Introduction

An infection caused by a bacteria or virus that

can be passed from a mother to her baby during
pregnancy or delivery is called a Intrauterinel
infection.
The mother may or may not experience active
symptoms of the infection during the pregnancy.
The embryo and fetus have no immune function
or an immature immune function. They depend
on the immune function and freedom from
infection in the mother.
Several infectious agents are capable of crossing
the placenta and causing (perinatal) infection in
the embryo or fetus.
Vertically transmitted ( mother to child )
infections of the fetus and newborn can
generally be divided
Into two major categories :
1. Congenital infections : which are
transmitted to the fetus in utero.
2. Perinatal infections : which are
acquired intrapartum or in the
postpartum period.
 The first trimester is usually the most
dangerous time to acquire these
infections.
 Infection in the mother does not always
mean that the baby will be affected.
 Etiologic Agents:
Viruses: CMV,HSV,VZV,Rubella, Hepatitis B
virus, Parvovirus B19,HIV.
Bacteria: Treponema pallidum, Listeria
monocytogenes, Campylobacter fetus.
Fungi: Candida albicans.

Parasites: Toxoplasma gondii,Plasmodium

spp.,Trypanosoma cruzi.
 The most common means of infection of
the fetus is via the blood stream.

 Less common means of infections include:

* Extension from adjacent tissues and/organs.

*Invasive diagnostic or therapeutic
interventions.
( e.g. monitors, fetal blood sampling,
intrauterine
transfusions )
Clinical Sign Rubella virus CMV HSV Toxoplasma

Hepatospleno
megaly
+ + + +

Jaundice + + + +

Adenopathy
+ - - +

Pneumonitis
+ + + +
 Rubella CMV HSV TOXOPLAS
Clinical sign MA

Microceph _ ++ + +
aly

Hydroceph + + + ++
alus

Intracranial _ ++ _ ++
calcifications

Hearing + + _ _
deficits
Clinical Rubella CMV HSV Toxoplasmosis

sign
Skin lesions
+ + + +
purpura

Vesicles _ + ++ _

Maculopap _ _ + +
ular rash

CNS: + + + +
Meningo-
encephalitis
 TORCH INFECTIONS

The term TORCH complex refers to a

set of major infections that may be
caused by transplacental infection.

 Toxoplasmosis
 Rubella
 Cytomegalovirus
 Herpes/Hepatitis
 Toxoplasma gondii

 An obligate intracellular parasite.

 The cat is the only definitive host.
 Infection in the mother does not always cause
congenital
disease in the baby.

CONGENITAL INFECTION:
 Infection usually occurs after 1ry maternal infection,
recurrence is extremely rare.
 Neonatal symptomatic disease is usually severe, and is
characterized by a triad of HYDROCEPHALUS,
CHORIORETINITIS and I.C. CALCIFICATIONS.

 The sequelae of asymptomatic disease are unpredictable.

1. Ingestion of tissue cysts from contaminated raw or
undercooked beef, lamb, or pork.

2. Ingestion of oocysts from soil, milk, water, or

vegetables

3 Inhalation of oocysts.

4. Contaminated blood transfusions

organ transplants, and accidental
inoculation acquired in the laboratory
 Laboratory diagnosis:
 Serology: PCR

 Demonstration of IgM antibodies to

toxoplasmosis in cord
 serum or infant serum is diagnostic; IgM

antibodies in CSF supports the diagnosis in CNS

infection
 Double sandwich IgM-ELISA method is more

sensitive than IgM-IFA

 IgA antibodies to toxoplasmosis in infant

 Demonstration of Toxoplasma antigens in CSF

 CBC : leucocytosis or leucopenia, lymphopenia,

monocytosis, eosinophilia (30%),

thrombocytopenia.
 TREATMENT=> spiramycin is started when
evidence of maternal seroconversion is
noted and while fetal diagnosis is taking
place
 If fetal testing confirms infection, then a
combination of pyrimethamine and sulfa-
diazine is used. Pyrimethamine should not
be used before 12 weeks' gestation
because of possible teratogenic effects.
Both pyrimethamine and sulfadiazine are
folate antagonists and may suppress
maternal and fetal bone marrow.
Therefore, folic acid should be prescribed,
and bone marrow monitoring may be
considered.
 Chlamydia

 Chlamydia trachomatis is the most common bacterial sexually

transmitted disease.

