Perinatal Infections part 2

1. Perinatal Infections
part 2

2. Herpes simplex
Infective organism: Genital herpes is a sexually transmitted
infection and is most commonly caused by HSV-2
Neonatal herpes is most commonly acquired at or near the
time of delivery due to contact with infected secretions
Neonatal herpes can be caused by both HSV1 and 2

3. Herpes simplex
Maternal presentation:
-Primary or Recurrent ulcerative lesions on the vulva, vagina or cervix
-Erythema ---Vesicles that crust to ulcers
-A primary infection may be associated with systemic symptoms and may cause urinary
retention
-Remains latent in trigeminal nerve (HSV1) and sacral ganglia (HSV2)

4. Neonatal Herpes
-Neonatal herpes is classified into three subgroups:
1. Localized to skin, eye /mouth
2. Local central nervous system disease (encephalitis)
3. disseminated infection with multiple organ involvement

5. Neonatal Herpes
The risks are greatest when a woman acquires a new infection (primary genital herpes) in
the third trimester, particularly within 6 weeks of delivery
Mostly during labour
Very rarely, congenital herpes may occur as a result of transplacental intrauterine infection

6. Herpes simplex
-Acyclovir is recommended (400 mg three times daily) to reduce the duration and severity of
symptoms (safe in pregnancy)
Primary infections (maternal to fetal transmission of 41 %)
-If the delivery isn’t within the next 6 weeks, the pregnancy should be managed expectantly and
vaginal delivery anticipated
-Start acyclovir from 32 weeks of gestation to reduce HSV lesions at term
-C-section should be the recommended for all cases of primary genital herpes in the third
trimester(after 28 weeks )
-If the patient chooses vaginal birth, ROM, fetal scalp electrodes ,fetal blood sample should not
be used.
-IV acyclovir intrapartum to the mother is given

7. Herpes simplex
Recurrent infections
Risk of neonatal herpes 0-3 %
-A recurrent episode of genital herpes occurring during the antenatal period is not an
indication for delivery by C-section
-Daily suppressive acyclovir 400 mg three times daily should be considered from 32 weeks’
gestation.
-Invasive procedures in labour should be avoided for women with recurrent genital herpes
lesions

9. Group B streptococcus
Infective organism Group B streptococcus (Streptococcus agalactiae)
a vaginal commensal
most common cause of early neonatal sepsis
Transmission can occur from the time the membranes are ruptured until delivery
Universal screening is carried out in the USA
Selected screening by the MRCOG (low vaginal swab)

10. Group B streptococcus
Maternal presentation:
-Asymptomatic
Neonatal presentation:
-Signs of neonatal sepsis
-Sudden collapse
-Tachypnoea
-Nasal flaring
-Poor tone
-Jaundice

11. Group B streptococcus
management
If GBS is detected incidentally or by screening, treatment during labour is
needed
Antibiotics (benzylpenicillin) given in labour are effective in reducing
early-onset neonatal GBS infection
Clindamycin to be given if there is a history of penicillin anaphylaxis

12. Group B streptococcus
Management
IV penicillin G 3 g given as soon as possible after the onset of labour (or after
development of a risk factor) and 1.5 g four hourly until delivery.

13. Group B streptococcus
Management of neonates:
Blood cultures should always be obtained before antibiotic treatment is commenced, and
cerebrospinal fluid (CSF) cultures should be considered.
Any newborn infant with clinical signs of infection should be treated with broad-spectrum
antibiotics, which provide cover against early-onset GBS disease.

14. Group B streptococcus
All women with a previous baby with sepsis should be treated even if screened negative or
unscreened
Antenatal treatment of asymptomatic women is not needed
Treatment in planned caesarean section with intact membranes is not needed

15. Chlamydia
Infective organism: Chlamydia trachomatis is an obligate intracellular organism
Screening: it is not a routine antenatal screening test but needed before some procedures
as IUD insertion , HSG…..etc
Transmission to the fetus occurs at the time of delivery

16. Chlamydia
Neonatal and obstetric presentation:
-conjunctivitis (ophthalmia neonatorum) 30-50 %
-Pneumonia (10-20%)
-Preterm rupture of membranes
-Preterm delivery
-Low birthweight
-Post partum and intrapartum pyrexia
(chorioamnionitis and endometritis )

17. Management of chlamydia in pregnancy
Diagnosis by NAAT by vaginal swab or first urine catch
-Treatment with azithromycin or erythromycin
- drug of choice during pregnancy is erythromycin for 7 days

18. Gonorrhoea
Infective organism: Neisseria gonorrhoeae (gram negative diplococci)
Maternal presentation:
-Asymptomatic
-May present with a mucopurulent discharge or dysuria.
-Rarely disseminated gonorrhoea may cause low-grade fever, a rash and
polyarthritis
Neonatal presentation:
ophthalmia neonatorum
-Preterm rupture of membranes and preterm labour ?

