‫ بان عامر موسى‬.‫د‬
‫المرحلة الرابعة‬
OBSTETRICS
Lec.
perinatal infection
A perinatal infection is an infection caused by bacteria, viruses or,
in rare cases, parasites transmitted directly from the mother to an embryo,
fetus or baby during pregnancy or childbirth. The term congenital
infection is also sometimes used.
Transplacental
The embryo and fetus have little or no immune function. They depend
on the immune function of their mother. Several pathogens can cross the
placenta and cause (perinatal) infection. Often microorganisms that
produce minor illness in the mother are very dangerous for the
developing embryo or fetus. This can result in spontaneous abortion or
major developmental disorders. For many infections, the baby is more at
risk at particular stages of pregnancy. Problems related to perinatal
infection are not always directly noticeable.
The term STORCH complex refers to a set of several different
infections that may be caused by transplacental infection.
Transcervical
Babies can also become infected by their mother during birth. Some
infectious agents may be transmitted to the embryo or fetus in the uterus,
while passing through the birth canal or even shortly after birth. The
distinction is important because when transmission is primarily during or
after birth, medical intervention can help prevent infections in the infant.
During birth, babies are exposed to maternal blood and body fluids
without the placental barrier intervening. Because of this, blood-borne
microorganisms (Hepatitis B, HIV) & organisms associated with sexually
transmitted disease (e.g., Gonorrhoea and Chlamydia) are among those
commonly seen in infection of newborns.
STORCH is a medical acronym for a set of perinatal infections (i.e.
infections that are passed from a pregnant woman to her fetus). The
STORCH infections can lead to severe fetal anomalies or even fetal loss.
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They are a group of viral, bacterial, and protozoan infections that gain
access to the fetal bloodstream transplacentally via the chorionic villi.
Hematogenous transmission may occur at any time during gestation or
occasionally at the time of delivery via maternal-to-fetal transfusion .
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S- Syphilis
T – Toxoplasmosis / Toxoplasma gondii
O – Other infections (see below)
R – Rubella
C – Cytomegalovirus
H – Herpes simplex virus-
The "other agents" included under O are Varicella-Zoster Virus, HIV,
and Parvovirus B19.
Hepatitis B may also be included among "other agents", but the
hepatitis B virus is a large virus and does not cross the placenta, hence it
cannot infect the fetus unless there have been breaks in the maternal-fetal
barrier, such as can occur in bleeding during childbirth or amniocentesis.
Features
The STORCH infections cause a syndrome characterized by
microcephaly, sensorineural deafness, chorioretinitis,
hepatosplenomegaly and thrombocytopenia. Symptoms of a TORCH
infection may include fever and poor feeding. The newborn is often small
for gestational age. A petechial rash on the skin may be present, with
small reddish or purplish spots due to bleeding from capillaries under the
skin. An enlarged liver and spleen (hepatosplenomegaly) is common, as
is jaundice. However, jaundice is less common in Hepatitis B because a
newborn's immune system is not developed well enough to mount a
response against liver cells, as would normally be the cause of jaundice in
an older child or adult. Hearing impairment, eye problems, mental
retardation, autism, and death can be caused by TORCH infections. The
mother often has a mild infection with few or no symptoms.
Diagnosis
When physical examination of the newborn shows signs of the
STORCH syndrome, the examiner may test blood, urine, and spinal fluid
for evidence of the infections listed above. Diagnosis can be confirmed
by culture of one of the specific pathogens or by increased levels of IgM
against the pathogen.
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Syphilis
Syphilis is a sexually transmitted infection caused by the spirochete
bacterium Treponema pallidum . The primary route of transmission is
through sexual contact; it may also be transmitted from mother to fetus
during pregnancy or at birth, resulting in congenital syphilis.
