INFECTIOUS DESEASES IN PREGNANCY

MARGIE REYES-POSADAS, M.D.

OB GYN
 VIRAL INFECTIONS
VARICELLA-ZOSTER
- double stranded DNA herpesvirus
- PRIMARY INFECTION: Varicella or Chicken pox

MODE OF TRANSMISSION:
= direct contact with an infected person.

INCUBATION PERIOD: 10 to 21 days

CLINICAL MANIFESTATION:
1. 1- to 2-day flulike symptoms
2. followed by pruritic vesicular lesions that crust over in 3 to 7
days.
3. Infection tends to be more severe in adults

MORTALITY : due to varicella pneumonia ( more severe during

adulthood and particularly in pregnancy ( pneumonitis)
CONTAGIOUS: from 1 day prior to the onset of the rash until
the lesions are crusted over.
HERPES-ZOSTER (shingles) = reactivated primary
varicella infection
DIAGNOSIS:
Tzanck smear, tissue culture, or direct fluorescent antibody
testing.

PREVENTION: (pregnant women) Varicella-zoster

immunoglobulin (VZIG); given within 96 Hrs of exposure;
dose 125 U/10 kg IM
• administered to neonates born to mothers who have clinical evidence
of varicella 5 days before and up to 2 days after delivery

Varicella-Zoster
• Fetal Effects
1ST TRIMESTER: chorioretinitis, microphthalmia,
cerebral cortical atrophy, growth restriction, hydronephrosis,
and skin or bone defects
2ND TRIMESTER: congenital infections uncommon
• VACCINE – (VARIVAX)= An attenuated live-virus in
Two doses, given 4 to 8 weeks apart.
• CONTRAINDICATED PREGNANCY

Varicella-Zoster
• INFLUENZA
- RNA viruses (ORTHOMYXOVIRIDAE)
- Influenza A more serious than B
- Sxs: fever, dry cough, systemic symptoms
- pregnant women: causes pneomonia
- Dxtics: Rapid enzyme immunoassay or
immunoflourescence assay

INFLUENZA
• Prevention
- Vaccination – given during influenza season at any
AOG.; women with underlying medical disorders.
• Treatment
a. Amantadanes: Amantadine, Rimantadine
b. Neuraminidase inhibitors: Oseltamivir, Zanamivir
Category C for pregnant women used when the potential
benefits outweigh the risks.

Influenza
Fetal Effects
- No specific fetal or maternal complications

Influenza
• MUMPS
- RNA (PARAMYXOVIRUS)
- infects salivary glands, also gonads, meninges,
pancreas.
MOT: direct contact with respiratory secretions, saliva, or
through fomites.
TX: is symptomatic; during pregnancy is no more severe
than in nonpregnant adults.
VACCINE: MMR (measles, mumps, rubella) live
attenuated vaccine:
: contraindicated in pregnancy
* Pregnancy shld be avoided 30 days after vaccination

MUMPS
• Fetal Effects
• first trimester: increased risk of spontaneous
abortion.
• Infection in pregnancy is not associated with
congenital malformations, and fetal infection is
rare.

MUMPS
• RUBEOLA (MEASLES)
• Most adults are immune to measles due to childhood
immunization.
• increased risk of pneumonia for unvaccinated pregnant
women
• S/SX: fever, coryza, conjunctivitis, and cough
• —Koplik spots— (characteristic rash)= develops on the
face and neck and then spreads to the back, trunk, and
extremities.
• Treatment is supportive.

RUBEOLA
• Passive maternal immunization is given with immune
serum globulin—0.25 mL/kg with a maximum dose of 15
mL, administered intramuscularly within 6 days of
exposure.
• Active vaccination is not performed during pregnancy,
but susceptible women can be vaccinated routinely
postpartum.

RUBEOLA
• FETAL EFFECTS
- abortion, prematurity, & low-birth weight neonates

Rubeola
• RUBELLA (GERMAN MEASLES)
• RNA TOGAVIRUS
• directly responsible for abortion and severe congenital
malformations during the 1st trimester
• MOT: Transmission occurs via nasopharyngeal secretions
• S/SX: mild, febrile illness, generalized maculopapular
rash on the face & trunk.
• INCUBATION PERIOD: 12-23 days
• adults are infectious during viremia and through 5 to 7
days of the rash

RUBELLA
• Rubella is one of the most teratogenic agents known with the sequela
of fetal infection being worst during organogenesis.
• Eye defects (cataracts and congenital glaucoma)
• Heart disease (patent ductus arteriosus and pulmonary
artery stenosis)
• Sensorineural deafness (most common single defect)
• CNS defects (microcephaly, developmental delay, mental
retardation, and meningoencephalitis)
• Pigmentary retinopathy
• Neonatal purpuraHepatosplenomegaly and jaundice
• Radiolucent bone disease

