Biologia

https://doi.org/10.2478/s11756-018-0065-y

ORIGINAL ARTICLE

Orofacial clefts and infections during pregnancy

Agáta Molnárová 1 & Drahomír Palenčár 1 & Dagmar Fekiačová 1 & Eva Bieliková 2 & Eva Tichá 3 & Eduard Ujházy 4

Received: 15 January 2018 / Accepted: 18 May 2018

# Institute of Molecular Biology, Slovak Academy of Sciences 2018

Abstract
Orofacial clefts (OFCs) are common congenital malformations of the lip, palate, or both caused by complex genetic and
environmental factors. Specific antibodies against viruses influenza, rubella, cytomegalovirus, Epstein-Barr, parotitis and hep-
atitis B were investigated serologically in children with orofacial clefts and in their mothers. The results were compared with
those obtained in control children and their mothers. Evaluation of the results and their statistical processing supports the
assumption that infection during pregnancy may have occurred in the series studied induced by viruses of influenza, rubella,
cytomegalovirus and possibly also by the Epstein-Barr virus. No association with the viruses of hepatitis B and parotitis was
established.

Keywords Infections during pregnancy . Orofacial clefts . Cleft of the lip . Cleft of the palate . Cleft of the lip and palate

Abbreviations damage: a) acute generalized infection, b) chronic conditions,

HIT Hemagglutination inhibition test with signs occurring only at a later age of the child, and c)
KFR Complement fixation test congenital malformations (Rajčáni 1983). Traditionally, the on-
NIR Indirect immunofluorescence assay ly viral infections of concern during pregnancy were those
ELISA Enzyme-linked immunosorbent assay caused by rubella virus, cytomegalovirus (CMV), and herpes
RIA Radioimmuno assay.4 simplex virus (HSV). Other viruses now known to cause con-
genital infections include parvovirus B19 (B19V), varicella-
zoster virus (VZV), West Nile virus, measles virus, enterovi-
ruses, adenovirus, human immunodeficiency virus (HIV) and
Introduction Zika virus (WHO 2016; Sharma et al. 2017).
A virus can be transferred to the fetus by several ways,
The pathogenesis of congenital anomalies caused by intrauter- including infection of the germ cell, e.g. oncogenic retrovirus
ine infections rermains a matter of interest. Viral infections are or arenavirus, via transplacental infection of the embryo (in
much more likely to harm the fetus than previously assumed the first trimester) or fetus during maternal viremia and tro-
(Watkins 2014; Beloosesky et al. 2017). Transition from moth- phoblast infection, and also in the perinatal period from am-
er to fetus during pregnancy can cause three types of neonatal niotic fluid or during birth (Velemínsky and Potužník 1984).
Whether or not the virus is manifested in the fetus is deter-
* Eduard Ujházy mined by the virulence of the infectious agent. The type of mal-
eduard.ujhazy@savba.sk formation, however, depends not only on the virus. The decisive
factor is whether or not the fetus was infected by the virus at the
1
Department of Plastic Surgery, Faculty of Medicine, Comenius time of differentiation of the structure. Several papers confirm
University, Hospital Ružinov, Ružinovská 6,
82606 Bratislava, Slovakia
that, depending on the stage of fetal development, the fetus can
2
develop a variety of malformations and/or other forms of con-
Department of Gynecology, Faculty of Medicine, Comenius
University, Hospital Ružinov, Ružinovská 6, Bratislava 82606,
genital infections (Jelínek et al. 1983; Prince and Lapé-Nixon
Slovakia 2014). The most critical period for teratogenesis is the first tri-
3
Public Health Authority of the Slovak Republic, Trnavská cesta 52,
mester. For the emergence of orofacial clefts, the critical period
Bratislava 82645, Slovakia begins between the 26th and the 30th day of gestation (crown-
4
Institute of Experimental Pharmacology and Toxicology, Centre of
rump length – CRL – of the embryo is 3–5 mm) and ends
Experimental Medicine of the Slovak Academy of Sciences, between the 52nd to 56th day of gestation, when the CRL is
Dúbravská cesta 9, Bratislava 84104, Slovakia about 22–25 mm (Jelínek et al. 1983).