The signs and symptoms of syphilis vary depending in which of the
four stages it presents (primary, secondary, latent, and tertiary). The
primary stage classically presents with a single chancre (a firm, painless,
non-itchy skin ulceration), secondary syphilis with a diffuse rash which
frequently involves the palms of the hands and soles of the feet, latent
syphilis (early < 1yr &late >1yr) with little to no symptoms, and
tertiary syphilis (in one third of untreated patients) with gummas,
neurological, or cardiac symptoms. It has, however, been known as "the
great imitator" due to its frequent atypical presentations. Diagnosis is
usually via blood tests; however, the bacteria can also be detected using
dark field microscopy.
Diagnosis
1. darkfield microscopical examination of secretion from the chancre
for the presence of spirochetes .
2. serologic tests :- which include
a. nonspecific nontreponemal antibody test :-VDRL (Venereal Disease
Research Laboratory) test & RPR( Rapid Plasma Reagain ) test , are
used in screening for syphilis .
b. specific treponemal antibody test :- FTA-ABS (Fluorescent
treponemal antibody absorption) test & MHA-TP
(Microhaemoagglutination assay for antibody to Treponema Pallidum)
are confirmatory tests .
3. CSF examination in neurosyphilis .
Treatment
Syphilis can be effectively treated with antibiotics, specifically the
preferred intramuscular penicillin G (given intravenously for
neurosyphilis), or else ceftriaxone, and in those who have a severe
penicillin allergy, azithromycin can be used ,or desensitization followed
by pn. Therapy .
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Congenital syphilis is syphilis present in utero and at birth, and
occurs when a child is born to a mother with syphilis. Untreated syphilis
results in a high risk of a bad outcome of pregnancy. Syphilis can cause
miscarriages, premature births, stillbirths, or death of newborn babies.
Some infants with congenital syphilis have symptoms at birth, but most
develop symptoms later. Untreated babies can have deformities, delays in
development, or seizures along with many other problems such as rash,
fever, hepatosplenomegaly, anemia, and jaundice. Sores on infected
babies are infectious. Rarely, the symptoms of syphilis go unseen in
infants so that they develop the symptoms of late-stage syphilis, including
damage to their bones, teeth, eyes, ears, and brain.
Toxoplasmosis
Toxoplasmosis is a parasitic disease caused by the protozoan Toxoplasma
gondii. Cats are the primary source of infection to human hosts, although
contact with raw meat, is a more significant source of human infections in
some countries. Fecal contamination of hands is a significant risk factor.
During the first few weeks post-exposure, the infection typically causes a
mild flu-like illness or no illness. Thereafter, the parasite rarely causes
any symptoms in otherwise healthy adults .
Pregnancy precautions
Congenital toxoplasmosis is a special form in which an unborn fetus is
infected via the placenta. A positive antibody titer indicates previous
exposure and immunity and largely ensures the unborn fetus' safety. A
simple blood draw at the first pre-natal doctor visit can determine
whether or not the woman has had previous exposure and therefore
whether or not she is at risk. If a woman receives her first exposure to
toxoplasmosis while pregnant, the fetus is at particular risk. A woman
with no previous exposure should avoid handling raw meat, exposure to
cat feces, and gardening (cat feces are common in garden soil). Treatment
during pregnancy for those women exposed to T. gondii for the first time
decreases dramatically the risk of passing the parasite to the fetus.
1st trimester fetal infection , although less common than infection later in
pregnancy often result in miscarriage , stillbirth or severe sequelae in the
newborn .Most infants with congenital toxoplasmosis are asymptomatic .
Signs of infection present at birth may include fever ,maculopapular rash
hepatosplenomegaly , microcephaly ,seizure ,jaundice thrombocytopenia
& rarely generalized lymphadenopathy .The so called classic triad of
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congenital toxoplasmosis consist of chorioretinitis , hydrocephalus &
intracranial calcifications.
Diagnosis
Maternal :1- Enzyme linked immunosorbent assay (ELISA) :- for Ig M Ab
detection .
2- Sabin – Feldman dye test :- for IgG Ab which remain detectable
for life .
3- Most defenitive test is demonstration of the parasite in CSF & LN
tissue .
