Perinatal infection

1. Perinatal infection By Dr MOHAMED KHALIL MD MRCOG

2. Are pregnant women immuno- compromised?

3. For which infections should pregnant women be screened? HIV Syphilis GBS Rubella Cytomegalovirus? Toxoplasma ? Bacterial vaganosis?

4. Why are infections in pregnancy important ? Maternal ---fetal morbidity --mortality

5. What neonatal conditions are caused by Group B streptococcus? Early onset infection/ septicemia Late onset disease/meningitis

6. How can they be prevented? Screening for all pregnant women at 35-37 ttt +ve women/penicillin, vancomycin, cefazolin Identifying women with risk factors eg PTL <37 wks, SROM>18hs, intrapartum fever>38c, previous affected child, GBS bacteruria

7. Which common genital infections are implicated in preterm birth? Bacterial vaganosis/ Bad odor, PH>4.5 ,KOH, Clue cell , Metronidazol/ Clindamycin/ safe in pregnancy

8. What are examples of infections with minimal maternal effects but the potential for significant fetal compromise? Human Parvovirus, Cytomegalovirus Toxoplasma

9. What maternal and fetal effects are caused by parvovirus ? =fifth disease Usually asymptomatic in adult Maternal infection diagnosed by igG, igM Fetal anaemia, none immune hydrops/ death Fetal anaemia can be diagnosed by DOPPLER of MCA------MCAPSV Intrauterine transfusion may be necessary if MCPSV > 1.5 MOM

10. How does cytomegalovirus affect the fetus? Usually asymptomatic in adult Fetus could have CNS abnormalities, IUGR/IUFD The gold standard for the diagnosis of fetal CMV infection is the amniotic fluid CMV nucleic acid amplification testing

11. Should pregnant women be screened for antibodies to cytomegalovirus? NO

12. What is toxoplasma/mode of transmission? Parasite Ingestion of infected meat/ exposure to infected cat feces Infection in early pregnancy/ less incidence of fetal infection but it will be serious Infection in late pregnancy /higher incidence of fetal infection

13. Toxoplasmosis The reported overall risk of congenital toxoplasmosis ranges from 18% to 44%. The risk is low in early pregnancy (7-15 weeks) at 6% to 26% but with severe damage to the fetus. And rising to 32% to 93% at 29 to 34 weeks of gestation with less fetal damage

14. What is the significance of toxoplasmosis in pregnancy? Subclinical disease Acute toxoplasma infection can be indicated if maternal serum shows igG+, igM+, igG avidity index low IUGR, IUFD Multiple systems affection, CNS Scan---calcification—brain--liver Antiparasite therapy can prevent fetal sequel

15. Does maternal varicella infection pose risks during pregnancy? What about herpes zoster? Acute varicella infection=chicken pox Reactivation=shingles=zoster Chicken pox----maternal pneumonia/ death Time of fetal infection if infection happen ( ) 13-20wk mainly skeletal deformities, skin, CNS, Eyes defects Infection after 20 wks--- congenital zoster syndrome is uncommon

16. Can varicella-zoster infection be prevented by VZIG? Vaccination is contraindicated during pregnancy VZIG to susceptible individuals

17. How does infection with human immunodeficiency virus (HIV) impact pregnancy ? Maternal concern is to control the disease Pregnancy does not worsen the disease in mother Vertical transmission 50% occur during labour 10-20% with breast feeding

18. Can anti-retroviral therapy( AZT) be safely used in pregnancy? Safety concern need to be balanced against the potential benefit to mother and baby Antiretroviral reduces viral load

19. What steps can be taken to reduce the risk of vertical transmission? Antiretroviral during antepartum period Cesarean section even with ROM No breast feeding The risk is 15-25% without prevention versus <5% with preventive measures

20. Should pregnant women be routinely screened for HIV infection? Yes

21. What is the significance of rubella in pregnancy? Maternal : It cause german measles 100% of infants infected during the first 11 weeks of pregnancy will have rubella defects. and reduced to 25% at the end of the second trimester. Sensorineural deafness is the most common single defect, heart, CNS defect, IUGR, preconception vaccination can give protection Rubella susceptibility screening should be offered early in antenatal care to identify women at risk of contracting rubella infection and to enable vaccination in the postnatal period for the protection of future pregnancies. 6.