19. Gonorrhoea
management
Diagnosis needs a culture
There is an increased risk of coinfection with chlamydia
Testing for concomitant infection with chlamydia should be done
Cephalosporins are effective against gonococcus (ceftriaxone single dose )
Empirical treatment for chlamydia should also be considered (azithromycin in
pregnancy instead of doxycycline in non-pregnant women )
(Ceftriaxone 500 mg IM stat + azithromycin 1g po stat )

20. Human Immunodeficiency Virus
Infective organism: HIV virus is a ribonucleic acid (RNA) retrovirus
Transmission: through sexual contact; blood and blood products; shared needles for IV
drug users
Vertical transmission: mainly occurs in the late third trimester, during labour, delivery or
breast feeding.
Screening: Routine antenatal screening is done for all pregnant women

21. Human Immunodeficiency Virus
The principal risks of vertical transmission are related to maternal plasma viral load,
obstetric factors and infant feeding.
Risk factors for vertical transmission of HIV:

22. Human Immunodeficiency Virus
Interventions to reduce the risk of HIV transmission:
Overall risk is 2 % , risk of transmission with full precautions is 0.57%
-Delivery by elective caesarean section in the presence of a high viral load more than 400 HIV RNA
copies/ml after 36 weeks with IV zidovuidine is still needed in CS if the viral load is more than 1000
-Viral load more than 50 can be managed by caesarean section taking into account patient risks and
consultant opinion
-Vaginal delivery can be allowed if the patient is on treatment and viral load is less than 50 HIV RNA
copies/ml and resume therapy during labor

23. Antiretroviral therapy, given antenatally and intrapartum to the mother and to the
neonate for the first 4–6 weeks of life
All pregnant women with HIV should be treated at least starting from 24 weeks with
combination antiretroviral therapy
Women who do NOT require HIV treatment for their own health should be offered
antiretroviral therapy between 28 and 32 weeks’ and be continued intrapartum to prevent
vertical transmission
Avoid breastfeeding

24. Human Immunodeficiency Virus
Neonatal management:
The cord should be clamped as early as possible after delivery and the baby should be
bathed immediately after the birth
HIV positive patients should be advised not to breastfeed
All infants born to women who are HIV positive should be treated with antiretroviral
therapy from birth for 4–6 weeks
PCR is used for the diagnosis of infant infections. done at birth, then at 3 weeks, 6
weeks and 6 months.

25. HEPATITIS B
Infective organism: hepatitis B virus (HBV) is a DNA virus
Transmission: mainly in blood, other body fluids such as saliva, semen and vaginal fluid
Vertical transmission is very common (95 % if active with positive e Ag )
Screening; Serological screening for HBV should be offered to pregnant women
Mother-to-child transmission of HBV is preventable through administration of vaccine and Ig
to the baby at birth (vaccine : at birth, at 1 month and at 6 months )

26. HEPATITIS B
incubation period of 6 weeks to 6 months
Management:
Women who screen positive for hepatitis B should be referred to hepatologist for
ongoing monitoring
To prevent vertical transmission a combination of hepatitis B Ig and hepatitis B vaccine
are given.
The active vaccine is given to the neonate in three doses: at birth, at 1 month and at 6
months of age.

27. HEPATITIS C
Infective organism: hepatitis C virus (HCV) is a RNA virus.
Vertical transmission can occurc due to contact with infected maternal blood around
the time of delivery.
The risk of vertical transmission increases with increasing maternal viral load but less
than hepatitis B (5%)
Screening: not recommended for low risk paitents.

28. HEPATITIS C
Clinical presentation:
After initial infection only 20% of women will have hepatic symptoms, 80% being
asymptomatic.
Management:
The patient should be offered post test counselling and referral to a hepatologist for
management and treatment of her infection
Screen for HIV
Interferon and ribavirin are contraindicated in pregnancy
Not an indication for CS nor breastfeeding

29. Hepatitis A and E
Hepatitis A has no risk on the baby
Hepatitis A in pregnancy is dangerous with maternal mortality of 5 % and
fulminant liver failure of 15 %