma, heart disease, deafness, microcephaly and mental retardation are permanent abnormalities </li></ul><ul><li>Diabetes, thyroid abnormalities, precocious puberty & Progressive panencephalitis (late) </li></ul>
  11. 11. Rubella <ul><li>Vaccination (95% seroconversion) </li></ul><ul><li>@ 15 months and early adulthood </li></ul><ul><li>Immune status checking in teenagers, pre-college and pre-pregnancy </li></ul><ul><li>Antenatal testing </li></ul><ul><li>Serology testing for presumed exposures (paired Sera) </li></ul><ul><li>No in-utero therapy </li></ul>
  12. 12. Parvovirus <ul><li>Human parvovirus B19 (DNA virus) </li></ul><ul><li>- erythema infectiosum in childhood </li></ul><ul><li>- chronic arthropathy </li></ul><ul><li>- chronic bone marrow failure (immunodefic) </li></ul><ul><li>- aplastic crisis (Sickle disaease) </li></ul><ul><li>Incubation 4-14 days </li></ul><ul><li>Respiratory droplet spread </li></ul><ul><li>High fever, “Slapped cheek syndrome’ </li></ul><ul><li> non specific rash, no symptoms </li></ul>
  13. 13. Parvovirus and fetus <ul><li>Hydrops (anaemia, myocarditis) </li></ul><ul><li>Adults 60% sero-positive </li></ul><ul><li>1/3 fetuses affected in acute infection </li></ul><ul><li>Fetal loss rare with appropriate treatment </li></ul><ul><li>Assess serology - IgG, IgM, paired serology </li></ul><ul><li>Serial ultrasound, intrauterine transfusion </li></ul>
  14. 14. Varicella <ul><li>Varicella-Zoster virus (DNA) </li></ul><ul><li>Incubation - 10-20 days </li></ul><ul><li>Respiratory droplet inoculation </li></ul><ul><li>Fever, malaise, pruritic rash (maculopapular with vesicles) </li></ul><ul><li>Pneumonia (+/- bacterial), encephalitis, myocarditis, pericarditis and adrenal insufficiency especially in adults </li></ul>
  15. 15. Varicella and pregnancy <ul><li>Mild immunocompromise of pregnancy increases risk </li></ul><ul><li>10% develop pulmonary complications - main cause of mortality </li></ul><ul><li>Fetal effects </li></ul><ul><li>Preterm delivery </li></ul><ul><li>Varicella syndrome </li></ul><ul><li>Neonatal varicella (VZ first 2 months) </li></ul>
  16. 16. Varicella Syndrome <ul><li>Cutaneous scarring </li></ul><ul><li>Limb hypoplasia </li></ul><ul><li>Missing/hypoplastic digits </li></ul><ul><li>Limb paralysis/muscle atrophy </li></ul><ul><li>Psychomotor retardation </li></ul><ul><li>Convulsions </li></ul><ul><li>Microcephaly </li></ul><ul><li>Cerebral atrophy </li></ul><ul><li>Chorioretinitis/ chorioretinal scarring/optic disc hypoplasia </li></ul><ul><li>Cataracts </li></ul><ul><li>Horner’s Syndrome </li></ul><ul><li>Early childhood Zoster </li></ul>
  17. 17. Cytomegalovirus <ul><li>DNA virus </li></ul><ul><li>Congenital infection - 1% </li></ul><ul><li>5-10% of those infected show clinical illness at birth </li></ul><ul><li>Neonatal MR - 20-30% </li></ul><ul><li>90% of survivors get late complications </li></ul><ul><li>5-15% with no demonstrable disease at birth get some abnormality (deafness) </li></ul>
  18. 18. CMV Congenital Infection <ul><li>Hepatomegaly } </li></ul><ul><li>Spleenomegaly } </li></ul><ul><li>Jaundice }TORCH </li></ul><ul><li>Thrombocytopenia }Syndrome </li></ul><ul><li>Petechiae } </li></ul><ul><li>Microcephaly } </li></ul><ul><li>Intrauterine growth retardation } </li></ul>
  19. 19. CMV Congenital Infection (Late) <ul><li>Venticulomegaly </li></ul><ul><li>Cerebral atrophy </li></ul><ul><li>Mental retardation </li></ul><ul><li>Psychomotor delay </li></ul><ul><li>Seizures </li></ul><ul><li>Learning difficulties and language delay </li></ul><ul><li>Chorioretinitis / Optic atrophy </li></ul><ul><li>Intracranial calcifications </li></ul><ul><li>Long bone radiolucencies, dental abnormalities </li></ul><ul><li>Pneumonitis </li></ul>
  20. 20. CMV Congenital Infection <ul><li>Prolonged virus shedding </li></ul><ul><li>No vaccine </li></ul><ul><li>No treatment </li></ul><ul><li>Risk group advice </li></ul>
