1. Infections in Pregnancy Dr Shahnaz Aram

2. 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

3. Fetus and Infection Indirect effect - O 2 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

4. Fetus and Infection Infections cause - miscarriage - congenital anomalies - fetal hydrops - fetal death - preterm delivery - preterm rupture of the membranes

5. Viral Diseases Rubella Parvovirus Cytomegalovirus Varicella Zoster Herpes Hepatitis HIV Rubeola

6. 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

7. 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

8. Measles (Rubeola) Preventionvaccine (95% recipients protected) Treatmentantipyrexials cough suppresants Antibiotics for bacteria Suppress uterine contractions ? Immune serum globulin Isolation precautions

9. 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

10. 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)

11. Rubella Vaccination (95% seroconversion) @ 15 months and early adulthood Immune status checking in teenagers, pre- college and pre-pregnancy Antenatal testing Serology testing for presumed exposures (paired Sera) No in-utero therapy

12. 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

13. 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

14. 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

15. 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)

16. 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

17. 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)

18. CMV Congenital Infection Hepatomegaly} Spleenomegaly} Jaundice}TORCH Thrombocytopenia}Syndrome Petechiae} Microcephaly} Intrauterine growth retardation}

19. 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

20. CMV Congenital Infection Prolonged virus shedding No vaccine No treatment Risk group advice

21. 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

22. 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

23. 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

24. 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 4- fold Viral counts <1000 - negligible risk to fetus

25. Bacterial Infections Bacteruria* Vaginal infections (BV, TV, Candida) Group B Streptococci* Gonorrhoea* Chlamydia* Toxoplasmosis* Listeria

26. 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)

27. 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

28. Gonorrhoea Neissseria Gonorrhoea (1-6% pop) Pre-term labour, PPROM, Chorioamniionitis, Endometritis Gonococcal opthalmia neonatorum (40%) 80% asymptomatic Screening needed? Cephtriaxone IM stat

29. 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

30. Syphilis T.Pallidum <1:1000 pregnant women Can infect trans placenta from 15 th week Second stage by birth if not treated Screening – VDRL, RPR Diagnostic tests – TPI, FTA-Abs High dose Penicillin's

31. Toxoplasmosis Toxoplasma Gondii (Protozoa) Cat faeces, raw/undercooked meats TORCH syndrome Chorioretinitis, Encephalitis, Neonatal Jaundice Serology =/- PCR Sulfonamides + Pyrimethamine

32. 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

33. Miscellaneous Malaria Mycoplasma HPV Tropical diseases