Congenital Rubella Syndrome

• DIAGNOSIS:
ISOLATION: urine, nasopharynx, and cerebrospinal
fluid.
SEROLOGY: enzyme-linked immunoassay = ↑ specific
IgM antibody (4 to 5 days) after onset of clinical disease,
& up to 8 weeks after appearance of the rash.
• MANAGEMENT & PREVENTION:
- no specific treatment for rubella
- MMR vaccine should be offered to non pregnant
women of childbearing age
- Rubella vaccination should be avoided 1 month before
or during pregnancy because the vaccine contains
attenuated live virus

Congenital Rubella Syndrome

• HANTAVIRUS
- RNA (BUNYAVIRIDAE)
- rodent reservoir, from inhalation of virus excreted in
rodent urine & feces.
- resembles ARDS
- cause maternal death, fetal demise & preterm birth

HANTAVIRUS
• ENTEROVIRUS
• major subgroup of RNA PICORNAVIRUSES
that include poliovirus, coxsackievirus, and
echovirus.
• trophic for intestinal epithelium but can also
cause widespread maternal, fetal, and neonatal
infections that may include the central nervous
system, skin, heart, and lungs

ENTEROVIRUS
• COXSACKIEVIRUS
• Infections with coxsackievirus group A and B are usually
asymptomatic.
• Symptomatic infections—usually with group B
• include aseptic meningitis, polio-like illness, hand foot
and mouth disease, rashes, respiratory disease,
pleuritis, pericarditis, and myocarditis.
• No treatment or vaccination is available.

COXSACKIEVIRUS
• COXSACKIEVIRUS
• Congenital malformations: increased slightly in pregnant
women who had serological evidence of coxsackievirus

• Coxsackie viremia: cause fetal hepatitis, skin lesions,

myocarditis, and encephalomyelitis

COXSACKIEVIRUS
• PARVOVIRUS
- Human Parvovirus B19 = erythema infectiosum or 5th
disease
- Single-stranded DNA virus= replicates in rapidly
proliferating cells such as erythroblast precursors.
- This can lead to anemia, which is its central fetal effect

PARVOVIRUS
• MOT: respiratory or hand-to-mouth contact

• VIREMIA: 4-14 days after exposure; last few days of

the viremic phase = fever, H/A, flulike symptoms;
several days later, bright red rash appears

• DIAGNOSIS:
SEROLOGY: detecting IgM, IgG, PCR (polymerase
chain reaction)

PARVOVIRUS
• FETAL EFFECTS
- infection associated with abortion, nonimmune
hydrops, fetal death.
- critical period: between 13 & 16 weeks AOG
• PROGNOSIS: POOR
MANAGEMENT:
- serial sonography every 2 weeks should be performed in
women with recent infection
- Fetal blood sampling is warranted with hydrops to assess the
degree of fetal anemia
• PREVENTION: no approved vaccine for human parvovirus
B19, and there is no evidence that antiviral treatment prevents
maternal or fetal infection

PARVOVIRUS
• CYTOMEGALOVIRUS
- DNA herpesvirus
- most common cause of perinatal infection
• MOT: body fluids & person-to-person transmission with
infected nasopharyngeal secretions, urine, saliva, semen,
cervical secretions, or blood.
• S/SX: Pregnancy does not increase the risk or severity of
maternal CMV infection.
• Most infections are asymptomatic
• 15 %: have a mononucleosis-like syndrome characterized
by fever, pharyngitis, lymphadenopathy, and polyarthritis

CYTOMEGALOVIRUS
• CONGENITAL CMV INFECTION
- low birthweight
- microcephaly
- intracranial calcifications
- chorioretinitis
- mental & motor retardation
- sensorineural deficits
- hepato-splenomegaly
- jaundice
- hemolytic anemia
- thrombocytopenic purpura

Cytomegalovirus
• DIAGNLOSIS:
CMV serological screening- not routinely requested
• MANAGEMENT & PREVENTION:
- SYMPTOMATIC TREATMENT
- immunocompetent pregnant woman
- There is no CMV vaccine.
- Prevention of maternal primary infection,
especially in early pregnancy.
- Basic measures such as good hygiene and hand
washing.