 The majority of women with chlamydial infection experience no

obvious symptoms. The infection affects the reproductive tract
and causes pelvic inflammatory disease, infertility, and ectopic
pregnancy (the fertilized egg implants somewhere other than in
the uterus).

 This infection can cause premature rupture of the membranes and

early labor. It can be passed to the infant during delivery and can
cause ophthalmia neonatorum within the first month of life and
pneumonia within one to three months of age.
 Symptoms of chlamydial pneumonia are a repetitive cough and
rapid breathing. Wheezing is rare and the infant does not develop
a fever.
 Chlamydia
 Chlamydial bacteria can be
diagnosed by taking a cotton swab
sample of the cervix and vagina
during the third trimester of the
pregnancy. Chlamydial cell cultures
take three to seven days to grow but
many laboratories are not equipped
to run the tests necessary to confirm
the diagnosis.
 Chlamydia

 Treatment(during pregnancy)
=>macrolides and amoxicillin
( tetracycline is contraindicated).
 Pregnant women can be treated during the
third trimester with oral erythromycin, for
seven to 14 days depending on the dose
used.
 Newborn infants can be treated with
erythromycin liquid for 10–14 days at a
dosage determined by their body weight.
 Gonococcal Infection
 Risks to neonate include ophthalmia
neonatorum and systemic neonatal
sepsis
 Possible increased risk of preterm
premature rupture of the membrane
 Recommended Therapy =Ceftriaxone
125 mg IM once or Cefexime 400 mg
PO once plus Erythromycin base 500
mg POQID x 7days
 Cytomegalovirus
 Cytomegalovirus (CMV) is a very common virus in the
herpes virus family. It is found in saliva, urine, and other
body fluids and can be spread through sexual contact or
other more casual forms of physical contact like kissing. In
adults, CMV may cause mild symptoms of swollen lymph
glands, fever, and fatigue. Many people who carry the virus
experience no symptoms at all.

 Infants can become infected with CMV while still in the

uterus if the mother becomes infected or develops a
recurrence of the infection during pregnancy. Most infants
exposed to CMV before birth develop normally and do not
show any symptoms. Remaining cases;CMV interferes with
normal fetal development and can cause mental retardation
, blindness, deafness, or epilepsy in these infants.
 Ctyomegalovirus
 CMV can also be acquired by the
newborn through cervical secretions,
saliva, urine, or breast milk.
 Past or recent infection with CMV can
be identified by antibody tests and
CMV can be grown from body fluids.
 No proper drugs or vaccines are
currently available for prevention or
treatment of CMV.
congenital CMV infection :
microcephaly
 Congenital cytomegalovirus infection and microcephaly in a
neonate. Semi lateral skull radiograph shows intracranial
calcifications that conform to the shape of the ventricles.
Hepatosplenomegaly in Congenital
CMV
 Diagnosis :
 Culture.

 PCR.

 CMV IgM & IgG.

 CT scan, abnormal CT predicts high

probability of CNS sequalae.

Treatment:
Gancyclovir – valgancyclovir
 Ctyomegalovirus-Prognosis

 Exposure to CMV can be very serious

and even life threatening for mothers
and infants whose immune systems
are compromised, for example those
receiving chemotherapy or who have
AIDS/HIV infections. Those infants
who develop birth defects after CMV
exposure may have serious and life
long complications.
 Genital herpes
 Genital herpes, which is usually
caused by herpes simplex virus type
2 (HSV-2), is a sexually transmitted
disease that causes painful sores on
the genitals. Women who have their
first outbreak of genital herpes
during pregnancy are at high risk of
miscarriage or delivering a low birth
weight baby.
Most mothers of infants with neonatal HSV
DO NOT have a history of HSV.

IN-UTERO INFECTION of the fetus with

HSV is RARE. The most severe IUI has a
triad of:

1. Skin vesicles or scarring.

2. Eye disease : chorioretinitis,

keratoconjunctivitis.

3. Microcephaly or hydrancephaly.
 INTRA-PARTUM
INFECTION :
Always symptomatic and frequently
fatal particularly with primary
maternal infection.
The risk of intra-partum transmission
increases with ruptured membranes
more than 4 hours.
Intra-partum and post-natal infection
may present with:

1. Disease localized to skin, eye, or mouth.

2. Encephalitis with or without skin ,eye or

mouth involvement.

