Infections in pregnancy, foetus and neonates


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Infections in pregnancy, foetus and neonates

  1. 1. Infections in Pregnancy, Foetusand NeonatesDr. Devika IddawelaDepartment of ParasitologyY3S2
  2. 2. ObjectivesList common infections in pregnancy, and NeonatesKnow the principals of diagnosis, management andprevention of thoseRevise information on TORCH screening
  3. 3. Fetal and Neonatal infectionInfections occur in the pre, peri and post natalperiodsBaby tends to be susceptible because of Immature host defense Primary encounter with the organism Passive immunity from the maternalantibodies
  4. 4. Modes of transmissionVertical transmission – transmission that is unique toa mother/baby relationship.Note: All neonatal infections where mother is asource are transmitted verticallyIn utero(congenital)AscendingtransplacentalIntra partum GenitalPostpartummotherOther
  5. 5. VirusesRubellaCytomegalovirus(CMV)Parvo virus B 19Varicellar ZosterHepatitis B virusHIVMaternal infections transmitted to foetusSpirochetesTreponema PallidumListeriamonocytogenesBacteriaMicobacterium lepraeGroup B streptococciTissue protozoaToxoplasma Gondii
  6. 6. Site of infection PhenomenonNeisseria gonorrhoea Conjunctiva Neonatal conjunctivitis (NC)Clamydia trachomatisConjunctiva, NC, Pneumoniarespiratory tractHSV Skin, Eye, mouth Neonatal herpeticinfectionGenital Papilloma virus Res. Tract Laryngeal wartsGroup B sreptococci, RT septicemiagram-negative bacilliCandida albicans Oral cavity Neonatal oral thrushNeonatal infections acquired during passage down aninfected birth canal
  7. 7. Infections that are more severe in pregnancyInfection CommentMalaria CMI,Choice of treatmentViral hepatitis - Fulminant liver necrosisInfluenza Increased mortalityPoliomyelitis Paralysis commonUTI Cystitis; pyelonephritis morecommon, atony of bladder anduterine pressure leads to lesseffective flushing, empting
  8. 8. Reactivation or persistent infections inPregnancy• CMV• EBV• HSV
  9. 9. RubellaRNA virusClinical features: Maculopapuar rash Lymphadenopathy FeverArthropathyaffect anyone of any age andis generally a mild disease,
  10. 10. Risks of rubella infection during pregnancyPreconception minimal risk0-12 weeks 100% risk of fetus being congenitallyinfected resulting in majorcongenital abnormalities.Spontaneous abortion occurs in 20%of cases.13-16 weeks deafness and retinopathy 15%after 16 weeks normal development, slight riskof deafness and retinopathy
  11. 11. Congenital rubella syndromeClassical triad Cataract Heart defectsperipheral pulmonary stenosis,pulmonary valvular stenosis,patent ductus arteriosus,ventricular septal defect) Sensorineural deafness
  12. 12. Organ involved effectBrain Small brain, mental retardationEye retinopathy, Cataract,micropthalmiaear Hearing defectsSensorineural deafnessLiver, spleen HepatosplenomegalyThrombocytopenic purpuraanaemiaGeneral Low birth weightFailure to thriveIncreased infant motility
  13. 13. Laboratory diagnosisAcute infectionRaising titres of IgG – ELISAPresence of Rubella specific IgM -ELISAThe diagnosis of congenitally acquired rubella is made by;• The presence of rubella IgM in cord blood or serum samplestaken in infancy.• Detection of rubella antibodies at a time when maternalantibodies should have disappeared (approx.6 months of age)•Isolation of rubella virus from infected infants in the first fewmonths of life.