Orofacial clefts (OFC) - cleft lip (CL), cleft palate (CP) and
cleft lip and palate (CLP) - are among the most common birth
defects and are a significant health and population burden
since treatment requires long-term comprehensive care. The
pathogenesis of OFC has already been well studied on exper-
imental models, but the etiology in humans, probably multi-
factorial, remains quite uncertain. It is assumed that the causes
of OFC formation could be the genetic predisposition itself or
involve the interaction of the genetic predisposition with ex-
ternal factors, or the action of an external factor alone - terato-
gen, or the interaction of several teratogens (David 2013;
Molnárová et al. 1997).
Many authors associate the origin of OFC with prenatal
infection. Hanson (1980) reports the appearance of clefts after
infection with cytomegaloviruses. Plachý et al. (1979) found
two children with clefts out of 145 autopsy children with
cytomegalovirus cells in the salivary glands. Černý et al.
(1987) assumed that cytomegalovirus can participate in the
etiology of some forms of clefts. The relationship between
prenatal rubella and OFC were shown for example by Sibille
et al. (1986), Goodday and Precious (1988) and Hall (1989).
Saxen (1975) observed the association between influenza in-
fection of pregnant women during early pregnancy, drug in-
take, fever and OFC. She found a significant link between all
the observed factors and the birth of children with OFC. Leck
and Steward (1971) described data on congenital defects in
influenza epidemics in Birmingham and compared them with
data on congenital anomalies after an influenza epidemics in
the United States. The results showed several similarities, es-
pecially in the increased incidence of limb deformities and
orofacial abnormalities after influenza A2 epidemics.
Since the discovery of congenital malformation by ru-
bella virus infection in 1941 by Gregg, other viruses that
can damage the fetus have been identified. The number of
infective viruses is most important, however many other
factors are still unknown. Especially dangerous is the pri-
mary viral infection of a pregnant woman (Buxmann et al.
2017). Some viruses (HSV) damage the fetus by being
able to persist within the organism throughout the life of
the host, which is important for vertical transmission of
the infection. During pregnancy, a persistent viral infec-
tion is often activated (Mims 1976). Some viruses, such
as measles and poliomyelitis, probably do not induce con-
genital defects but rather abortion or acute neonatal dis-
ease. Malformations occur at a critical time (2nd to 3rd
month of gestation), when even slightly damaged devel-
oping cells result in malformation due to impairment of
the organ development process, e.g. in rubella and cyto-
megalovirus (CMV) infection. If the fetal infection is se-
vere, the result is in most cases death of the fetus and
abortion. Viruses can damage the fetus without penetrat-
ing into fetal tissue when located in the placenta they
induce vascular damage, fetal anoxia, abortion and death.
Biologia
In the case of a mother’s improper viremia, the rubella virus
gets into the placenta. This infection stays in the placenta and
the virus is distributed via fetal circulation forming infection
deposits in the heart and other organs. IgG immunoglobulins
pass the placenta into the fetus and limit the spread and extent
of infection. The fetus produces antibodies against rubella
virus type IgM (Miller 1980). The newborn may have a low
birth weight and is affected by congenital heart, brain, eye,
auditory, urethral and urological malformations, lung and di-
aphragm defects. The presence of high levels of total IgM
antibodies in umbilical cord blood is an indicator of congenital
infection and a finding of specific (anti-rubella) IgM persisting
for at least three to six months confirms the unambiguous
diagnosis. An active immunization is essential for the preven-
tion of rubella. Women of childbearing age have to take con-
traceptives for two months in case of vaccination. In Slovakia,
12- to 13-year-old girls are already vaccinated. After vaccina-
tion, an increase in antibodies occurs and vaccination is likely
to leave sufficient immunological memory. The rubella virus
has until recently been considered the most important virus
with a teratogenic effect.
At present, the most important cause of congenital
malformations is the human CMV (Goderis et al. 2014). It be-
longs to herpes viruses and persists for a long time in the human
body, thus pregnant women are not only the primary infection
but also the reactivation of the latent infection (Velemínsky and
Potužník 1984). Infectious CMV can be isolated from the pla-
centa of mothers with viremia, from the lung, brain, and fetal
kidney. The virus is also present in the arterial endothelium and
fetal leukocytes. CMV-induced fetopathy, most commonly
known to date, is microcephaly, mental retardation, neuromuscu-
lar disorders and hearing disorder. CMV disease may also in-
clude icterus, hepatosplenomegaly, anemia, thrombocytopenia,
pneumonia and chorioretinitis.
Epstein-Barr virus (EBV) inducing mononucleosis in the
first trimester has been repeatedly associated with birth of a
child with a congenital defect. In particular, malformations of
the eye, micrognosis, heart and skeletal defects, cryptorchi-
dism, hypotonia, proteinuria, hepatosplenomegaly and throm-
bocytopenia have been identified. However, EBV teratogenic-
ity is not yet clearly established. Not enough transplacental
transmission of EBV and HSV has been achieved (Avgil and
Ornoy 2006). The potential teratogenicity of EBV and the
relationship of herpes simplex with OFC was reported in our
previus study (Molnárová et al. 1993, 1995).
By analyzing many observations, prospective and retrospec-
tive, the influenza virus was also found to act as a teratogen.
Conclusions coming from many authors are different, resulting
from the difficulties of accurate diagnosis of influenza. The vast