3. Disseminated infection of multiple organs.

 The infection can be passed to the infant
at the time of delivery if the mother has
an active sore. The most serious risk to
the infant is the possibility of developing
HSV-2 encephalitis, an inflammation of the
brain, with symptoms of irritability and
poor feeding.
 DIAGNOSIS: Specific IgM, DFA,
CSF
The appearance of a genital sore is enough
to suspect an outbreak of genital herpes.
The sore can be cultured and tested to
confirm that HSV-2 is present.
 The antiviral drugs acyclovir or famciclovir can be
administered to the mother during pregnancy.
 Infants with suspected HSV-2 can be treated with
acyclovir.
 once a woman or infant is infected, outbreaks of genital
herpes sores can reoccur at any time during their
lifetimes. Delivery of the infant by cesarean section is
recommended if the mother has an active case of genital
herpes.
 Cesarean delivery can reduce disease transmission to
the neonate as the risk of disease transmission increases
by six hours after premature rupture of membranes
(PROM)
 If maternal HSV is suspected, a fetal scalp monitor should
be avoided, as this creates a direct portal of entry for the
infection
Congenital HSV infection
Congenital HSV infection
 VARICELLA –ZOSTER VIRUS

CONGENITAL VARICELL SYNDROME:

Occurs if infection is acquired between 7-
20 weeks gestation and characterized by:
1. Ocular defects.
2. CNS abnormalities.
3. IUGR.
4. Early death.
These babies are unlikely to have an active
viral disease and antiviral therapy is NOT
indicated.
Congenital varicella infection
SEVERE DISEASE:
When varicella occurs in the mother in the 5 days before or in
the 2 days after delivery.

 Symptoms in the newborn begin 5-10 days after delivery.

 Mortality 30%.

 These babies may be given VZIG prophylactically within 72

hours of
exposure.

 Acyclovir safety and dose is not established in newborns

When in-utero transmission occurs before the peripartum

period there is no clinical impact in most cases.
Congenital varicella infection
POST- NATAL VARICELLA:
 Usually a mild disease.
 Rarely severe disseminated disease occurs in
newborns exposed shortly after birth.
 Treatment with acyclovir may be beneficial, the
dose and safety of acyclovir in treating neonatal
vzv, however, is not established.
 Breast feeding is deferred during the period of
time in which the mother is likely to be viremic
and/or infectious.
 Isolate the infant from the mother during this
period.
 HEPATITIS

 HEPATITIS A: No horizontal transmission.

 Hepatitis B Virus (HBV) is a contagious virus that

causes liver damage and is a leading cause of
chronic liver disease and cirrhosis.
 HBV is contracted through direct contact with the
blood or other body fluids of an infected
individual. Infants are at high risk for developing
hepatitis B infection through exposure to their
mothers blood. Infants are mostly infected by
vaginal birth.
HEPATITIS B

 A blood test can be used to screen pregnant women for the

hepatitis B surface antigen (HBsAg)

 Infants born to mothers who test positive to the HBsAg test

should be treated with hepatitis B immune globulin (HBIG)
0.5ml - 1st dose of hepatitis B vaccine immediately after
birth.These infants, as well as all infants, should also
receive a series of three hepatitis B vaccine injections as
part of their routine immunizations.

 Infants born to HBsAg - negative mothers:

Give hepatitis B vaccine within 2 months after
birth

 Infants born to mothers whose HBsAg is

unknown:
Give 1st dose of vaccine within 12-hours of
birth, determine Mother’s serology ….etc
 The disease may present in very mild form, with
no symptoms and only detected through liver
function tests, or may be severe, even fatal, if it
has advanced to liver necrosis.
Symptoms of HBV infection include:
 jaundice

 fatigue

 rash

 fever that is usually either not present, or very

mild
 vague abdominal discomfort

 abdominal pain

 loss of appetite

 nausea

 vomiting

 joint pain
 HEPATITIS C:

Vertical transmission is rare ( 5% ).

