Infections in Pregnancy

Dr.Tetty Aman Nasution,MMedSc

Departemen Mikrobiologi
FK USU Medan

Infections in Pregnancy
Etiology :
Bacteria
Virus
Fungi
Risk :
Mother
Neonatus

Reproductive tract infections :

A. Vaginitis & Bacterial Vaginosis (BV)
B. Discharge as major manifestation :
- Gonorrhoeae
- Chlamydia
- NGU (Non Gonococcal
Urethritis)
C. Genital ulcer as major manifestation :
- Syphilis
- Chancroid
D. Group B Streptococcus colonization
Other infections :
Tetanus
Mycobacterium tuberculosis
Erysipelas

Vaginitis
An inflammation of the vagina,
most commonly caused by Candida
albicans.
Vulvovaginal candidiasis nearly
always an opportunistic infection.
Women with HIV infection
experience frequently recurring
yeast infection

Bacterial vaginosis
Gardnerella is associated with vaginosis that
has a discharge but no inflammation in the
vagina.
Vaginosis could lead to complications such
as PID (Pelvic inflammatory disease)
PMNs generally absent from exudate
Mostly in women 20-30 years old
Clinical manifestation:
decreased H2O2 -producing Lactobacilli
increase of other vaginal bacteria (esp.
anaerobes); Gram negative coccobacilli
and curved rods adhering to epithelial
cells (clue cells)

Bacterial vaginosis
Etiology:
Gardnerella vaginalis - small, non-motile,
gram negative/variable facultative
anaerobic coccobacilli present in most
healthy women
Mobiluncus sp. - thin, curved, gram
negative anaerobic bacilli; recently
demonstrated to be the chief cause (not
normal flora)
Trichomonas vaginalis - parasite
Yeast/fungi - mostly Candida spp
Mycoplasma hominis and Ureaplasma,
etc.

Bacterial vaginosis
Diagnosis criteria:
watery, gray discharge - no PMNs
vaginal pH 4.5+ (normal 3.8-4.2)
positive amine (fish) odor with 10%
KOH
presence of clue cells - epithelial
cells covered by Gardnerella like
organisms spreading past cell
boundries

Neissseria Gonorrhoea
Morphology and structure :
Gram negative cocci `kidney bean shape, appear
in pairs, flattened opposing sides
Readily phagocytosed by polymorphonuclear
cell(PMN)
Rapidly killed by drying, sun light, moist heat and
many disinfectants
Size varies 0.6 - 1.5 m depending on
species, source of isolates and age of
culture.
Cell wall - typical of gram negative bacteria
- peptidoglycan backbone, endotoxic
LPS
complex and outer membrane
protein
Capsule and pili - may be demonstrated

Neissseria Gonorrhoea
Grow well on chocolate agar
- specialized medium (enriched)
- Require CO2 supplement
- 48 hours incubation - well developed
- Colony smooth, non pigmented
smaller than other spp

Produce autolytic enzyme

- swelling and lysis at 25oC and at
alkaline pH

Gonorrhoea
Symptoms

- may be mild or absent

- 2 - 7 days after exposure
Men :
Primary site - urethra
Purulent urethral discharge and dysuria
Local extension - epididymitis
Prostatitis
Women : Primary site - endocervix
Increase vaginal discharge
Urinary frequency, dysuria
Abdominal pain
Menstrual abnormalities

Gonorrhoea

Transmissions: sexual contact

Non sexual transmission - extremely rare

Difficult to control:
- changed sexual modes and practices
- lack of effective means to detect
asymptomatic case
- increase antibiotic resistance
- lack of appreciation of the importance of the
disease
- asymptomatic reservoir
- 50% infected
women
- 5% infected male
Untreated symptomatic case will become
asymptomatic but infectious

Gonorrhoea
Other localized infections
Rectal gonorrhoea
- rectal intercourse
- infected vaginal secretion
- Generally asymptomatic
- May cause tenesmus, discharge or rectal bleeding
Pharyngeal gonorhoea
- Asymptomatic (majority)
- Sorethroat and cervical adenitis
- Oro-genital sex
Bartholin abscess
- Infection of bartholin gland
- In women
Conjunctivitis - Severe, acute purulent
- Any age including neonates

Gonorrhoea
Pelvic Inflamatory Disease
Infection spread to:
Fallopian tube salpingitis
Pelvic cavity pelvic peritonitis and
abscess
Fever,
Lower abdominal pain and rectal
tenderness
Leukocytosis
Complication
- ectopic pregnancy
- infertility.