majority of authors, however, believe that a flu infection of a
pregnant mother can cause abortion, birth of a dead fetus or birth
of a fetus with congenital defects. The authors report defects of
the central nervous system, orofacial abnormalities, limb defects
Biologia
and malignant diseases (Griffith et al. 1972; Bauer et al. 1973;
Molnárová and Blaškovič 1975; Sever 1985).
The teratogenic effect of the parotitis virus is still under
discussion. It has been linked, though not confirmed, to the
onset of diabetes mellitus and fibroelastosis. Garcia et al.
(1980) described three cases of women who had a history of
parotitis during pregnancy. One of them aborted spontaneous-
ly and in the other two pregnancy was interrupted artificially.
Necrotizing proliferative villitis was found in the placenta
with placental circulatory disorder. Necrosis and organ miner-
alization have been found in organs of the fetus. Other authors
(Thompson and Glasgow 1980; Koskiniem and Vaheri 1982;
Enders 1983; Tyor and Harrison 2014) were also involved in
the monitoring of parotitis during pregnancy.
Infection with hepatitis B virus has not yet revealed
embryopathy, but premature birth or miscarriage are common.
The transmission of hepatitis B virus infection from mothers
who are carriers of the surface antigen of hepatitis B (HBsAg)
to the newborn has been found to be a very serious way of
transmitting this disease. A pregnant woman who has persistent
hepatitis B virus infection, especially with positive evidence of
HBsAg and who has a high titer of infectious virus (Dane’s
bodies), can contaminate her child mainly during or near birth.
The effects on the fetus are particularly low birth weight,
HBsAg persistence, moderate hepatitis and slightly increased
transaminase activity. Hepatitis B during pregnancy was de-
scribed by Rosenberg et al. (1981), Knorr (1983) and Enders
(1983). The possible teratogenic effect of enteroviruses was
also observed by Molnárová et al. (2001). Markers of viral
infection coxackie in newborns with OFC indicate their terato-
genic potential (Molnárová et al. 2002). Monitoring the rela-
tionship of toxoplasmosis with OFC revealed a possible tera-
togenic effect as well (Molnárová et al. 1992; Holková et al.
1994). A possible relationship of prenatal chlamydia and my-
coplasma infections with OFC was reported in our previous
studies (Molnárová et al. 2003, 2004, 2005, 2006, 2007).
The aim of our work was to obtain data on the presence of
antibodies against these selected viruses (the potential culprit
of prenatal developmental disorders) in children with orofacial
abnormalities and their mothers compared to the control group
of healthy children and their mothers, and to contribute to the
explanation of the ethnological context of viral infections in
pregnancy with orofacial factors.
Materials and methods
Levels of antibodies in sera of infants with OFC and their
mothers were monitored and compared to control sera of
healthy infants and their mothers. The cases were analyzed
from the Plastic Surgery Department, Medical Faculty
Comenius University in Bratislava, Hospital Ruzinov,
Slovakia within a seven year period. Serological examination
was performed in the mothers and their children who did not
confirm a genetic predisposition to this congenital defect, and
where the mothers indicated that during the crippling period
they had overcome some viral disease characterized as flu-like
illness or cold. The women included had been in contact with
such a condition (e.g. rubella). Antibodies to rubella virus,
influenza A2 (H3N2) Bangkok, parotitis, cytomegalovirus,
Epstein-Barr virus, and hepatitis B, HbsAg were assessed.
Several Bmicromethods^ were used for these examinations,
such as of HIT (hemagglutination inhibition test) to detect
specific antibodies against rubella (Strauss 1981), parotitis
(Fedová et al. 1987), influenza (modified micromethod
according to Takatsy 2003). KFR (complement-fixation test)
- to detect specific antibodies against cytomegalovirus
(Horáček 1987); NIR (indirect immunofluorescence assay) -
for the detection of IgG and IgM specific antibodies against
Epstein-Barr capsid antigen (VCA-EBV) (Merlin 1986);
ELISA (enzyme-linked immunosorbent assay) and RIA
(radioimmunoassay) - for detection of antibodies to hepatitis
B and HBsAg (commercially produced kits from ABBOT,
SORIN and SEVAC).
We compared a group of children aged from 1 day after
birth up to 10 months with a respective control group of chil-
dren. Mothers of children with OFC were compared with
mothers of healthy control children. Control groups were tak-
en from the Obstetrics Department and Child Counseling in
Bratislava, Slovak Republic.
A high titer of antibodies was an indication for repeated
blood collection, and in the case of EBV, we tested for specific
IgM antibodies. We also investigated the total level of serum
immunoglobulins. For an increased-pathogenic IgM level that
should be a sign of overcoming infection, we considered in
children 0.3 mg/mL, IgG above 4.5 mg/mL and IgA above
13 mg/mL; in mothers IgM over 2.0 mg/mL, IgG above
15 mg/mL and IgA above 4.0 mg/mL.
Results
The specific IgG antibodies against Epstein - Barr virus
(VCA-EBV) were detected in 208 mother-child pairs. We
found 43.7% positive children and 72.2% positive mothers
(on counting all the positives). When we only counted for
titers 1:40 and above (1: 40+), positivity was present in
7.6% of children and in 21.2% of mothers. In control children
and their mothers, the VCA-EBV positivity was 33.4% of the
children and 42.8% of their mothers (all positives were count-
ed). Only 1: 40+ titers were positive for 3.8% of children and
10.2% of mothers. After statistical evaluation (chi-quadrate),
the differences in control were significant in children p = 0.05
and mothers p = 0.01 (all positives were counted) (Table 1).
For specific IgM antibodies against the capsid VCA-EBV
antigen, 52 pairs of mothers and their children were examined
 Biologia