 Mode of transmission unknown.
 Horizontal transmission:
Contaminated syringes,
transfusions,...etc
 Infants born to HCV infected mothers
have
antibodies.
 To diagnose infection in NB do PCR.
 Human immunodeficiency virus
(HIV)
 Human immunodeficiency virus (HIV) is a serious, contagious virus
which causes acquired immunodeficiency syndrome (AIDS). About
one-fourth of pregnant women with HIV pass the infection on to
their newborn infants. An infant with HIV usually develops AIDS
and dies before the age of two.

 HIV can be detected using a blood test and is part of most prenatal
screening programs.

 Pregnant women with HIV should be treated as early in the

pregnancy as possible with zidovudine (AZT, formerly called
azidothymidine ). Other newer drugs designed to treat
HIV/AIDS may also be used during pregnancy with the knowledge
that these drugs may have unknown effects on the infant.
 AZT therapy

 ANTEPARTUM: AZT 100mg po 5X/day between 14 to 34 weeks

gestation
 INTRAPARTUM: AZT IV LD 2mg/kg over 1 hour, then 1mg/k/hr
until delivery
 POSTPARTUM: AZT 2mg/kg po every 6 hours for first 6 weeks of
life beginning 8 to 12 weeks after delivery

 Treatment with AZT during pregnancy significantly reduces the

chance that the infant will be infected with HIV from the mother.
 AZT used during pregnancy and given to the neonate for six
weeks postpartum resulted in a 70% decrease in maternal HIV
transmission to the infant. Cesarean birth also reduces
transmission, as compared with vaginal birth.
 Avoidance of breast-feeding can also decrease the risk of
transmission.
 a single dose of nevirapine given to infected mothers during labor
in addition to a single dose given to the neonate within three days
of birth cut the transmission rate in half, as compared with those
treated with AZT throughout pregnancy and during the first six
weeks of life.
 Human papillomavirus

 Human papillomavirus (HPV) is a sexually

transmitted disease that causes genital warts
and can increase the risk of developing some
cancers. HPV appears to be transferred from
the mother to the infant during the birth
process.
 HPV causes the growth of warts in the genital
area. The wart tissue can be removed with a
scalpel and tested to determine what type of
HPV virus caused the infection.
 Genital warts are very difficult to treat and
frequently reoccur even after treatment. They
can be removed by cryotherapy (freezing),
laser or electrocauterization (burning), or
surgical excision (cutting) of the warts.
 Some medications (imiquimod 5% cream,
podophyllin, trichloroacetic acid or topical 5-
fluorouracil) can be applied to help dissolve
genital warts. Cesarean delivery rather than
vaginal delivery seems to reduce the risk of
transmission of HPV from mothers to infants.
 Once infected with HPV, there is a life-long
risk of developing warts and an increased risk
of some cancers.
 Rubella (German measles)
 Rubella is a virus that causes German measles, an illness
that includes rash, fever, and symptoms of an upper
respiratory tract infection. Most people are exposed to
rubella during childhood and develop anti-bodies to the
virus so they will never get it again.

CONGENITAL RUBELLA SYNDROME

 The risk of infection is greatest in 1st trimester, cardiac and
hearing abnormalities invariably occur
 The classic CRS is characterized by:
* Eye anomalies: cataracts, retinopathy,
microphthalmia.
* Congenital heart: PDA, P.S.
* Neurological: meningoencephalitis, EEG
abnormalities, psychomotor retardation.
* Sensorineural hearing loss.
* Hematological: HSM, purpura.
* Radiological: bone lucencies.

 Some of these anomalies may not show until

months or years later.
 Pregnant women are usually tested for antibodies to
rubella, which would indicate that they have been
previously exposed to the virus and therefore would
not develop infection during pregnancy if exposed.
 Infection after 20 weeks gestation not a fetal issue.
 No treatment is available. Some health care
providers recommend giving the mother an
injection of immune globulin (to boost the
immune system to fight off the virus) if she is
exposed to rubella early in the pregnancy.
However, no evidence to support the use of
these injections exists.
 Exposure to rubella early in pregnancy poses a
high risk that the infant will have serious birth
defects. Termination of the pregnancy may be
considered. Women who have not been
previously exposed to rubella will usually be
vaccinated immediately after the first
pregnancy to protect infants of future
pregnancies.
Rash in Congenital Rubella
Hemorrhagic Rash in Congenital
Rubella
Congenital Rubella Cataract
 VACCINATION
 Routine vaccine prophylaxis is available in
the form of a live attenuated virus.
 If they have not been exposed to
rubella, they can be vaccinated
against the disease, but should not
become pregnant for three months
following the vaccination, and Patient
shouldn’t be vaccinated during the first
trimester due to potential
devastating effects on the fetus.
 Erythrovirus ( Parvovirus 19 )
 A common viral infection causing the slapped
cheek syndrome; fifth disease.
 Has been implicated in 10% of cases of fetal
non-immune hydrops fetalis.
 A small percentage of susceptible women
exposed to the virus are infected.
fifth disease
 Perinatal and intrapartum infections are very
rare.
 Inutero infections can result in fetal death,
nonimmune fetal hydrops, birth defects ( eyes,
CNS ) and prematurity.
Diagnosis:
 Serum IgM & IgG:
 Absent IgG antibodies in mother rules out
infection.

