Transcript Infections in Pregnancy

Infections in Pregnancy
Dr Shahnaz Aram
General Principles
Pregnancy does not alter resistance to
infection
Severe infections have greater effects on the
fetus
Maternal antibodies cross the placenta and
give passive immunity to the fetus
Fetus becomes immunologically competent
from the 14th week
Fetus and Infection
• Indirect effect - O2 transport, nutrient
exchange
• Direct effect - invasion of placenta and
infection of fetus
• Viruses more than bacteria
• rarely effect fetus unless maternal infection is severe
– exception: Rubella, CMV, Herpes Simplex
Fetus and Infection
Infections cause
- miscarriage
- congenital anomalies
- fetal hydrops
- fetal death
- preterm delivery
- preterm rupture of the membranes
Viral Diseases
•
•
•
•
•
•
•
•
Rubella
Parvovirus
Cytomegalovirus
Varicella Zoster
Herpes
Hepatitis
HIV
Rubeola
Measles (Rubeola)
•
•
•
•
Paramyxovirus
Incubation - 10-14 days
Respiratory droplet inoculation
Fever, rash, cough, rhinorrhea,
conjunctivitis and Koplik’s spots
• Pneumonia (2nd bacterial) main cause of
death
• Encephalomyolitis, SSPE, Hepatitis
Measles (Rubeola)
•
•
•
•
No increased maternal or fetal deaths
Risk of preterm delivery
No specific syndrome
Neonatal measles and pneumonia if active
disease in mother
• Increased PNM in developing countries
Measles (Rubeola)
• Prevention
vaccine (95% recipients
protected)
• Treatment antipyrexials
cough suppresants
Antibiotics for bacteria
Suppress uterine contractions
? Immune serum globulin
• Isolation precautions
Rubella
• Togavirus (RNA virus)
• Incubation - 14-21 days
• Respiratory droplet inoculation
– only modestly contagious
• Fever, rash (3 days), cough, arthralgias, post
auricular and suboccipital lymphadenopathy
• Usually mild, overt clinical symptoms 50-75% of
cases
• Encephalitis, bleeding diathesis & arthritis are rare
complications
Rubella and the Fetus
• Purpura, Splenomegaly, jaundice,
meningoencephalitis, thrombocytopenia are
transient
• Congenital cataracts, Glaucoma, heart disease,
deafness, microcephaly and mental retardation are
permanent abnormalities
• Diabetes, thyroid abnormalities, precocious
puberty & Progressive panencephalitis (late)
Rubella
• Vaccination (95% seroconversion)
@ 15 months and early adulthood
• Immune status checking in teenagers, precollege and pre-pregnancy
• Antenatal testing
• Serology testing for presumed exposures
(paired Sera)
• No in-utero therapy
Parvovirus
• Human parvovirus B19 (DNA virus)
- erythema infectiosum in childhood
- chronic arthropathy
- chronic bone marrow failure (immunodefic)
- aplastic crisis (Sickle disaease)
• Incubation 4-14 days
• Respiratory droplet spread
• High fever, “Slapped cheek syndrome’
non specific rash, no symptoms
Parvovirus and fetus
•
•
•
•
•
Hydrops
(anaemia, myocarditis)
Adults 60% sero-positive
1/3 fetuses affected in acute infection
Fetal loss rare with appropriate treatment
Assess serology - IgG, IgM, paired serology
• Serial ultrasound, intrauterine transfusion
Varicella
•
•
•
•
Varicella-Zoster virus (DNA)
Incubation - 10-20 days
Respiratory droplet inoculation
Fever, malaise, pruritic rash (maculopapular
with vesicles)
• Pneumonia (+/- bacterial), encephalitis,
myocarditis, pericarditis and adrenal
insufficiency especially in adults
Varicella and pregnancy
• Mild immunocompromise of pregnancy
increases risk
• 10% develop pulmonary complications main cause of mortality
• Fetal effects
Preterm delivery
Varicella syndrome
Neonatal varicella (VZ first 2 months)
Varicella Syndrome
Cutaneous scarring
Limb hypoplasia
Missing/hypoplastic digits
Limb paralysis/muscle atrophy
Psychomotor retardation
Convulsions
Microcephaly
Cerebral atrophy