Table 1 Incidence of IgG and

IgM antibodies agaist capsid IgG VCA-EBV
antigen of Epstein-Barr virus in Series n VP %VP/1:10+/ X2 1:80+ %/1:80+/ X2
sera of children with orofacial CL/CP/CLP D 208 91 43.7 p = 0.05 7 3.3 NS
clefts and in sera of their mothers
in comparison with control sera of M 208 150 72.2 p = 0.01 14 6.8 NS
healthy children and their mothers Control D 119 39 33.4 _ 2 1.6 _
M 119 51 42.8 3 2.5 _
IgM VCA-EBV
Series n VP %VP/1:10+/ X2
CL/CP/CLP D 52 14 27.1 p = 0.01
M 52 9 17.2 p = 0.02
Control D 48 5 10.4 _
M 48 2 4.3 _

CL/CP/CLP-cleft lip/palate/lip and palate, D-children, M-mothers, n-number of investiated sera, VP-all positiv-
ities, 1:10 + −titer of antibodies 1:10 and higher, X2-Chí-square, NS-nonsignificant dependence between series
with clefts and controls

with a score compared with the control of 48 pairs of healthy
mothers and their healthy children. We found 27.1% of posi-
tive children and 17.2% positive mothers compared to 10.4%
positive children and 4.3% positive mothers in controls.
Differences from control were statistically significant in chil-
dren (p = 0.01) and in mothers (p = 0.02) for a positive 1: 10+
titer (see Table 1).
A positive antibody titer (KF) against CMV (strain AD 169)
of 1: 8+ was found in 64.5% of children and in 84.2% of their
mothers versus control in 32.2% of children and 49.1% of
mothers (positive 1: 8+ titer). Differences from control were
significant, both in children and mothers, p = 0.001 (Table 2).
A positive titer of specific HI anti-rubella antibodies was
found in 13.3% of children and 65.9% of their mothers (pos-
itive 1: 80+) compared with controls in 2.8% of children and
48.6% of their mothers (at 1: 80+). Differences from control
were statistically significant, both in children and mothers,
p = 0.001 (Table 3).
A positive titer of specific HI antibodies against the A2
Bangkok Influenza Virus, (1: 40+) was detected in 72.5% of
Table 2 Incidence of CMV-KF antibodies in sera of children with
orofacial clefts /CL/CP/CLP/ and in sera of their mothers in comparison
with control sera of healthy children and their mothers
CMV-KF
Series n VP %VP/1:8+/ X2
CL/CP/CLP D 152 98 64.5 p = 0.001
M 152 128 84.2 p = 0.001
Control D 119 38 32.2 _ cules do not pass through the placenta, hence the IgM present
M 119 58 49.1 _ in newborn serum in increased concentration is of fetal origin.
CL/CP/CLP-cleft lip/palate/lip and palate, D-children, M-mothers, n-
number of investigated sera, VP-all positives, 1:8 + −titer of antibodies
1:10 and higher, X2-Chí-square, CMV-KF-complement fixation antibod-
ies against cytomegalovirus
children with cleft and 87.3% of their mothers compared to
controls in 27.1% of children and 44.5% of their mothers
(1:40+). Differences from control were highly significant,
both in children and mothers, p = 0.001 (Table 4).
A positive titer of specific HI-antibody against parotitis
virus was found in 10.2% of mothers and in 4.1% of children
(1: 40+) versus 9.4% in control mothers and 3.6% of their
children (1:40+). The results were non-significant (Table 5).
75 sera tested for antibodies to hepatitis B and
HBsAg were negative.
Discussion
For a long time it was believed that the human fetus is not
capable of synthesizing immunoglobulins and that immuno-
globulins found in fetal and neonatal serum are exclusively of
maternal origin. The ability of the fetus to perform an antibody
response and IgM synthesis after antigenic stimulation, e.g. in
intrauterine infections, and the finding of plasma cells in these
pathologies proves that fetal lymphatic cells can proliferate
under the influence of antigenic stimuli and differentiate into
immunoglobulin-synthesizing plasma cells. Therefore, the hu-
man fetus is able to synthesize IgG and IgM antibodies ap-
proximately from the 20th week of pregnancy (Miller 1980).
The fact that the fetus is able to synthesize IgM during intra-
uterine life in response to a transplacental infection has thus
been used as one of the diagnostic criteria for these infections.
This method is further based on the fact that the IgM mole-
Abnormally elevated levels of IgM in serum from umbilical