Fetal :IgM or IgA Ab in fetal blood or polymerase chain reaction (PCR) .
Treatment
Spiramycin 3 weeks course of 2-3 gm / d is administered during
pregnancy to reduce the incidence of transplacental infection
Cytomegalovirus
CMV cause a wide variety of clinical manifestations . primary
infection and reactivation of the virus can occur during pregnancy &
both can result in congenital infection ,it is the most common cause of
congenital infection . Infection require intimate contact with a person
excreting the virus in saliva, urine & body fluid .
Clinical Features
Maternal infection:- Primary infection in pregnant lady may cause
mild febrile illness or be unapparent .
Congenital infection :- In utero transmission can occur as a result of
primary infection or reactivation
1- As many as 90% of newborn who are congenitally infected with
CMV are asymptomatic at birth , 15% of them of them will
experience progressive hearing loss .
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2- Approximately 10% of congenitally infected newborn will have
symptoms ( IUGR, hepatoseplenomegally , petechiae & purpura of
the skin , microcephally , seizures & jaundice at birth .
Diagnosis
1- viral culture & PCR .
2- Serology for Ig M Ab in cord blood .
Treatment
Acyclovir ( contraindicated in pregnancy )
Rubella
Rubella, also known as German measles , is a disease caused by
the rubella virus. This disease is often mild and attacks often pass
unnoticed. The disease can last one to three days. Children recover more
quickly than adults. Infection of the mother by Rubella virus during
pregnancy can be serious; if the mother is infected within the first 20
weeks of pregnancy, the child may be born with congenital rubella
syndrome (CRS), which entails a range of serious incurable illnesses.
Spontaneous abortion occurs in up to 20% of cases.
Rubella is a common childhood infection that can sometimes be fatal
usually with minimal systemic upset although transient arthropathy may
occur in adults. Serious complications such as deterioration of the skin
are very rare. Apart from the effects of transplacental infection on the
developing fetus, rubella is a relatively trivial infection.
Congenital rubella syndrome :- Rubella can cause congenital rubella
syndrome in the newly born. The syndrome (CRS) follows intrauterine
infection by the Rubella virus and comprises cardiac, cerebral (mental
retardation ) , ophthalmic ( cataract) and auditory defects( sensorineural
deafness ) . It may also cause prematurity, low birth weight, and neonatal
thrombocytopenia, anaemia and hepatitis. The risk of major defects or
organogenesis is highest for infection in the first trimester. CRS is the
main reason a vaccine for rubella was developed. Many mothers who
contract rubella within the first critical trimester either have a miscarriage
or a still born baby. If the baby survives the infection, it can be born with
severe heart disorders (Patent ductus arteriosus being the most common),
or other life threatening organ disorders.
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The classic triad for congenital rubella syndrome is:
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Sensorineural deafness (58% of patients)
Eye abnormalities—especially retinopathy, cataract and
microphthalmia (43% of patients)
Congenital heart disease—especially patent ductus arteriosus (50%
of patients)
Diagnosis
1- serology :- ELISA
2- Rubella culture .
Treatment
Symptomatic treatment
Prevention
Live attenuated vaccine is recommended for all children .
Postpartum vaccination programs have been shown to significantly
reduce rubella susceptibility in seronegative women . Rubella vaccine
virus may cross the placenta & infect the fetus , so it contraindicated
during pregnancy , women had been advised to avoid pregnancy for
three months following vaccination .
Varicella-zoster virus
It is the causative agent of varicella ( chickenpox) , & herpes zoster
(shingles) .
Infection in pregnancy and neonates
For pregnant women, antibodies produced as a result of immunization
or previous infection are transferred via the placenta to the fetus.[19]
Women who are immune to chickenpox cannot become infected and do
not need to be concerned about it for themselves or their infant during
pregnancy.
The incubation period of chickenpox is 10-21 days ,many patient
experience a prodrome of fever , malaise & myalgia 1-4 days prior to
rash . A vesicular rash may involve the trunk ,face , oropharynx & scalp .
