Infections during Pregnancy

 Identify some of the important infections that can happen during pregnancy
o Bacterial as group B streptococci, gonorrhea, syphilis
o Viral as Rubella, Herpes, Cytomegalovirus, HPV, parvovirus, Hepatitis, HIV,
Varicella
o Protozoal as toxoplasma
o Chlamydia
 Identify the effect of these infections on pregnancy
 Identify the effect of pregnancy on these infections
 Identify methods of diagnosis of these infections
 Describe treatment protocols of these infections
 Appreciate screening and prevention of these infections
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Introduction:
Pregnant women are at higher risk of severe infection and death from certain pathogens compared
with non-pregnant women.
In addition to rubella and syphilis, for which pregnant women are routinely screened,
the following infections during pregnancy place the mother and the infant at high risk for potential
morbidity and mortality:
 The TORCH syndrome refers to an infection developing in a fetus or newborn.
o T – Toxoplasmosis.
o O – Other, which includes (syphilis, hepatitis B and C, and HIV).
o R – Rubella.
o C – Cytomegalovirus.
o H – Herpes simplex virus.

IMMUNOLOGIC RESPONSE DURING NORMAL PREGNANCY:

- The nonspecific (innate) mechanisms of the immunologic system
(including phagocytosis and the inflammatory response) are not affected by pregnancy.
- The specific (adaptive) mechanisms of the immune response (humoral and cellular) are also not
significantly affected.
- Vitamin D may be an important regulator of the immune system during pregnancy.

Infections:
- Exposure to certain infections during pregnancy has been recognized as a significant cause of:
1. Birth defects.
2. Abortion.
3. Preterm labor.

Knowledge of the potential effects of fetal infection is important for:

 Counselling patients with known exposures to these pathogens in pregnancy.
 As well as in the work-up of an abnormal fetus or neonate.

In addition, some congenital infections may lend themselves to various interventions to improve
outcomes (e.g., fetal transfusion for parvovirus, antibiotics for toxoplasmosis).

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Classification of Infections and Pregnancy (Turner, 2014):
Infections in pregnancy are 3 categories:

A. Infections specific to B. Infections exacerbated during C. Infections incidental to

pregnancy pregnancy e.g. pregnancy e.g.
1. Chorioamnionitis 1. Urinary tract infection, 1. Viral hepatitis
2. Endometritis (with or without including pyelonephritis 2. Human Immunodeficiency Virus
retained products of conception) 2. Pneumonia (HIV)
3. Wound infection post 3. Rubella 3. Sexually Transmitted Diseases
caesarean section 4. Listeria (STDs)
4. Perineal infection 5. Influenza 4. Tuberculosis
5. Lactational mastitis 6. Varicella 5. Endocarditis
7. Toxoplasmosis
8. Herpes infection
9. Parvovirus
10. Cytomegalovirus (CMV)
Bacterial diseases:
Important bacterial diseases include:
1. Group B streptococci.
2. Gonorrhoea.
3. Syphilis.
4. Chlamydia
1. Group B streptococci (Streptococcus agalactiae):
Group B streptococci are NOT the group A beta hemolytic that cause upper respiratory tract
infections.
- (Streptococcus agalactiae) is the most common cause of severe early onset
(< 7 days of age) infection in new born infants.

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2. Gonorrhoea:

Group B streptococci Gonorrhea Syphilis

3. Syphilis:
The rise in congenital syphilis has paralleled the increase in primary and secondary syphilis in
adults.
- T. pallidum appears to be able to cross the placenta at any time during pregnancy.
- The incidence of congenital infection is inversely proportional to the:
o Duration of maternal infection
And to the
- Degree of spirochetemia – directly proportional
Recent or secondary infection in the mother confers the greatest risk of fetal infection.

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Effects of syphilis also include:
1. In utero infection may result in:
- miscarriage
- hydrops
- stillbirth
- neonatal death.

2. Congenital infection can manifest as:

1. Hepatosplenomegaly.
2. Characteristic desquamative skin rash.
3. Snuffles.
4. Jaundice.
5. Pseudoparalysis.
6. Anemia, and thrombocytopenia.
3. Later manifestations in childhood include:
1. Interstitial keratitis.
2. Nerve deafness.
3. Anterior bowing of (“saber”) shins.
4. Frontal bossing.
5. Mulberry molars.
6. Hutchinson’s teeth.
7. Saddle nose.

Screening: All pregnant women are screened for syphilis.

- ACOG recommends that all patients be tested at their first prenatal visit.
- Repeat testing is recommended in the third trimester (at 28 to 32 weeks)
- And again at delivery in women who are at high risk for syphilis,
- Or those who had a positive screening test in the first trimester.
Any woman who delivers a stillborn infant after 20 weeks should also be tested.

Diagnosis: All are screened and confirmatory test is done.