cord and a newborn child is an indicator of an intrauterine
infection, even in cases where it does not manifest clinical
signs. Generally, the concentration above 20 mg 100 mL of
Biologia

Table 3 Specific
hemagglutination-inhibition Rubella-HI
antibodies against antigen of
rubella virus in sera of children Series n VP %VP/1:8+/ X2 1:80+ %/1:80+/ X2
with clefts CL/CP/CLP/, in sera CL/CP/CLP D 345 215 62.4 p = 0.001 46 13.3 p = 0.001
of their mothers and in control M 345 314 91.2 p = 0.001 116 65.9 p = 0.001
sera of healthy children and their
mothers Control D 119 59 50.2 _ 33 27.8 _
M 119 98 82.5 _ 58 48.6 _

CL/CP/CLP-cleft lip/palate/lip and palate, D-children, M-mothers, n-number of investigated sera, VP-all positiv-
ities, 1:10 + −titer of antibodies 1:10 and higher, X2Chí-square, HI-hemagglutination-inhibition antibodies

IgM in umbilical cord and neonatal serum is abnormal and is
considered an indirect proof of infection. Several authors in
their articles on the relationship of prenatal infections with
orofacial wounds (OFCs) only assume that prenatal infection
could be teratogenic, because in most causes it might concern
interaction with other teratogens, e.g. drugs, hyperthermia,
etc. or just these teratogens alone could be the cause of OFC
(Saxen 1975; Koskimies et al. 1978; Peterka et al. 1994;
Molnárová et al. 1997; Edwards et al. 1995; David 2013).
We can speak only of indirect evidence of the teratogenic
effect of prenatal infections.
The clinical relevance of prenatal infections in malformed
fetuses, as we saw in our study, can be found in the work of
Lošan et al. (1985). They report that a group of infections called
TORCH (toxoplasmosis, other, rubella, cytomegalovirus infec-
tion, herpes infections) are of considerable importance in de-
tecting the etiology of congenital developmental defects. Most
of these infections cause fetal malformation. Early diagnosis is
thus very important for the fate of pregnancy. In such cases, any
positive finding confirming the non-genetic etiology of con-
genital developmental defects is of great importance. These
authors performed a serological examination of the TORCH
group in fetuses with CNS disorders, e.g. microcephaly, anen-
cephaly, hydrops fetus universalis, etc. In this case, serological
examination of mothers and children showed high levels of
CMV antibodies (1: 128+).
Evidence of intrauterine infection by Epstein-Barr virus was
reported by Goldberg et al. (1981). They isolated EBV virus
from serum of an infected intrauterine infant. The mother over-
came infectious mononucleosis in the first trimester of pregnan-
cy. Her child developed the syndrome of many congenital anom-
alies, including micrognathia, eye malformations, heart and skel-
etal defects, and cryptorchidism. Moreover, hypotonia, protein-
uria, hepatosplenomegaly and thrombocytopenia were also re-
ported. Lymphocytes were positive for the EBV core antigen
and persisted in culture for three months. On the 22nd day of
the child’s life, antibodies against early antigens, IgM anti-capsid
antigens and anti-nuclear antigens were found. All attempts to
isolate other infectious agents were negative. Second and third
week serological examinations excluded, based on antibody
levels, rubella, cytomegalovirus infection and toxoplasmosis.
In children with orofacial abnormalities, Černý et al.
(1988) did not show a teratogenic effect of EBV mater-
nal infection in pregnancy. Vojtěchovský (1982) also
reported comparable results.
Similarly to our work, Černý et al. (1987) analyzed the
relationship of cytomegalovirus infection with orofacial
clefts. They claimed that prenatal infection can only be
suspected because they could not measure IgM antibodies
for technical reasons.
By investigating various viral antibodies in children with
orofacial aberrations and their mothers compared with control
children and their mothers, we attempted to answer the ques-
tion of whether some viral infections can be seen as an etio-
logical factor of the orofacial clefts as well. After reviewing
our results, i.e. comparison of the levels of specific antibodies