Chorioretinitis/ chorioretinal scarring/optic disc hypoplasia
Cataracts
Horner’s Syndrome
Early childhood Zoster
Cytomegalovirus
• DNA virus
• Congenital infection - 1%
• 5-10% of those infected show clinical
illness at birth
• Neonatal MR - 20-30%
• 90% of survivors get late complications
• 5-15% with no demonstrable disease at
birth get some abnormality (deafness)
CMV Congenital Infection
•
•
•
•
•
•
•
Hepatomegaly
Spleenomegaly
Jaundice
Thrombocytopenia
Petechiae
Microcephaly
Intrauterine growth retardation
}
}
}TORCH
}Syndrome
}
}
}
CMV Congenital Infection (Late)
•
•
•
•
•
•
•
•
•
•
Venticulomegaly
Cerebral atrophy
Mental retardation
Psychomotor delay
Seizures
Learning difficulties and language delay
Chorioretinitis / Optic atrophy
Intracranial calcifications
Long bone radiolucencies, dental abnormalities
Pneumonitis
CMV Congenital Infection
• Prolonged virus shedding
• No vaccine
• No treatment
• Risk group advice
Herpes Simplex
• Disseminated disease in pregnant woman death from hepatitis, encephalitis
• Miscarriage (severe disease)
• No congenital syndrome known
• Intrapartum infection
• disseminated disease - chorioretinitis, meningitis,
encephalitis, mental retardation, seizures and death
• Primary infection >>>secondary infection
• HSV II - 75%; HSV I - 25% cases
Hepatitis B
•
•
•
•
Intrauterine infection - 5%
Intrapartum infection - 95%
Congenital infection - 90% chronic carriers
About 1% mothers are potential risks for
their newborns
• Newborns should receive passive (HBIg)
and active immunization (vaccine x 3
doses) - protective in over 90% of cases
Hepatitis C
•
•
•
•
•
Risk of transmission to fetus 6-30%
Increased if other infections such as HIV
No treatment
Value of C Section is uncertain
Avoid invasive procedures
HIV
• Infection rates variable
• Risk of vertical transmission 20-40%,
mostly peri-partum
• Screening and treatment can almost
completely reduce vertical transmission
• C Section reduces risk of transmission x 4fold
• Viral counts <1000 - negligible risk to fetus
Bacterial Infections
•
•
•
•
•
•
•
Bacteruria*
Vaginal infections (BV, TV, Candida)
Group B Streptococci*
Gonorrhoea*
Chlamydia*
Toxoplasmosis*
Listeria
Bacteruria
•
•
•
•
•
•
•
Asymptomatic
5-8% of all pregnancies (2% Non-preg)
Urinary stasis, tract dilatation
30% symptomatic UTI (Pyelonephritis)
Diagnosis
Treatment
Subsequent care (MSU v Prophylaxis)
Group B Streptococci
•
•
•
•
•
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)
• Screening v Risk factor prophylaxis
Gonorrhoea
• Neissseria Gonorrhoea (1-6% pop)
• Pre-term labour, PPROM,
Chorioamniionitis, Endometritis
• Gonococcal opthalmia neonatorum (40%)
• 80% asymptomatic
• Screening needed?
• Cephtriaxone IM stat
Chlamydia
• 5-7% reproductive population
• Pre-term labour, PPROM,
Chorioamniionitis, Endometritis
• Conjunctivitis (18-50%), Pneumonia (18%)
• Most are asymptomatic
• Screening needed
• Azithromycin 1 gram stat
Syphilis
•
•
•
•
•
•
•
T.Pallidum
<1:1000 pregnant women
Can infect trans placenta from 15th week
Second stage by birth if not treated
Screening – VDRL, RPR
Diagnostic tests – TPI, FTA-Abs
High dose Penicillin's
Toxoplasmosis
•
•
•
•
Toxoplasma Gondii (Protozoa)
Cat faeces, raw/undercooked meats
TORCH syndrome
Chorioretinitis, Encephalitis, Neonatal
Jaundice
• Serology =/- PCR
• Sulfonamides + Pyrimethamine
Intra-Amniotic Infection
• 1-2% all deliveries
• Clinical Diagnosis – fever, uterine tenderness,
Leucocytosis
• Histologic chorioamnionitis more common
• Ascending infection, rarely haematogenous
• Polymicrobial
• Increased PTD, PNMR, C Palsy, Endometritis
• Treatment – Antibiotics and delivery
Miscellaneous
•
•
•
•
Malaria
Mycoplasma
HPV
Tropical diseases