Cytomegalovirus
• GROUP A STREPTOCOCCUS
- most frequent bacterial cause of acute pharyngitis
- S.Pyogenes (M3 strain) = bacteremia, metritis,
peritonitis & septic abortion; also causes toxic shock-like
syndrome
- Treatment: penicillin & debridement

BACTERIAL INFECTIONS
• GROUP B STREPTOCOCCUS
• It colonizes the gastrointestinal and genitourinary tract in 20
to 30 % of pregnant women, which serves as a source for
perinatal transmission.
- S.Agalactiae = preterm labor, prematurely ruptured
membranes, chorioamnionitis; postpartum maternal
osteomyelitis & mastitis
- Early onset dse.= neonatal sepsis = infxn occurs less
than 7 days after birth
- Late onset dse.= meningitis= 1 wk to 3 mons afetr
birth

BACTERIAL INFECTIONS
PREVENTION:

GROUP B STREPTOCOCCUS
BACTERIAL INFECTIONS
• TREATMENT:
• Penicillin G, 5 million units IV initial dose, then 2.5
million units IV every 4 hours until delivery
• ALTERNATIVE: Ampicillin, 2 g IV initial dose, then 1
g IV every 4 hours or 2 g every 6 hours until delivery
• PENICILLIN ALLERGIC: give cefazolin, clindamycin,
erythromycin, vancomycin

GROUP B STREPTOCOCCUS
• LISTERIOSIS
• Listeria monocytogenes
• facultative intracellular gram-positive bacillus can be
isolated from the feces of 1 to 5 % of adults
• Food-borne disease
• Caused: raw vegetables, coleslaw, apple cider, melons,
milk, fresh Mexican-style cheese, smoked fish, and
processed foods and sliced deli meats

LISTERIOSIS
• CLINICAL PRESENTATION:
• 1. Febrile illness: confused w/ influenza, pyelonephritis,
or meningitis
• 2. Chorioamnionitis
• 3. Placental lesions: include multiple, well-demarcated
macroabscesses
• 4. Abortion or stillbirth
• 5. Neonatal sepsis

LISTERIOSIS
• TREATMENT:
• Ampicillin plus gentamicin
• Trimethoprim-sulfamethoxazole= penicillin-allergic
women.
• No vaccine for listeriosis.
• Pregnant women should thoroughly cook raw food, wash
raw vegetables, and avoid the implicated foods listed
previously.

LISTERIOSIS
• SALMONELLA
• food-borne illness
SALMONELLA typhimurium and enteritidis
- gastroenteritis = diarrhea, abdominal pain, fever,
chills, nausea & vomiting.
- Tx = IV fluid rehydration
• Diagnosis: stool analysis

SALMONELLA
 SHIGELLA
• Bacillary dysentery
• Highly contagious cause in adults of inflammatory
exudative diarrhea, frequently with bloody stools
• Fecal oral route
• CLINICAL MANIFESTATIONS: mild diarrhea to
severe dysentery, abdominal cramping, tenesmus, fever,
and systemic toxicity.
• TREATMENT:
• fluoroquinolones, ceftriaxone, azithromycin, or
trimethoprim-sulfamethoxazole
• IV hydration

SHIGELLA
TYPHOID FEVER
- Salmonella enterica
- oral ingestion of contaminated food, water or milk
- antepartum typhoid fever results in abortion, preterm
labor, & maternal or fetal death.
- Tx : Fluoroquinolones; IV 3rd gen cephalosporin;
azithromycin

TYPHOID FEVER
• HANSEN DSE.
• LEPROSY
• Mycobacterium leprae
• low-birth weight newborns born to infected women
• Vertical transmission is common in untreated
mothers
• Diagnosis: PCR.
• TREATMENT: Multidrug therapy with dapsone,
rifampin, and clofazimine (safe in pregnancy)

HANSEN DSE.
• LYME DISEASE
• spirochete Borrelia burgdorferi
• most commonly reported vector-borne illness in
the United States
• CLINICAL MANIFESTATIONS:
• 1. Early infection: local skin lesion, erythema
migrans
• 2. flulike syndrome
• 3. regional adenopathy.

LYME DISEASE
• DIAGNOSIS:
• Serolory: ELISA or Western Blot assay
• TREATMENT:
• doxycycline, amoxicillin, or cefuroxime for 14
days
• Intravenous ceftriaxone, cefotaxime, or
penicillin G: complicated early infections that
include meningitis or carditis.