Gonorrhoea
Specimens:
Pus and secretion from appropriate site
urethra, cervix, rectum, conjunctiva, throat,
synovial
1.
Gram smear
Direct smear of specimen from
genital site
Multiple gram negative diplococci
`been
shaped'
Intra or extracellularly
Male : > 95% sensitive and 99%
specific
Female : 50 - 70% sensitive and 95%
specific
Positive urethral smear and conjunctiva
are diagnostic
Others need culture confirmation

Gram Staining of gonococcus:

Bacteria from culture
pus

Direct smear -

Gonorrhoea
Culture
Fragile organism, often mixed with normal
flora
Protect specimen from adverse
environmental
effect
Culture on appropriate enriched selective
media
(Modified Thayer-Martin medium)
Direct streaking at the bed side
Or transport to the lab (<4 hours) in suitable
transport
medium
Specify the request for culture
Incubated at 37oC containing 5% CO2 for 2448 hours

Chlamydia
5-7% reproductive population
Pre-term labour, PPROM,
Chorioamniionitis, Endometritis
Conjunctivitis (18-50%), Pneumonia
(18%)
Most are asymptomatic
Screening needed

CHLAMYDIA LIFE CYCLE

Chlamydia
Women
Intermenstrual or postcoital bleeding
Lower abdominal pain
Fever (in PID)
No symptoms in 80%
Men
Unilateral pain and swelling of the scrotum
Fever
Asymptomatic in 50%
Neonates
Injected conjunctivae
Mucopurulent discharge from eyes
Bilateral involvement of the eyes

Chlamydia
Physical:
Men may have any, all, or none of the following:
Mucopurulent urethral discharge
Unilateral epididymal tenderness and swelling
Mucopurulent rectal discharge (from anal
intercourse)
Women may have any, all, or none of the following:
Mucopurulent cervical or vaginal discharge
Cervical motion tenderness
Adnexal tenderness
Lower abdominal tenderness
Upper right quadrant abdominal tenderness (FitzHugh and Curtis syndrome)
Mucopurulent rectal discharge (from anal
intercourse)

Chlamydia
Neonates - Bilateral purulent
conjunctivitis
Lymphogranuloma venereum
Localized inguinal adenopathy or
buboes
Genital ulceration
"Groove sign" - Separation of inguinal
and femoral lymph nodes by the
inguinal ligament (15-20% of patients)

Chlamydia
Diagnosa Lab:
Chlamydia membentuk sitoplasmik
inklusi hanya dpt dilihat dgn
pewarnaan khusus spt pewarnaan
Giemsa atau dengan
immunofluorescence
Pewarnaan Gram tidak dapat dilihat
Jika dalam cairan exudat, bakteri dlm sel
epitel diidentifikasi dengan pewarnaan
Fluorescent Antibody atau DNA probe
assay

Chlamydia
Diagnosa Lab:
Antigen Chlamydia di dalam
exudat/cairan tubuh atau urine dapat
dideteksi dengan ELISA
DNA dari Chlamydia dalam exudat/cairan
tubuh atau urine dapat dideteksi dengan
PCR (Polymerase Chain Reaction)
Kultur Chlamydia sudah jarang
dilakukan untuk mendeteksi bakteri ini

Chlamydia
Diagnosa Lab :
Jika kultur, dilakukan kultur sel dengan
penambahan cycloheximide (inhibitor
protein sintesis pd sel host tp tdk pada
chlamydia replikasi)
C. trachomatis membentuk inklusi
mengandung glikogen dpt dilihat dgn
pewarnaan Iodine.
Exudat dr mata, sal.nafas atau
sal.genital kultur positif pada 50%
kasus