 IgM appears by day 3 after infection and

persists for 3 months at least.
 Streptococcus
 Group B streptococcus (GBS) infection is the most common
bacterial cause of infection and death in newborn infants.
In women, GBS can cause vaginitis and urinary tract
infections. Both infections can cause premature birth and
the bacteria can be transferred to the infant in the uterus
or during delivery. GBS causes pneumonia, meningitis, and
other serious infections in infants.

 Early neonatal disease

< 7 days of age, Higher rate of mortality, Septic shock.
 Late neonatal disease
7 days to 3 months of age, Lower rate of mortality,
Meningitis
 Streptococcus

 GBS can be detected by a vaginal or rectal swab culture,

and sometimes from a urine culture. Blood tests can be
used to confirm GBS infection in infants who exhibit
symptoms.
 Pregnant women diagnosed with GBS late in the pregnancy
should be treated with antibiotics injected intravenously to
prevent premature labor. If transmission of GBS to the
newborn infant is suspected or if the baby develops
symptoms of infection, infants can be treated with
antibiotics.

 Infection of the urinary tract or genital tract of pregnant

women can cause premature birth. Infants infected with
GBS can develop serious and life threatening infections.
 Syphilis
 Syphilis is a sexually transmitted infection
(a spirochete Treponema Pallidum) that
can be transferred from a mother to an
infant through the placenta before birth.
 Up to 50% of infants born to mothers with
syphilis will be premature, still-born, or
will die shortly after birth.
 Infected infants may have severe birth
defects. Those infants who survive infancy
may develop symptoms of syphilis up to
two years later.
 4 stages to the disease in the adult
which
 include: Primary, Secondary, Early
Latent, Late latent

Primary
 Without treatment, this will usually

resolve in 2 to 6 weeks. Probability

for fetal infection at this stage is
50%
 Secondary
Maculopapular rash involving palms and soles
Clears spontaneously in 2 to 6 weeks
Risk of fetal infection during this stage is 50%

Early Latent
< 4 years
May be associated with reactivation of secondary
symptoms
Risk of infection to the fetus is 40%

 Late Latent
> 4 years
Not infective sexually, but risk of fetal
If not treated in first 3 stages, 1/3 of patients will go
onto tertiary syphilis
involving the CNS and CV systems
 Congenital Infection:
 Can infect the fetus as early as 6 weeks, Clinical manifestations
not seen until fetal immunocompetence develops around 16 weeks
 The clinical spectrum of fetal infection includes stillbirth and
neonatal death
After birth, there can be early and late congenital syphilis
 Early => develops 10 to 14 days after birth and includes a rash,
hepatosplenomegaly,and jaundice
 Late => develops if not treated during early neonatal phase

Manifestations of Late Congenital Syphilis

 Hutchinson’s Teeth
 Mulberry Molars, Interstitial keratitis
 Eighth nerve deafness
 Saddle nose
 Saber shins
 Rhagades
 CV stigmata
 Syphilis

 Pregnant women are usually tested

for syphilis as part of the prenatal
screening.
 Antibiotic therapy, usually penicillin,
given early in the pregnancy can be
used to treat the infection and may
prevent transmission to the infant.
Prevention of Intrauterine Infection
 Use of a barrier method of contraceptive
can prevent transmission of some of the
infections. Intra-venous drug use and
sexual intercourse with infected partners
increases the risks of exposure to most of
these infections.
 Pregnant women can be tested for the
bacterial or viral infections; however,
effective treatment may not be available
to protect the infant.