  14. 14. PreventionVaccination - Live attenuated vaccinein childhood or immediately postpartumavoid pregnancy for 3 months
  15. 15. Cytomegalovirus• DNA virus ,member of the herpesvirus• primary infection usually asymptomatic. Virusthen becomes latent and is reactivated from timeto time.• 60% of the population eventually becomeinfected.• Virus is generally passed from infected people toothers through direct contact with body fluids, such asurine, saliva, or breast milk, vaginal secretions, semen
  16. 16. •Foetus can be infected by- transplacetal routePrimary maternal infection during first halfof pregnancy ( higher)ReactivationMay be transmitted to the foetus during allstages of pregnancy. Perinatal infection: Infected maternalgenital tract secretions, breast feeding
  17. 17. Defined as the isolation of CMV from the saliva or urinewithin 3 weeks of birth.Commonest congenital viral infection,affects 0.3 - 1% of all live births.The second most common cause of mental handicap afterDowns syndrome and is responsible for more cases ofcongenital damage than rubella.Congenital Infection
  18. 18. Mental Retardation,Cerebral Palsy, periventricular calcificationmost commonly, hearing impairmentEye abnormalities –ChorioretinitisHepatoslenomegaly, thrombocytopenic purpuraCMV retinitisClinical manifestations
  20. 20. TRANSPLACENTAL TRANSMISSIONPRIMARY MATERNAL INFECTION:2-6% mothers/yr seroconvert in pregnancyTransmission 40 – 50 %Earlier mat. inf. = more severe the fetal inf.RECURRENT MATERNAL INFECTION:Transmission 0.5-1.5%most infants asymptomaticInfection acquired during delivery or viabreast feeding poses negligible risk
  21. 21. DIAGNOSIS OF CONGENITAL CMV INFECTION IN FOETUSAmniocentesis - viral culture and PCRUltrasoundCerebralcalcification
  22. 22. Diagnosis in neonatea diagnosis can only be made if the virus is detected within2-3 weeks of life. Isolation of CMV from urine, saliva and throat swab ofthe neonate Presence of CMV IgMManagementPrimary infection – consider terminationAntenatal screeningVaccination- may become availablein the near futureTreatment for Babies Born with CMVGanciclovir, an antiviral drug, may prevent hearingloss and developmental outcomes in infantsHowever it has serious side effectsAntibody tests of mother cannot be used to diagnose congenitalCMV
  23. 23. Neonatal herpes simplexIntrauterine (5%), peripartum During delivery (85%), orpostpartum (10%)Transmission during birth is the commonestIf the lesions are present, cesarean section mayreduce the chance of transmissionPrimary infection make more damage thansecondary infection because of large viral loadPremature rupture of membrane is a risk factorRisk is small from recurrent infections in themother due to low viral load & antibodies
  24. 24. Clinical presentation1. skin, eyes, and mouth herpes (SEM)Most are asymptomatic at birth3 clinical presentations between birth and 4 weeks patterns of
  25. 25. 2.disseminated herpes (DIS) –Involve the liver, Lung, adrenals&brain3. central nervous systemherpes(CNS)- when the brain isinvolved prognosis is bad
  26. 26. A large number of survivors of HSVinfection have residual disabilitiesAcyclovir should be given to allsuspected cases of neonatal HSVinfection
  27. 27. Varicella Zoster ( Chicken pox)Maternal Inf Potential consequences<20 wks gest Spont abortionFetal Varicella Syn - 2%any stage Fetal death,herpes zoster 1st yr of lifeNear term5d<delivery2d>deliveryCong disseminated varicellaVaricella pneumonia(can be fatal)
  28. 28. Low birth weightSkin: Cicatricle lesionsin dermatomal distributionBone: Limb hypoplasiaequinovarus, calcaneovalgus;hypoplasia mandible, clavicle, scapula,digits.CNS: MR, seizures, cortical atrophyEye: chorioretinitis, nystagmus,microphthalmia, cataract,corneal opacities, optic atrophyFETAL VARICELLA SYNDROME - FVS
  29. 29. Varicella Zoster immunoglobulin (VZIG) and early antiviral treatment should be given according to state ofinfectionState RxMat exposure VZIG - non-immune motherMat infection(Prevent FVS)Acyclovir to Rx motherVZIG to the risk FVSMat infection5d beforeor 2d>deliveryAcyclovir to motherVZIG to neonateNeonatal varicella(life-threatening)IV Acyclovir(VZIG at birth)
  30. 30. Parvovirus B19Casual agent of 5th disease ( erythema infectiosum)Spread by the respiratory route. 60 -70% of thepopulation is infectedCongenital parvovirus infectionCause hydrops fetalis, haemolytic anaemia, myocarditis,abortionsRisk of foetal death highest when infection occurs during thesecond trimester
  31. 31. Spontaneous resolution of anemia andhydrops often occurs if > 20 wksFetus can rapidly deteriorate and should bemonitoredIf fetal anemia or hydrops persists determinefetal hemoglobin level.If fetal Hgb is <5 g/dLconsider intrauterine blood transfusion
  32. 32. Congenital syphilisVertical transmission commonly occur after 4months of pregnancy.Treatment of mother before 4 months ofpregnancy prevent foetal infectionClinical features in infants:RhinitisSkin & mucosal lesionsHepatosplenomegalyLymphadenopathyAbnormalities of bone , teeth andcartilage( Saddle shaped nose)
  33. 33. Congenital syphilis which may not be apparent untilabout 2 years of age ( facial and tooth abnormalitiesprevented by early detection of maternal infection ( <3 months) &Treatment of positives with penicillin.