Non Gonococcal Urethritis (NGU)

Mycoplasma hominis and Ureaplasma
urealyticum
Bacteria without cell walls, fried egg
colonies slow growers on
fat/cholesterol enriched media
Post abortion fever, post- partum
sepsis and neonatal
sepsis,pneumonia and meningitis
Ureaplasma urealyticum
Also assoc with chorioamnionitis, low
birth weight, and nongonococcal
urethritis in men

Group B Streptococci
colonization
25% women are carriers
50% of babies born will be
colonized
1-2% will have Grp B Strep
infection
1:1000 babies
Pneumonia (early), Meninigitis
(Late)

Female genital tract normal

flora
Lactobacilli

Gram positive rod in large numbers indicate

a healthy vagina
Produce lactic acid which helps maintain pH
needed for their survival
May play a role in protecting women from
gonococcal infections

Group B betahemolytic Streptococcus

agalactiae colonization
May be transmitted to neonate
Can cause systemic disease

Group B Streptococci
Epidemiology:
Colonizes the genital tract; risk groups
include:
Infants: Colonization during delivery
may results in invasive disease
Pregnant and post-partum women
Non-pregnant adults
Elderly
Individuals with chronic underlying
disease

Group B Streptococci
Clinical Presentation:
Neonates
Sepsis, meningitis, pneumonia, cellulitis,
osteomyelitis, septic arthritis

Pregnant and post-partum women

Mild UTI, sepsis; less commonly
osteomyelitis, endocarditis, meningitis

Non-pregnant adults
Bacteremia, skin or soft tissue infections >
pneumonia > urosepsis > endocarditis >
peritonitis > meningitis > empyema

Mother to Infant GBS

Transmission
10 35%
GBS colonized mother
50%

50%

Non-colonized
newborn

Colonized
newborn
98%

2%
Early-onset sepsis,
pneumonia, meningitis

Asymptomatic

Neurologic
sequelae

5%
Death

Gram Stain

Colonies on sheep
blood agar plate

Group B betahemolytic Streptococcus agalactiae

Syphilis
T.Pallidum
<1:1000 pregnant women
Can infect trans placenta from 15 th
week
Second stage by birth if not treated
Screening VDRL, RPR
Diagnostic tests TPI, FTA-Abs
High dose Penicillin's

Primary Syphilis
During the 1st 10-90 days after sexual
encounter with infected person disease
incubates within body.
Infected area will develop a sore also called
a Chancre or multiple sores
The sore is highly infectious

Chancre sore will resolve in 3-8 weeks if

left untreated
Chancre sore may not be visible and
may be painless

Primary Syphilis

Secondary Syphilis
Symptoms occur 6-8 weeks after initial
sore disappears and may include:
A rash on the palms of the hands and
soles of the feet lasting 2-6 weeks
Hair loss and patchy areas
Grayish-white sores in the mouths and
throat
Sense of not feeling good

Secondary Syphilis
It can last for 3-6 months with symptoms
disappearing then reappearing
Person infected is still capable of
transmitting the disease
Syphilis begins to affect the entire body

Latent Syphilis
Called the Hidden Stage
Begins w hen the Secondary symptoms disappear
The bacteria begins to infest the bone marrow, lymph glands, vital organs, and the central nervous system
It may last up to a month or a lifetime
1/3 of the cases left untreated w ill proceed to tertiary stage

Tertiary Syphilis
Disease is not infectious at this stage
Lesions develop on the skin, bones, and vital organs
Patient experiences lack of coordination, paralysis,
gradual blindness, dementia, and vomiting.
Gummas or painful tumors may appear on the skin
Late syphilis can result in mental illness, blindness,
other neurological problems, heart disease, and death.

Diagnoses

Syphilis is diagnosed in 3 ways

1) First recognize the signs and symptoms of
each stage.
2) Blood samples need to be obtained to test
for syphilis antibodies that the body
produces after the infection occurs.
3) A microscopic examination may be
performed of an active lesion to confirm
diagnosis.