Treatment:
Tetracyclines are contraindicated in pregnancy and erythromycin may not adequately treat the
fetus.
The treatment for syphilis in pregnancy is benzathine penicillin. (Dosage depends on the stage of the
disease.)
 Patients who have a positive penicillin skin test should be desensitized and
treated with penicillin, because the risks associated with syphilis during
pregnancy outweigh the risks of inpatient treatment of a penicillin allergy.
 Close monitoring of non-treponemal tests (RPR or VDRL)
should be followed to ensure an appropriate response to therapy.

4. Chlamydia:
- Source: STD
- Effect: Is related to preterm delivery
- Treatment: Azithromycin

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Viral Diseases:
1. Rubella
2. Herpes Simplex Virus
3. Cytomegalovirus
4. Human Papilloma Virus
5. Parvovirus
6. HBV
7. HIV
8. Vericella – Zoster

1. Rubella:

Vaccination has reduced the rate of infection in pregnant women with a reported incidence of
<0.1% of pregnancies, but the vaccine should not be given during pregnancy.
- In the mother, if infection occurs the symptoms are:
1. malaise and myalgia
2. In the presence of a nonpruritic, maculopapular, reddish rash.

- The highest risk to the fetus is associated with infection during the first trimester.
1. Deafness (Deafness occurs when infection takes place between Weeks 7
and 8. )
2. retinopathies, (infection occurs during Week 6, cataracts may form)
3. Central nervous system
4. cardiac malformations are the most common teratogenic manifestations.

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Screening: (all pregnant are screened)
If clinical data are suggestive of rubella infection then
Test serum for rubella-specific IgG and IgM.
Presence of a rubella infection is diagnosed by:
 A 4-fold rise in rubella IgG antibody titre between acute and convalescent serum.
 A positive serological test for rubella-specific IgM antibody.
 Serological tests are best performed within 7–10 days after the onset of the rash and
repeated 2–3 weeks later.
Diagnosis: - Acute infection in pregnancy.
- Fetal/neonatal affection.
Treatment: No treatment is available for rubella but prevention using the measles, mumps and
rubella (MMR) vaccine is strongly recommended.

2. Herpes Simplex virus:

It is estimated that 20-30% of pregnant women are IgG positive for HSV-2 before pregnancy and are
therefore at risk for shedding virus during pregnancy.
About 2-4% of IgG negative women acquire HSV-2 during pregnancy and are usually not diagnosed
because of a lack of symptoms.
Immunocompromised women and those who have another STI are at highest risk.
Some cases of postnatal transmission have been reported.
Factors which influence transmission:
1. Type of maternal infection (primary or recurrent).
2. Presence of transplacental maternal neutralizing antibodies.
3. Duration of rupture of membranes before delivery.
4. Use of fetal scalp electrodes.
5. Mode of delivery.

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The neonatal effects may be severe and are due to exposure to the virus in utero or during delivery.
The complications of disseminated neonatal disease are:
1. Seizures.
2. Tremors.
3. Poor feeding.
4. Bulging fontanelles.
Up to 30% of new born may die, with more than
50% having neurological damage despite antiviral Therapy.

It differs by the type of infection either it is primary or secondary

- Primary Infection – risk is greatest with a newly acquired infection (primary
genital herpes) in the third trimester, particularly within 6 weeks of delivery,
as viral shedding may persist and the baby is likely to be born before the
development of protective maternal antibodies.

- Recurrent genital herpes – associated with a very low risk of neonatal

herpes.
• Recurrent herpes at the time of delivery which is commonly asymptomatic
or unrecognized may cause localized forms of neonatal herpes, affecting the
CNS, skin, eye, and mouth.
• Transplacentally acquired HSV antibodies do not prevent neurogenic virus spread to the brain of
the neonate.
• Disease localized to skin, eye, and mouth – has the best prognosis; death is unusual.

Note: With antiviral treatment neurological and/or ocular morbidity is < 2%.

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3. Cytomegalovirus (CMV):
• The most common cause of intrauterine infection – 0.2% to 2.2% of all live births.
• A common cause of sensorineural hearing loss and mental retardation.

The Highest rate of transmission is in the third trimester but the severity of fetal effects is highest
in the first trimester. The infection may also be “reactivated” during pregnancy.

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Screening: Do not routinely test (serological) pregnant women for CMV to identify those who have
acquired primary infection during pregnancy.

Diagnosis of Fetus: It is helpful but not diagnostic because CMV has features in common with other
intrauterine infections and these abnormalities are observed in < 25% of infected fetuses.
Fetal USS is neither sensitive nor specific to congenital CMV infection.

Treatment: Ganciclovir and valacyclovir have been used in non-pregnant women and in neonates
after birth.

Human Papilloma Virus (HPV):

5. Parvovirus:
The virus targets rapidly growing erythroid progenitor cells in:
1. bone marrow
2. fetal liver
3. umbilical cord
4. Peripheral blood.
Infection – common with 50–60% of adults having been infected.
Risk of acquiring parvovirus infection in pregnancy is 1:400.

