Infection during

Pregnancy and Delivery

Toxoplasmosis
Rubella
CMV
Herpes simplex virus

11 OKTOBER 2021

Dr. dr. Novia Fransiska, SpOG

SMF Obgin RSU A.Wahab Sjahranie
TOXOPLASMOSIS
 Epidemiology
❖ In the United States, the incidence of acute toxoplasmosis
infection in pregnancy has been estimated to be 0.2–1.0%
❖ Congenital toxoplasmosis occurs in 1–8:1000 live births
❖ Transmission occurs primarily via :
- ingestion of undercooked or raw meat containing cysts
- ingestion of food or water contaminated by the feces of an
infected cat
- handling of material contaminated by the feces of an
infected cat
❖ Approximately one-third of American women carry
antibodies to Toxoplasma
TRANSMISSION
 Clinical manifestations

1. Maternal infection
▪ Specific symptoms signaling acute toxoplasmosis
infection are uncommon in pregnant women
▪ A mononucleosis-like syndrome, including : fatigue,
malaise, cervical lymphadenopathy, and atypical
lymphocytosis
▪ Placental infection and subsequent fetal infection
occur during the spreading phase of the parasitemia.
▪ The overall risk of fetal infection is estimated to be
30–40%
▪ The rate of transmission increases with gestational
age
 Clinical manifestations
2. Fetal infection

❖ During the 1st trimester, the rate of transmission is approximately 15%

2nd second trimester transmission is approximately 30%
3rd trimester transmission 60%.
❖ Fetal morbidity and mortality rates are higher after early transmission
❖ Infected neonates often have evidence of disease, including :
low birth weight, hepatosplenomegaly, icterus, and anemia
❖ Sequelae : vision loss, psychomotor and mental retardation (common)
Hearing loss is demonstrated in 10–30%
developmental delay in 20–75%
❖ Chorioretinitis often develops.
 Diagnosis
❖ Screening for toxoplasmosis is not routine 🡪 because
most women with acute toxoplasmosis are
asymptomatic, the diagnosis is not suspected until an
affected infant is born

❖ For women who do present with symptoms of acute

toxoplasmosis, both IgM and IgG titers should be
measured as soon as possible
 Management
Therapy must be initiated immediately 🡪 continued in the
infant for a year or more to decrease the risk of development
of sequelae

Medical therapy : the risk of development of permanent

sequelae by 50%

1. Spiramycin
❖ Reduces the incidence of fetal infection but not necessarily
the severity of fetal infection
 Management
❖ Recommended for the treatment of acute maternal
infections diagnosed before the third trimester
🡪continued for the duration of the pregnancy
❖ If amniotic fluid PCR results for Toxoplasma are
negative, spiramycin is used as a single agent
❖ If results are positive🡪 pyrimethamine and
sulfadiazine should be added
❖ Spiramycin dosing is 500 mg PO five times daily, or
3g/day in divided doses.
 Management
2. Pyrimethamine and sulfadiazine
🡪 act synergistically against Toxoplasma gondii
❖ The dosing is pyrimethamine, 25 mg PO daily, or sulfadiazine,
1 g PO four times daily, for 28 days.
❖ Folinic acid, 6 g IM or PO, is administered three times per
week to prevent toxicity
❖ During 1st trimester, pyrimethamine is not recommended due
to a risk of teratogenicity
❖ Sulfadiazine is omitted from the regimen at term
RUBELLA
 Epidemiology
❖ Rubella (measles) is highly contagious
❖ Its incubation period is 10–14 days
❖ Since the advent of the measles vaccine, rates have
fallen 99%
❖ Rubella is extremely rare in pregnancy because of
low susceptibility in adults
 Reported rubella and CRS: United States, 1966-2004

Meissner, H. C. et al. Pediatrics 2006;117:933-935

 Rubella
❖ Single-stranded RNA virus
❖ Vaccine-preventable disease
🡪 No longer considered endemic in the U.S.
❖ Mild, self-limiting illness
❖ Infection earlier in pregnancy has a higher
probability of affected infant
 Clinical manifestations
1. The prodome
consists of fever, cough, conjunctivitis, and coryza, lasts
1–2 days;
Koplik spots (pinpoint gray-white spots surrounded by
erythema) appear on the second or third day; a rash
emerges on the fourth day.
CONTAGIOUS from the onset of symptoms until 2–4 days
after the appearance of the maculopapular and
characteristic semiconfluent rash
 Clinical manifestations
1. The prodome
Measles may be complicated by pneumonia, encephalitis, or
otitis media
❖ Pneumonia occurs in 3.5–50%
🡪 suspected in patients with deterioration, an elevated
WBC with a leftward shift, and a chest radiograph of
multilobar infiltrates
❖ Encephalitis occurs in 1:1000 cases of measles and may
result in permanent neurologic impairment and a
mortality rate of 15–33%
❖ Subacute sclerosing panencephalitis occurs in
0.5–2:1000 cases🡪 usually has a fatal outcome
 Clinical manifestations
2. Maternal infection
✔ Higher rates of mortality have been observed in pregnant
women with measles, primarily due to pulmonary
complications.
✔ A small increase in spontaneous abortion and preterm
labor

3. Fetal infection
✔ No definitive evidence of a teratogenic influence exists
✔ Infants born to infected mothers are at risk of neonatal
infection resulting from transplacental viral transmission
“Blueberry muffin” spots representing
extramedullary hematopoesis
 CRS - Congenital Rubella Syndrome
❖ Sensorineural hearing loss (50-75%)
❖ Cataracts and glaucoma (20-50%)
❖ Cardiac malformations (20-50%)
❖ Neurologic (10-20%)
❖ Others to include growth retardation, bone
disease, thrombocytopenia, “blueberry
muffin” lesions
 Diagnosis

