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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.
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:
*Invasive diagnostic or therapeutic interventions. ( e.g. monitors, fetal blood sampling, intrauterine transfusions )
* Extension from adjacent tissues and/organs.
Clinical Sign Rubella virus
Microceph aly Hydroceph alus
Intracranial calcifications Hearing deficits
Skin lesions purpura
Rubella CMV + _ _ + + + _ +
HSV + ++ + +
+ _ + +
Maculopap ular rash
The term TORCH complex refers to a set of major infections that may be caused by transplacental infection.
Toxoplasmosis Rubella Cytomegalovirus Herpes/Hepatitis
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 sulfadiazine 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 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.
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.
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.
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 (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.
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
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, 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. 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.
Specific IgM, DFA,
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 720 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
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 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.
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
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.
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 (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 5fluorouracil) 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
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.
Perinatal and intrapartum infections are very rare. Inutero infections can result in fetal death, nonimmune fetal hydrops, birth defects ( eyes, CNS ) and prematurity. 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.
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
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 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
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
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.
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