Update on diagnosis & treatment of Perinatal infections

1. Dr. Padmesh

2. • INTRODUCTION:
• Important cause of still births and morbidity
• Many diseases go undiagnosed
• Appropriate treatment can prevent morbidity/mortality
• 1971: Andres Nahmias proposed acronym ToRCH
• 1975: Harold Fuerst added Syphilis to the acronym.

3. • ACRONYM: TORCHES CLAP
-TOxoplasmosis -Chickenpox
-Rubella -Lyme disease
-CMV -AIDS
-Herpes simplex -Parvovirus B19
-Enterovirus
-Syphilis
• Latest addition: Zika virus

5. • Toxoplasma:
• Diagnosis :
• IgG, IgM, IgA (Serum/CSF)
• PCR
• Ophthalmologic, auditory, and neurologic
examinations
• CT Brain
Redbook American Academy of Pediatrics.
2012. p. 720–8.

6. • Toxoplasma:
Investigations
Normal
Negative
Abnormal
TREAT FOR 12
MONTHS
Positive
Repeat
IgG after
6 months

7. • Toxoplasma:
• Treatment :
• Pyrimethamine, sulphadiazine and folinic acid for a
duration of 1 year.

8. • Toxoplasma:
• Prevention- counselling :
– Avoid raw/undercooked meat
– wash hands after gardening
– wash raw vegetables
– minimise contact with young kittens and their litter etc

10. • Rubella:
• In Maternal infection:
- No treatment available
1st Trimester: Consider termination.
2nd Trimester: Consider fetal testing.
After 20 wks gestation: Rarely causes CRS

11. • Rubella:
• Diagnosis :
• Isolation of virus by PCR or culture
• Rubella-specific IgM (False positivity +/-)
• Increasing IgG over first 7 to 11 months of life.
• Avidity testing of IgG
• Rubella virus RNA by reverse transcriptase PCR in
nasopharyngeal swabs, urine, CSF, and blood at
birth

12. • Rubella:
• Diagnosis : Avidity:
• Strength with which IgG binds to antigenic epitropes
expressed by a specific protein.
• Gradually matures over months.
• IgG produced in first few months following primary
infection  Low avidity (Bind weakly to Ag)
• Therefore, LOW IgG avidity is a marker of RECENT PRIMARY
infection.
• High avidity excludes primary infection in preceding 3
months.

13. • Rubella:
• Diagnosis : Avidity:

14. • Rubella:
• Diagnosis :
AT BIRTH:
• Ophthalmology screening,
• Cardiac screening
• Hearing assessments
FOLLOW UP
UPTO 12 MONTHS

15. • Rubella:
• Treatment :
• No specific treatment
• Breast feeding not contraindicated
• Prevention:
• Vaccination

17. • CMV:
• Diagnosis :
• Virus culture from urine/saliva
• CMV-DNA PCR in urine, blood, saliva and CSF
• CMV IgM antibodies in blood before 3 weeks of age.
• IgG Avidity testing
Rev Med Virol 2010;20(4): 202–13.

18. • CMV: Treatment :
Virologically proven CMV in
Newborn
Underlying Immune
disorder
Treat as Life
threatening
infection
Immunocompetent
Life
threatening
symptoms
Non-Life
threatening
symptoms
No
Symptoms
No treatment

19. Life Threatening
infection
IV Ganciclovir for
4-6 weeks
Oral Valganciclovir
for 6 months
Non-Life threatening
infection
• CMV: Treatment :
Continue for
12 months/ Change in regimen
Viremia at 6 mths

20. • CMV:
• Treatment :
• Foscarnet, Cidofovir for refractory CMV/ Ganciclovir
resistance

22. • HSV:
• Diagnosis :
• Surface cultures: HSV culture on swab specimens
from mouth, nasopharynx, conjunctivae, and anus
12-24 hours after birth
• HSV culture & PCR from any skin vesicle present
• HSV PCR on CSF and whole blood

23. • HSV:
START EMPIRICAL IV ACYCLOVIR
Diagnostic evaluation of Newborn
Positive
SEM disease CNS/ Disseminated
Negative
IV Acyclovir for
14 days
IV Acyclovir for
21 days
IV Acyclovir for
10 days

24. • HSV:
• Treatment:
• After completion of parenteral therapy 
suppressive course of oral acyclovir for 6 months

25. • HSV:
• 85% neonatal HSV are acquired perinatally.
• True intrauterine infection  5%
• Careful speculum examination for active genital HSV
• Caesarean section reduces risk of HSV transmission

27. • Syphilis:
• Diagnosis :
• Adequacy of maternal treatment
• Examination of placenta/umbilical cord for pathology
• Dark field microscopy of suspicious lesions/body fluid
• Clinical findings suggestive of syphilis: Non immune
hydrops/ jaundice/ hepatosplenomegaly/ rhinitis/ skin rash
• Quantitative VDRL / RPR (FTA-ABS or TPHA not required)
BMC Public Health 2011;11(Suppl 3):S9.