  21. 21. Herpes Simplex <ul><li>Disseminated disease in pregnant woman - death from hepatitis, encephalitis </li></ul><ul><li>Miscarriage (severe disease) </li></ul><ul><li>No congenital syndrome known </li></ul><ul><li>Intrapartum infection </li></ul><ul><ul><ul><li>disseminated disease - chorioretinitis, meningitis, encephalitis, mental retardation, seizures and death </li></ul></ul></ul><ul><ul><ul><li>Primary infection >>>secondary infection </li></ul></ul></ul><ul><ul><ul><li>HSV II - 75%; HSV I - 25% cases </li></ul></ul></ul>
  22. 22. Hepatitis B <ul><li>Intrauterine infection - 5% </li></ul><ul><li>Intrapartum infection - 95% </li></ul><ul><li>Congenital infection - 90% chronic carriers </li></ul><ul><li>About 1% mothers are potential risks for their newborns </li></ul><ul><li>Newborns should receive passive (HBIg) and active immunization (vaccine x 3 doses) - protective in over 90% of cases </li></ul>
  23. 23. Hepatitis C <ul><li>Risk of transmission to fetus 6-30% </li></ul><ul><li>Increased if other infections such as HIV </li></ul><ul><li>No treatment </li></ul><ul><li>Value of C Section is uncertain </li></ul><ul><li>Avoid invasive procedures </li></ul>
  24. 24. HIV <ul><li>Infection rates variable </li></ul><ul><li>Risk of vertical transmission 20-40%, mostly peri-partum </li></ul><ul><li>Screening and treatment can almost completely reduce vertical transmission </li></ul><ul><li>C Section reduces risk of transmission x 4-fold </li></ul><ul><li>Viral counts <1000 - negligible risk to fetus </li></ul>
  25. 25. Bacterial Infections <ul><li>Bacteruria* </li></ul><ul><li>Vaginal infections (BV, TV, Candida) </li></ul><ul><li>Group B Streptococci* </li></ul><ul><li>Gonorrhoea* </li></ul><ul><li>Chlamydia* </li></ul><ul><li>Toxoplasmosis* </li></ul><ul><li>Listeria </li></ul>
  26. 26. Bacteruria <ul><li>Asymptomatic </li></ul><ul><li>5-8% of all pregnancies (2% Non-preg) </li></ul><ul><li>Urinary stasis, tract dilatation </li></ul><ul><li>30% symptomatic UTI (Pyelonephritis) </li></ul><ul><li>Diagnosis </li></ul><ul><li>Treatment </li></ul><ul><li>Subsequent care (MSU v Prophylaxis) </li></ul>
  27. 27. Group B Streptococci <ul><li>25% women are carriers </li></ul><ul><li>50% of babies born will be colonized </li></ul><ul><li>1-2% will have Grp B Strep infection </li></ul><ul><li>1:1000 babies </li></ul><ul><li>Pneumonia (early), Meninigitis (Late) </li></ul><ul><li>Screening v Risk factor prophylaxis </li></ul>
  28. 28. Gonorrhoea <ul><li>Neissseria Gonorrhoea (1-6% pop) </li></ul><ul><li>Pre-term labour, PPROM, Chorioamniionitis, Endometritis </li></ul><ul><li>Gonococcal opthalmia neonatorum (40%) </li></ul><ul><li>80% asymptomatic </li></ul><ul><li>Screening needed? </li></ul><ul><li>Cephtriaxone IM stat </li></ul>
  29. 29. Chlamydia <ul><li>5-7% reproductive population </li></ul><ul><li>Pre-term labour, PPROM, Chorioamniionitis, Endometritis </li></ul><ul><li>Conjunctivitis (18-50%), Pneumonia (18%) </li></ul><ul><li>Most are asymptomatic </li></ul><ul><li>Screening needed </li></ul><ul><li>Azithromycin 1 gram stat </li></ul>
  30. 30. Syphilis <ul><li>T.Pallidum </li></ul><ul><li><1:1000 pregnant women </li></ul><ul><li>Can infect trans placenta from 15 th week </li></ul><ul><li>Second stage by birth if not treated </li></ul><ul><li>Screening – VDRL, RPR </li></ul><ul><li>Diagnostic tests – TPI, FTA-Abs </li></ul><ul><li>High dose Penicillin's </li></ul>
  31. 31. Toxoplasmosis <ul><li>Toxoplasma Gondii (Protozoa) </li></ul><ul><li>Cat faeces, raw/undercooked meats </li></ul><ul><li>TORCH syndrome </li></ul><ul><li>Chorioretinitis, Encephalitis, Neonatal Jaundice </li></ul><ul><li>Serology =/- PCR </li></ul><ul><li>Sulfonamides + Pyrimethamine </li></ul>
  32. 32. Intra-Amniotic Infection <ul><li>1-2% all deliveries </li></ul><ul><li>Clinical Diagnosis – fever, uterine tenderness, Leucocytosis </li></ul><ul><li>Histologic chorioamnionitis more common </li></ul><ul><li>Ascending infection, rarely haematogenous </li></ul><ul><li>Polymicrobial </li></ul><ul><li>Increased PTD, PNMR, C Palsy, Endometritis </li></ul><ul><li>Treatment – Antibiotics and delivery </li></ul>
  33. 33. Miscellaneous <ul><li>Malaria </li></ul><ul><li>Mycoplasma </li></ul><ul><li>HPV </li></ul><ul><li>Tropical diseases </li></ul>

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