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Hydrops: Fetal anaemia, combined with the shorter half-life of fetal red blood cells, leads to:
1. severe anemia (due to hemolysis)
2. hypoxia
3. high output cardiac failure
Treatment may include intrauterine transfusion

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6. Hepatitis B Virus (HBV):

7. Human immunodeficiency virus (HIV):

HIV positive mother

• to optimize health of mother and baby – advise to delay conception until:
1. HAART regimen is optimised and is effectively suppressing viraemia.
2. Prophylaxis against PCP is no longer required.
3. Any opportunistic infections are treated.
• Folate supplementation – higher dose folate (5 mg) for women taking cotrimoxazole.
• Yearly cervical cytology because of the association of HIV, immunosuppression, and cervical
neoplasia.
Without treatment, the risk of transmission to the fetus is 15% to 25%.
Breastfeeding increases transmission by an additional 12% to 14%.
The benefits of ARV drugs for a pregnant woman must be weighed against the risks of adverse
events to her, the fetus, and new born. Combination drug regimens are considered the standard of
care both for treatment of HIV infection and for prevention of perinatal transmission of HIV.
After counselling and discussion about ARV drug use during pregnancy, a pregnant woman’s
informed choice should be respected.

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8. Varicella – Zoster:
 The infection is much more severe in adults than in children, and pregnancy does not
seem to alter this risk.
 The frequency of fetal infection secondary to the first-trimester maternal infection is less
than 5%, although transplacental transmission occurs in about 24% of maternal
infections in the last month of pregnancy.
 Maternal zoster is not associated with a significant risk to the fetus.
 May affect cutaneous or mucocutaneous, neurologic and occular abnormalities:

 Neonatal varicella can occur when maternal viremia occurs around the time of delivery.
Thus, neonates born to women with clinical varicella occurring several days prior to and
within a few days after delivery should be appropriately treated and monitored.

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Toxoplasma:

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Q1) A 22-year-old woman presents to your clinic to establish prenatal care after having a positive
pregnancy test. Her last menstrual period (LMP) was 5 weeks ago and was certain. She has no past
medical or surgical history and this is her first pregnancy. You do a complete physical examination
and inform the patient you have some routine labs you would like to order for you to have in the
management of her care. The results are as follows:
HIV: negative
HbsAg: negative
Rubella IgG: 1 0
Rapid plasma reagin: nonreactive
GCC (a test for gonorrhea and chlamydia) : negative
What further steps should you take in this patient's care from these results, if any?
(A) Repeat GCC during the second trimester
(B) Get a full hepatitis panel and viral load
(C) Immunize the patient for hepatitis B
(D) Immunize the patient with MMR postpartum
(E) Order a treponema! antibody test

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Q2 A 20-year-old, G2P0, presents for prenatal care at 12 weeks. Her initial prenatal bloodwork
shows that she is nonimmune for rubella. She is concerned with the risks that rubella infection can
have on the developing fetus and desires vaccination. You counsel her that:
A Congenital rubella is a leading cause of deafness and that vaccination should be administered as
soon as possible.
B Rubella vaccine is a live virus and should be administered only after the first trimester.
C Rubella vaccine is a live virus and is contraindicated in pregnancy because of the high rate of
congenital infection.
D Rubella vaccination in pregnancy poses a theoretical risk only in pregnancy, but is still
contraindicated because of this theoretical risk.

Q3 History
A 31-year-old pregnant Russian woman came to the Egypt 6 weeks ago with her husband.
As a result she booked late with the midwife at 31 weeks’ gestation. This is her first ongoing
pregnancy, having had two uncomplicated surgical terminations approximately 10 years ago.
She reports a history of genital herpes diagnosed by her general practitioner several weeks ago.
There is no relevant previous general medical history or family history.
She had an apparently normal first-trimester scan and has had a normal anomaly scan in this hospital
at 30 weeks’ gestation.
Examination
Blood pressure is normal and symphysiofundal height is consistent with menstrual dates.
Investigations

Questions:
1. What is diagnosis?

2. How should the women be further investigated and treated?

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Q4.
A 28-year-old G1P0 woman at 28 weeks’ GA comes to your office for a routine prenatal visit. She works as a
kindergarten teacher and one of her students was recently sent home with a rash and fever. She states that
the child had a rash on both cheeks and the pediatrician said it was a viral infection called fifth disease. She
relates the baby is moving well and denies any vaginal bleeding, abnormal vaginal discharge, or contractions.
She wonders if she needs any more testing to see if she has been affected.

1. What is the most likely causative organism of the child’s infection?

2. How would it be transmitted to the fetus?

You send serologies for the agent above and they come back showing the patient has a positive IgM and
negative IgG consistent with an acute infection.
3. What is the most common fetal/neonatal complication of this infection during pregnancy?

Q6. How would you counsel 2 pregnant women; one exposed to a child with diagnosed rubella infection and
the other exposed to another child with chicken pox?

Q7. In this wide range of infections with pregnancy, would you try to suggest a screening program for these
problems?

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