28. • Syphilis: Treatment :
PHYSICAL EXAM
SUGGESTIVE OF
CONGENITAL
SYPHILIS
BABY’S
VDRL/RPR
4 TIMES HIGHER
TITRE THAN
MOTHER
MOTHER NOT
TREATED OR
INADEQUATELY
TREATED
INJ. PENICILLIN G OR PROCAINE PENICIILIN FOR 10 DAYS
ADDL TESTS: CSF VDRL,
LONG BONE XRAY,
OPHTHAL EVALUATION,
BERA

29. • Syphilis: Treatment :
PHYSICAL EXAM
NORMAL
BABY’S
VDRL/RPR
LESS THAN 4
TIMES
MOTHER’S TITRE
MOTHER NOT
TREATED OR
INADEQUATELY
TREATED
INJ. PENICILLIN G OR PROCAINE PENICIILIN FOR 10 DAYS
ADDL TESTS: CSF VDRL,
LONG BONE XRAY,
OPHTHAL EVALUATION,
BERA

30. • Syphilis: Treatment :
PHYSICAL EXAM
NORMAL
BABY’S
VDRL/RPR
LESS THAN 4
TIMES
MOTHER’S TITRE
MOTHER NOT
TREATED OR
INADEQUATELY
TREATED
INJ. BENZATHINE PENICILLIN 50000 U/Kg/dose IM
SINGLE DOSE
ADDL TESTS: CSF VDRL,
LONG BONE XRAY,
OPHTHAL EVALUATION,
BERA

31. • Syphilis: Treatment :
PHYSICAL EXAM
NORMAL
BABY’S
VDRL/RPR
LESS THAN 4
TIMES
MOTHER’S TITRE
MOTHER
ADEQUATELY
TREATED
DURING
PREGNANCY
NO TREATMENT REQUIRED IF FOLLOW-UP IS CERTAIN
ELSE, INJ. BENZATHINE PENICILLIN 50000 U/Kg/dose IM
SINGLE DOSE
NO FURTHER EVALUATION

33. • Varicella:
-7 -5-6 -2-4 -3 +1-1 +3+2 +4

34. • Varicella:
-7 -5-6 -2-4 -3 +1-1 +3+2 +4
Newborn will have protective antibodies
Likelihood of severe disease is low
- Do not separate baby from mother
- Continue breast feeding
- No VZIG
-Acyclovir if baby develops rash

35. • Varicella:
-7 -5-6 -2-4 -3 +1-1 +3+2 +4
Newborn will not have protective antibodies
Likelihood of severe disease is high
-Separate baby from mother
-If baby devps rash  stay with mother
-VZIG within 72 hours
-Acyclovir

36. • Varicella:
-7 -5-6 -2-4 -3 +1-1 +3+2 +4
Newborn will not have protective antibodies
But, likelihood of severe disease is low
-Separate baby from mother
-If baby devps rash  stay with mother
-No VZIG
-Acyclovir if baby develops rash

38. • TB: MOTHER WITH TB
ON TREATMENT/ NO
TREATMENT
TREATMENT
COMPLETED
LOOK FOR CLINICAL EVIDENCE OF CONGENITAL TB
ABSENT PRESENT ABSENT
CXR,
3 GASTRIC ASPIRATES
CXR, LP
3 GASTRIC ASPIRATES
Treat : HRZE
INH
PROPHYLAXIS MANTOUX AT 3 MONTHS
FOLLOW UP
AND EVALUATE
FOR CLINICAL
EVIDENCE TILL
6 MONTHS

39. • TB:
• Reassure the mother to breast feed the baby
• Separation of mother & baby required only if mother
– is sick
– non adherent to treatment
– has MDR TB

40. • CONCLUSION:
• Universal vaccination.
• Prompt recognition and management.
• Public health measures: antenatal screening for
syphilis, HIV and hepatitis B .
• Good hygiene