Table 4 Specific HI antibodies against virus influenza A2/Bangkok/ Table 5 Incidence of specific HI antibodies against parotitis virus
H2N2 in sera of children with clefts /CL/CP/CLP/, in sera of their antigen in sera of children with clefts /CL/CP/CLP/, in sera of their
mothers, and in control sera of healthy children and their mothers mothers, and control sera of healthy children and their mothers

Influenza-HI Parotitis-HI

Series n 1:40+ %/1:40+/ X2 Series n 1:40+ %/1:40+/ X2

CL/CP/CLP D 715 519 72.5 p = 0.001 CL/CP/CLP D 258 10 4.1 NS
M 715 626 87.5 p = 0.001 M 258 26 10.2 NS
Control D 119 32 27.1 _ Control D 119 3 3.6 _
M 119 53 44.5 _ M 119 10 9.4 _

CL/CP/CLP-cleft lip/palate/lip and palate, D-children, M-mothers, n- CL/CP/CLP-cleft lip/palate/lip and palate, D-children, M-mothers, n-
number of investigated sera, 1:40 + −titer of antibodies 1:40 and higher, number of investigated sera, 1:40 + −titer of antibodies 1:40 and higher,
X2-Chí-square, HI-hemagglutination-inhibition antibodies X2-Chí-square, HI-hemagglutination-inhibition antibodies

in the examined set of children with clefts and their mothers
with the control group of healthy children and their mothers,
after comparing maternal and child titers and after evaluating
all the data about these pairs, i.e., time of birth, IgM-antibody
levels, we can only assume that prenatal infection and fetal
damage (clefts) were present in our set, especially in cases
where mothers reported flu-like symptoms during the critical
period of pregnancy and where influenza was also confirmed
serologically, moreover, in the case of rubella, where the an-
tibodies persisted after the sixth month of the child’s age, in
the case of CMV and most probably in EBV. We assume that
prenatal parotitis infection and hepatitis B virus has not oc-
curred due to the non-significant occurrence of specific anti-
bodies and negative HBsAg.
To prevent the occurrence of congenital defects in a child,
pregnancy planning is very important. In an unplanned preg-
nancy, we usually learn about it at about 6 weeks when the
most vulnerable period of embryo development has taken
place or is just going on. At this time, it is already decided
whether or not the newborn will develop an abnormality or
congenital defect. The question of rubella prevention is basi-
cally solved by vaccinating 12–13 year old girls, which is of
great socio-cultural significance. Prevention against CMV
could be accomplished by similarly active immunization with
attenuated vaccine at the same time as vaccination against
rubella. Prevention of influenza is rather difficult because of
the variability of the virus (Fell et al. 2017). Reduction of
morbidity in women in gestational age implies a rigorous in-
vestigation and targeted influence on all possible causes of
prenatal development disorders. This requires active and time-
ly access to preventive measures (Swamy and Heine 2015;
Cohen 2015), an increased standard of diagnosis and an indi-
vidual approach to the health of each newborn.
Acknowledgments This work was supported by the and Grant VEGA 2/
0129/15. Authors would like to thank to team of Center for Orofacial
Clefts in Hospital Ružinov Bratislava.
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