  34. 34. • During Pregnancy 30%• Intrapartum 70%• Breast feedingexcess risk to uninfected = 12 –14%Human immunodeficiency virusVertical HIV transmission can occurin utero, during delivery andduring breastfeeding
  35. 35. Risk Increased, if:Prolonged laborPreterm deliveryInvasive proceduresChorioamnionitisAdvanced maternal disease, low CD4Risk Reduced, if:Antiviral RxElective CS before labor/ROMINTRAPARTUM RISK FACTORS
  36. 36. Clinical problems :appear sooner in infectedbaby 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 oroverwhelming infection( 20% at 18 months
  37. 37. Hepatitis BVertical transmission specially in the third trimesterIn acute infection and in chronic infectionScreening: Routine HBsAg (performed in 1sttrimester).Prevention: HBIG (Hepatitis B immuneglobulin) and HBV vaccine should be givento baby at birth.If non-immune mother exposed inpregnancy give HBIG and HBV vaccine.Complications: may cause Hepatitis ,Cirrhosis and/orliver cancer (as an adult at age of 30- 40 years)·
  38. 38. GonorrheaInfection through birth canalCan lead toConjunctivitis ( ophthalmia neonatorum)ArthritisMeningitis
  39. 39. Group B Streptococci ( GBS) 5 -20% of ladies carry GBS in vagina Infection is through birth canal Is associated with PROM Can lead to neonatal meningitis, pneumonia,sepsis Intrapartum prophylaxis is indicated for carriers
  40. 40. Urinary tract InfectionDilatation of ureters and pelvisReduction of bladder tonePressure from the gravid uterusDue to :Bacteriology – similar to non pregnant womenAsymptomatic bacteriurea unless treated a significant proportionwould develop pyelonephritis and this in turn is associated withadverse pregnancy outcomesTreatment – antibiotics should be given with care
  41. 41. Maternal parasitaemia and subsequentplacentitisMaternal infection in early pregnancy –Foetal damageTransmissionCongenital toxoplasmosisDue to Primary maternal infection
  42. 42. CF ranges from death in utero to an infected butclinically unaffected childSever congenital toxoplasmosis -10% of allcongenital infected infants ( Classical triad)HydrocephalusCerebral calcificationRetinochoroiditisSkin rash, hepatitis, pneumonia, myocarditis and myositisMay be presentCan develop ocular disease in later lifeSever congenital eye manifestations: Microphthalmia,cataract, strabismus and nystagmus
  43. 43. HydrocephalusIntracranial caicification Retinochoroiditis
  44. 44. TOXO – PRENATAL DIAGNOSIS• Amniotic Fluid - PCR parasite particles• AF and fetal blood –specific IgM, IgA, IgG• Blood / placental tissueinoculation into mice• Fetal HUS - calcifications / hydrocephalus• Isolation of parasiteplacenta, amniotic fluid, fetal blood
  45. 45. Amniocentesis• Done around 16th week of pregnancy• A long needle is inserted into the Amniotic sac andamniotic fluid is drawn.
  46. 46. Diagnosis of acute infection in pregnant mothersDetection of Toxoplasma specific IgG and IgMAcute infection:IgG – raising titerIgM, Detection of Low avidity IgG or IgA is morespecific
  47. 47. TreatmentImmunocompetent patients : Does not needtreatmentExcept when the illness is prolong or unusuallyseverePyrimethamine and Sulfadiazine+ Vitamin supplement folinic acid to prevent bonemarrow toxicitySpiramycin – pregnant mothers
  48. 48. Congenital infection;All infected infants are given specifictherapy until the age of 1 year irrespectiveof the severity of the diseaseOcular disease:Quiescent lesions recognized >1year _ observationActive inflammation: Sulphadiazine and pyrimethamineToxoplasmosis in AIDSTreatment with Sulphadiazine and pyrimethamine for 6weeks
  49. 49. Pregnant women:Spiramycin is given throughout the confinement toreduce the transplacental passage of parasite.If foetal infection is confirmed by amniocentesisPyrimethamine and Sulfadiazine+ Vitamin supplement folinic acid alternate withSpiramycin
  50. 50. Prenatal Management of CongenitalToxoplasmosis– Identified acute maternal Toxo infection– Test amniotic fluid for parasite particles– confirmed foetal CNS involvement (ultrasound)•spiromycin for acute infection inaffected mother•add pyrimethamine /sulfadiazine if fetusis affected–reduced congenital symptoms by 70%»2 of 15 children infected in uterohad chorioretinitis(
  51. 51. TORCH infectionsT = ToxoplasmosisO = Other ( Congenital syphilis, HIV, etc)R = RubellaC = Cytomegalovirus (CMV)H = Herpes simplex ( HSV)