22. What are the fetal effects of congenital syphilis? Treponema pallidum Tests of diagnosis VDRL, TPHA, TPI TPHA false +ve results(pregnancy, malaria, leprosy, glandular fever) Hydrops, hepatosplenomegally, IUFD, Congenital syphilis (frontal bossing, high arched palate, hutchington,s teeth, 8th nerve deafness, interstitial keratitis) Antenatal screening is recommended Treatment is by penicillin

23. What are the fetal effects of congenital syphilis? Treponema pallidum In pregnant women with early untreated syphilis , Mother-to-child transmission of syphilis in pregnancy is associated with 70% to 100% of infants will be infected , 41% congenital syphilis (which may cause long-term disability), 25% stillbirth 25% preterm birth. [EL = 3] 14% neonatal death, .

24. How does herpes simplex virus (HSV) affect pregnancy? During vaginal delivery Primary infection Secondary infection Neonatal disease ranges from asymptomatic infection to disseminated disease and death

25. How is transmission of HSV to the fetus/newborn prevented? by CS if delivery can happen within a month from the primary infection.

26. Screening for Hepatitis B virus • The prevalence of hepatitis B surface antigen (HBsAg) in pregnant women in the UK range from 0.5% to 1%. • 85% of babies born to mothers who are positive for the hepatitis e antigen (eAg) will become HBsAg carriers and subsequently become chronic carriers, • Compared with 31% of babies who are born to mothers who are eAg negative (RR2.8, 95% CI 1.69 to 4.47).

27. Screening for Hepatitis B virus • Mother-to-child transmission of the hepatitis B virus is approximately 95% preventable through administration of vaccine and immunoglobulin to the baby at birth. • Serological screening for hepatitis B virus should be offered to pregnant women so that effective postnatal intervention can be offered to infected women to decrease the risk of mother-to child transmission.

28. Screening for Hepatitis C virus • Incidence ranges from 0.14 in the West Midlands (95% CI 0.05 to 0.33) to 0.8 in London (95% CI 0.55 to 1.0). • Mother-to-child transmission in the UK is estimated to lie between 3% and 5%. • A higher proportion of infected babies has been observed among those delivered vaginally compared with those delivered by caesarean section but only one study has demonstrated a statistically significant difference.

29. Screening for Hepatitis C virus • All infants with HCV-RNA will be negative and lost HCV antibodies by 6 months after birth. • Pregnant women should not be offered routine screening for hepatitis C virus because there is insufficient evidence to support its effectiveness and cost-effectiveness.

30. HIV Is a retrovirus Asymptomatic infection has no significant effect on pregnancy complication Does not influence the mode of delivery About 15% of babies will remain HIV +ve at 6 months of age Can be isolated from cervical secretion abde

31. All pregnant women are still screened for syphilis VDRL test is a specific test VDRL remain +ve for ever congenital syphilis causes skeletal damage Ttt in early pregnancy will not protect fetus Untreated syphils may result in prematurity C,e

32. Which of the following vaccines is recommended to be given during pregnancy? A- MMR B- Varicella C- Influenza D- All of the above C

33. Rubella infection Rapidly cross the placenta May lead to fetal cataract May cause thrombocytopenia Can be confirmed by fetal blood sample to detect IgG antibodies Can be confirmed by CV sampling at 10 wk abce

34. The following may cross the placenta Neisseria gonorrhoeae cytomegalovirus Herpes genitalis -------------------- false parvovirus Toxoplasma Syphilis Rubella HIV