LYME DISEASE
• TOXOPLASMOSIS
• Toxoplasma gondii
• Complex life cycle with three forms:
• (1) tachyzoite: invades and replicates
intracellularly during infection,
• (2) bradyzoite: which forms tissue cysts during
latent infection
• (3) sporozoite, which is found in oocysts that can
be environmentally resistant

PROTOZOAL INFECTIONS
• TOXOPLASMOSIS
• MOT: by eating raw or undercooked meat that is infected
with tissue cysts or through contact with oocysts from
infected cat feces in contaminated litter, soil, or water
• CLINICAL MANIFESTATIONS:
• Maternal S/SX: fatigue, fever, muscle pain,
maculopapular rash and posterior cervical
lymphadenopathy
• Neonatal S/SX: low birthweight, hepatosplenomegaly,
jaundice, and anemia
- TRIAD: chorioretinitis, intracranial calcifications &
hydrocephalus

PROTOZOAL INFECTIONS
 DIAGNOSIS:
• DNA amplification techniques
• Ultrasound
• PCR of amnionic fluid or fetal blood
TREATMENT:
• Spiramycin= reduced congenital inection
• Pyrimethamine= eradicates parasite in the placenta &
fetus
• Sulfonamides
• Folinic acid
 PREVENTION:
•(1) cooking meat to safe temperatures
•(2) peeling or thoroughly washing fruits and vegetables (3)
cleaning cooking surfaces and utensils that contain raw
meat, poultry, seafood, or unwashed fruits and
vegetables
•(4) wearing gloves when changing cat litter or delegating
this duty
•(5) avoiding feeding cats raw or undercooked meat and
keeping cats indoors.
• MALARIA
- FOUR SPECIES:
- PLASMODIUM vivax, ovale, malariae & falciparum
- Malaria remains the most common human parasitic
disease (common in Africa)
- CLINICAL MANIFESTATIONS:
- Fever & flu-like symptoms (chills, H/A, myalgia)
- anemia, jaundice
- P. Falcifarum: kidney failure, coma, and death.
- Pregnancy enhances severity of falciparum malaria=
abortion, preterm delivery, and fetal-growth restriction

MALARIA
• MALARIA
- TREATMENT:
- antimalarial drugs: not contraindicated in pregnancy
- CHLOROQUINE: treatment of choice for malaria caused
by all Plasmodium.
- Quinine & Clindamycin: for resistant to chloroquine
- Mefloquine or atovaquone-proguanil: C/I in pregnancy

MALARIA
• AMEBIASIS:
• Entamoeba histolytica
• Amebic Dysentery
• S/SX: fever, abdominal pain, bloody stools.
• Prognosis is worse if complicated by a hepatic abscess.
• TREATMENT:
• METRONIDAZOLE

AMEBIASIS
• Infectious diseases whose incidence in
humans has increased in the past two
decades or has high potential to increase in
the near future.

Emerging Infections
• WEST NILE VIRUS
• Mosquito-borne flavivirus is a human neuropathogen
• Mosquito bites in late summer, or perhaps through blood
transfusion
• Incubation period: 3 to 14 days
• S/SX: fever, mental status changes, muscle weakness, and
coma
• DIAGNOSIS: West Nile virus IgG and IgM in serum and
IgM in cerebrospinal fluid.

Emerging Infections
WEST NILE VIRUS
• SEVERE ACUTE RESPIRATORY SYNDROME
(SARS)
coronavirus—SARS-CoV
• MOT: droplets, close contact with infected secretions,
fluids, and waste
• Incubation period: 2 to 16 days
• TRIPHASIC PATTERN to the clinical progression of
SARS:
• 1ST WEEK: characterized by prodromal symptoms of
fever, myalgias, headache, and diarrhea

Severe Acute Respiratory Syndrome (SARS)

• SEVERE ACUTE RESPIRATORY SYNDROME
(SARS)
2ND WEEK: recurrent fever, watery diarrhea, and a dry
nonproductive cough with mild dyspnea
3RD WEEK: lethal phase= progression to the acute
respiratory distress syndrome
DIAGNOSIS:
CHEST X-RAY: ground-glass opacities and airspace
consolidations that can rapidly progress to extensive
consolidation within 1 to 2 days.

Severe Acute Respiratory Syndrome (SARS)

• SEVERE ACUTE RESPIRATORY
SYNDROME (SARS)
TREAMENT:
• currently is no proven treatment
• ANTI-MICROBIALS:
• clarithromycin plus amoxicillin with
clavulanate
• Ribavirin: decrease viral replication
• Corticosteroids: modulate the immune response

Severe Acute Respiratory Syndrome (SARS)

• SEVERE ACUTE RESPIRATORY
SYNDROME (SARS)
PERINATAL OUTCOME:
• miscarriage
• fetal-growth restriction
• preterm delivery

Severe Acute Respiratory Syndrome (SARS)

THANK YOU!