Laboratory Tests
In the later stages of syphilis, blood or cerebrospinal
fluid for serological tests are necessary for
diagnosis.
Non-specific non-Treponemal tests RPR, VDRL
May cross-react resulting in low-level false positive tests

during pregnancy, other infections, drug abuse, connective

tissue disease and aging.
Levels usually relate to disease activity and are used for
monitoring treatment.
After effective treatment of syphilis these tests usually
become negative but in some people, may retain positive at
low levels

Laboratory Tests
Specific anti-treponemal antibody tests TPHA,

EIA
These detect antibody due to past or present
infection with Treponema pallidum or
another treponema species.
They cannot distinguish between different
types of Treponema infection ex. Yaws
Syphilis of the duration of the infection.
Most people with reactive treponemal tests
will continue to have reactive tests for the
remainder of their lives, regardless of
treatment or disease activity.

Chancroid
An ulcerative disease caused by a
pleomorphic gram-negative rod
called Haemophilus ducreyi
Transmitted exclusively through
direct-mainly sexual-contact

Tetanus

Tetanus is an acute,often fatal,disease

caused by an exotoxin produced by the
bacterium Clostridium tetani.
Can be prevented
tetanus toxoid.

by

immunization

with

Characterized by generalized rigidity and

convulsive spasms of skeletal muscles.The
muscle stiffness usually involves the jaw
(lockjaw)and
neck
and
then
becomes
generalized.

Courtesy : Google Image on tetanus

Tetanus
C.tetani is a slender,gram-positive,anaerobic
rod that may develop a terminal spore,giving it
a drumstick appearance.
The organism is sensitive to heat and cannot
survive in the presence of oxygen.The spores,in
contrast,are very resistant to heat and the usual
antiseptics.
They can not survive autoclaving at 249.8 F
(121 C)for 20 minutes.
The spores are also relatively resistant to
phenol and other chemical agents.

Tetanus
The spores are widely distributed in soil
and in the intestines and faeces of
horses,sheep,cattle,dogs,cats,rats,
guinea pigs. Spores may persist for
months to years.
C. tetani produces two exotoxins,
tetanolysin and tetanospasmin. The
function of tetanolysin is not known with
certainty. Tetanospasmin is a neurotoxin
and causes the clinical manifestations of
tetanus.
Tetanospasmin estimated Human lethal
dose 2.5 ng/kg

Occurrence: Tetanus occurs worldwide but is most

frequently encountered in densely populated regions in
hot,damp climates with soil rich in organic matter.
Reservoir:Organisms are found primarily in the soil and
intestinal tracts of animals and humans.
Mode of Transmission:Transmission is primarily by
contaminated wounds,Tissue injury( surgery,burns,deep
puncture wounds,crush wounds,Otitis media ,dental
infection,animal bites, abortion,and pregnancy).
Communicability
Tetanus is not contagious from person to person.It is
the only vaccine-preventable disease that is infectious
but not contagious.
Temporal pattern:Peak in winter and summer season
Incubation Period: 8 DAYS ( 3-21 DAYS)

Maternal Tetanus
Maternal tetanus, defined as tetanus occurring during
pregnancy or within 6 weeks after any type of
pregnancy termination, is one of the most easily
preventable causes of maternal mortality.
It includes postpartum or puerperal tetanus
(i) postpartum or puerperal tetanus, usually resulting
from septic procedures during delivery,
(ii) postabortal tetanus, following septic maneuvers
during induced abortion
and (iii) tetanus during pregnancy, generally resulting
from inoculation through a nongenital portal of entry

TETANUS TOXOID
Tetanus toxoid was developed by Descombey in
1924,
Tetanus toxoid immunizations were used
extensively in the armed services during World War
II.
Tetanus toxoid consists of a formaldehyde-treated
toxin.
There are two types of toxoid available adsorbed
(aluminum salt precipitated)toxoid and fluid toxoid.
Although the rates of seroconversion are about
equal,the adsorbed toxoid is preferred because the
antitoxin response reaches higher titers and is
longer lasting than that following the fluid toxoid.