Complications include bacterial super infection of vesicles , arthritis ,
pneumonia , glomerulonephritis , myocarditis ,& death .
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Varicella pneumonia is seen in up to 20 % of adult chickenpox cases ,in
pregnancy ,it is a medical emergency .the mortality rate is in excess 40% .
Prompt supportive care & acyclovir are the mainstays of therapy .
Varicella infection in pregnant women could lead to viral transmission
via the placenta and infection of the fetus. If infection occurs during the
first 28 weeks of gestation, this can lead to fetal varicella syndrome (also
known as congenital varicella syndrome). Effects on the fetus can range
in severity from underdeveloped toes and fingers to severe anal and
bladder malformation. Possible problems include:
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Damage to brain: encephalitis, microcephaly, hydrocephaly,
aplasia of brain
Damage to the eye: microphthalmia, cataracts, chorioretinitis, optic
atrophy
Other neurological disorder: damage to cervical and lumbosacral
spinal cord, motor/sensory deficits, absent deep tendon reflexes.
Damage to body: hypoplasia of upper/lower extremities, anal and
bladder sphincter dysfunction
Skin disorders: (cicatricial) skin lesions.
Infection late in gestation or immediately following birth is referred to
as "neonatal varicella". Maternal infection is associated with premature
delivery. The risk of the baby developing the disease is greatest following
exposure to infection in the period 7 days prior to delivery and up to 7
days following the birth. The baby may also be exposed to the virus via
infectious siblings or other contacts, but this is of less concern if the
mother is immune. Newborns who develop symptoms are at a high risk of
pneumonia and other serious complications of the disease.
Diagnosis
The diagnosis is usually made clinically. VZV may be cultured from
vesicular fluid .Serological tests ,IgM Ab may be detected as soon as
three days after symptoms appear & IgG Ab may be detected as early as
seven days after symptoms .
Prevention
VZIG can be administered after exposure to chickenpox to try to
prevent development of infection in non immune women .
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Management
Pregnant women who develop VZ shold be monitor closely for signs of
pneumonia .VZIG should be administered to the neonate immediately if
the mother develop chickenpox 2 days before to 5 days after delivery .If
chickenpox develops during the first month of life , IV acyclovir should
be administered .
Parvovirus B19 infection
Parvovirus B19 causes prolonged epidemics of erythema infectiosum,
particularly in primary school-aged children. Infection causes clinically
significant anaemia in individuals with high red cell turnover, including
the fetus. Maternal infection in the first half of pregnancy is associated
with fetal loss and hydrops fetalis in (of which up to 60% resolve
spontaneously or with appropriate management). No congenital
abnormalities or long-term sequelae have been attributed to parvovirus
B19 infection.
Clinical features and pathogenesis
Human parvovirus B19 causes an acute, usually self-limiting, infection
which is often asymptomatic. The usual clinical manifestation is
erythema infectiosum (fifth disease), characterized by a mild prodrome mild fever, malaise, myalgia - followed by a biphasic rash. A bright red
malar eruption, 'slapped cheek syndrome', with circumoral pallor is
followed by a maculopapular rash on the extremities and trunk, which
fades to a reticular appearance and often recurs, transiently, for weeks.
The virus primarily infects erythroid precursors and causes haemolytic
anaemia, which is subclinical and spontaneously reversible in otherwise
normal people. Fetal infection is usually benign and self-limiting but, in a
small proportion, causes severe anaemia and hydrops fetalis, usually in
the second trimester .
Diagnosis
Pregnant women who have been exposed to parvovirus infection
(erythema infectiosum/fifth disease) should be offered serological testing
for parvovirus-specific IgG to determine their susceptibility. The
diagnosis of parvovirus infection is usually made, serologically, by
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demonstration of IgG seroconversion and/or the presence of parvovirus
IgM. IgM is usually detectable within 1-3 weeks of exposure and lasts for
2-3 months. Various serological methods are available, of which enzyme
immunoassay and immunofluorescence are most commonly used.