1. Maternal infection
✔ Clinical diagnosis is considered to be reliable
✔ When the patient's presentation is atypical,
laboratory confirmation of the diagnosis by
serologic studies may be required
✔ A pregnant woman with measles should be
evaluated for preterm labor, volume depletion,
hypoxemia, and secondary bacterial pneumonitis
 Diagnosis

2. Fetal infection
Ultrasonographic evaluation of the fetus is
sufficient :
✔ microcephaly
✔ growth restriction
✔ oligohydramnios
 Management
❖ Susceptible (nonimmune) women should receive
a vaccine postpartum and should be advised to
use contraception for 3 months after vaccination,
because the vaccine is of the live, attenuated viral
variety
❖ Susceptible pregnant women who are exposed to
measles should receive immune globulin, 0.25
mg/kg IM
❖ Measles is not a contraindication for breast
feeding
 Management
❖ No specific therapy is available for measles other
than supportive measures and close observation for
the development of complications

❖ Infants delivered to mothers who develop measles

within 7–10 days of delivery 🡪 should receive IM
immune globulin (0.25 mg/kg)
 Treatment
❖ Prevention…
immunize, immunize, immunize!
❖ Supportive care only with parent education
CYTOMEGALOVIRUS
 Epidemiology
❖ CMV infection is the most common congenital infection,
affecting 0.4–2.3% of neonates
❖ CMV is a ubiquitous DNA herpesvirus
❖ In US, approximately half of the population is CMV
seropositive
❖ The virus has been isolated from saliva, cervical
secretions, semen, and urine
❖ Infection can also be contracted by exposure to infected
breast milk or blood products.
❖ Transmission can occur from mother to child both in
utero and postpartum
 Clinical Manifestations

1. Maternal infection

reliably only by documenting maternal

seroconversion using serial Immunoglobulin G
(IgG) measurements during pregnancy
If seropositivity is detected at least several
months before conception, symptomatic fetal
infection is unlikely
Most primary infections are clinically silent, so
the majority are undiagnosed
 Clinical Manifestations

Screening of asymptomatic pregnant women for

seroconversion is not recommended because
distinguishing primary from secondary CMV
infection is frequently difficult using CMV
serology
The CMV IgM test result is positive in only 75%
of primary infections and in 10% of secondary
infections
Screening is also of limited value due to the lack
of a CMV vaccine and the inability to predict
severity of sequelae of primary infection
 Clinical Manifestations
2. Fetal infection

❖ Ultrasonography may enable the detection of the

fetal anomalies that characterize CMV infection
❖ Amniocentesis and cordocentesis 🡪 used to
diagnosis fetal infection using measurement of total
and specific IgM antibodies and viral culture
 Management
❖ Effective CMV therapy in utero for the fetus
does not exist
❖ Given the difficulty in distinguishing primary
from secondary maternal CMV infection,
counseling patients about pregnancy
termination is problematic because most
infected fetuses do not suffer serious sequelae
❖ Breast feeding is discouraged in women with
active infection
HERPES SIMPLEX
 Herpes Simplex (HSV)
❖ HSV1 or HSV2
❖ Primarily transmitted through infected
maternal genital tract
🡪 Rationale for C-section delivery prior to
membrane rupture
❖ Primary infection with greater transmission
risk than reactivation
 Epidemiology

Type 1 herpes simplex virus (HSV) is responsible

for most nongenital herpetic infections and
infrequently involves the genital tract
Type 2 HSV is usually recovered from the genital
tract
Approximately 1:7500 live-born infants contracts
HSV perinatally
.
 Epidemiology
1. Primary maternal infection with HSV results from
direct contact, generally sexual, with mucous
membranes or intact skin infected with the virus
2. Fetal infection with HSV can occur via three
routes :
▪ utero transplacental transmission
▪ ascending infection from the cervix both occur
▪ most common route : direct contact with infectious
maternal genital lesions during delivery
 Clinical manifestations
Maternal infection
❖ Primary infections are often severe but may be mild or
even asymptomatic
❖ Vesicles appear 2–10 days after exposure on the cervix,
vagina, or vulva
❖ Swelling, erythema, and pain are common, as is
lymphadenopathy near the affected region
❖ The lesions generally persist 1–3 weeks, with
concomitant viral shedding
❖ Reactivation occurs in 50% of patients within 6 months of
the initial outbreak and subsequently at irregular
intervals
 Diagnosis

❖ a swab specimen may be obtained from the lesion or

vesicle and sent for tissue culture
❖ Tissue culture has 95% sensitivity and very high specificity.
❖ Obtain samples from the endocervical canal and
exfoliated cells from all suspicious areas
❖ Smears of scrapings from the bases of vesicles may be
stained using Tzanck or Papanicolaou techniques, which
reveal multinucleated giant cells that implicate HSV
infection
 Management

❖ Patients with a history of genital herpes should

undergo a careful perineal examination at the
time of delivery
❖ Active genital HSV in patients in labor or with
ruptured membranes is an indication for cesarian
section, regardless of the duration of rupture
❖ Vaginal delivery is indicated if there are no signs
or symptoms of HSV
 Management

❖ Acyclovir may be used to treat HSV infection in

pregnancy
❖ Valacyclovir hydrochloride (Valtrex) has been
shown to be more effective and is more easily
tolerated due to a twice-daily dosing schedule
❖ Third trimester suppression with valacyclovir,
500 mg PO daily, should be considered in
women with frequent outbreaks during their
pregnancies
Presentations of congenital HSV