Management of proven maternal parvovirus infection
in pregnant women
No intervention is available to prevent fetal infection or damage.
Because of the low risk of fetal damage neither termination of pregnancy
nor amniocentesis for diagnosis of asymptomatic intrauterine fetal
infection is recommended. Repeated ultrasound examination by an
experienced specialist to detect hydrops is recommended. If hydrops is
detected, further assessment is indicated to determine the need for
treatment (intrauterine transfusion).
Outcome from hydrops fetalis
Hydrops should be managed by a specialist with experience in
intrauterine transfusion. The outcomes are depending on the severity of
fetal anaemia and hydrops:
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spontaneous resolution in about one-third of cases;
fetal death occurs within a few days of diagnosis in about one-third
of cases;
intrauterine transfusion in about one-third of cases, with a success
rate of about 80% and fetal death in a small minority; and
there is circumstantial evidence that the prognosis can be
significantly improved by intrauterine transfusion in cases with
severe anaemia and hydrops.
Infection affecting the neonate at birth
1. Herpes simplex virus HSV
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HSV type 2 cause most cases of virologically confirmed genital
herpes infection . Type of infection are primary , non primary
& recurrent .
The most common mode of transmission is via direct contact of
the fetus with the infected vaginal secretion during delivery .
Treatment
Acyclovir 200 mg PO five times daily for 5 days .
2.Group B Streptococcus (GBS)
Infection with Group B Streptococcus (GBS) can cause serious
illness and sometimes death, especially in newborn infants, the elderly,
and patients with compromised immune systems. Streptococcus is a
Gram-positive bacteria .
Group B Streptococcus (GBS) is a part of normal flora of the gut and
genital tract and is found in 20–40% women. It may be harmful to both
mother and the baby itself. Infection of this organism may result in
neonatal death due to severe neonatal infection. Carriage of the organism
is asymptomatic. GBS infection is acquired in utero shortly before birth
or during passage through the vagina . Newborn GBS disease is separated
into early-onset disease occurring on living days 0–7 and late-onset
disease which starts on days 7–90. Early-onset septicemia is more prone
to be accompanied by pneumonia, this is thought to be due to aspiration
of GBS during birth, while late-onset septicimia is more often
accompanied by meningitis.
Prevention
Intrapartum antibiotic prophylaxis (IAP) is recommended for:
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Women who delivered a previous infant with GBS disease
Women with GBS bacteriuria in the current pregnancy
Women with a GBS-positive screening result in the current
pregnancy
Women with unknown GBS status who deliver at less than 37
weeks’ gestation, have an intrapartum temperature of 38°C
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(100.4°F) or greater, or have rupture of membranes for 18 hours or
longer.
Penicillin is the preferred agent for intrapartum antibiotic prophylaxis,
and ampicillin is an acceptable alternative. Simple anti-septic wipes do
not prevent mother-to-child transmission. Up to 90% of early-onset GBS
infection would be preventable if intravenous antibiotics were offered in
labour to all GBS carriers identified by universal sensitive testing late in
pregnancy plus to the mothers of babies in the recognised higher risk
situations. Early onset GBS infection is most likely to present with
breathing problems and pneumonia; late onset GBS infection is more
likely to present with meningitis and septicaemia. Once symptoms are
present, the condition can be difficult to treat.
3.Chlamydia trachomatis
Is the most common agent of STD, in infant born to mother through an
infected birth canal , conjunctivitis & pneumonia can occur.
Clinical features :-although the majority of infected women are
asymptomatic , clinical manifestation range from cervicitis to PID .
Treatment
Azithromycine 1 gm PO single dose
4.Gonorrhea
infection is often asymptomatic but may cause neonatal eye infection
that is if untreated , can progress to blindness due to corneal scarring .
Clinical features :-cervicitis ,urethritis , Bartholin gland infection ,
PID.
Treatment
Cephalosporin
The End
Thank you
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