PREGNANCY AND INFECTIOUS DISEASE Presenter : Anil K Malik Moderator : Dr V. Darlong www.anaesthesia.co.in anaesthesia.co.in@gmail.com

Most infection are no more serious than in non-pregnant woman. Transmitted to fetus in utero or during or immediately after delivery. Serious illness in mother can have nonspecific fetal or obstetric effects.

major causes of neonatal death were: 1. Infection (35%) 2 major causes of neonatal death were: 1. Infection (35%) 2. Preterm birth (28%) 3. Asphyxia (23%)

Infectious diseases and pregnancy Infections with anesthesia implications: HIV Varicella zoster virus Syphilis Hepatitis Malaria Tuberculosis Borreliosis (Lyme disease)

Other infections: Toxoplasma Rubella CMV Herpes simplex virus Parvovirus B19 Group B streptococcus STI UTI Listeria

Human immunodeficiency virus (HIV) young women account for 66% of infections among young people leading cause of death and disease among women of reproductive age worldwide One half of people living with HIV globally are women

 In 2006, CDC published "Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health- Care Settings". -opt-out HIV screening for all pregnant women, -repeat HIV screening in the 3rd trimester for women who are at high risk

Women whose HIV status is unknown at the time of labor should be offered opt-out screening with a rapid HIV test. Opt-out HIV testing: women are told that an HIV test will be included in the standard group of prenatal tests but that they may decline HIV testing. Opt-in HIV testing: women are provided pretest counseling and must specifically consent to an HIV test.

current recommendations are: HIV screening, included in the routine panel of prenatal screening tests opt-out screening Separate written consent for HIV testing should not be required Repeat screening in the third trimester is recommended

SYSTEMIC EFFECTS Nervous system: Myelopathy Aseptic meningitis HIV encephalopathy Dementia complex Peripheral neuropathy Autonomic neuropathy

Oppertunistic infections -pneumocystis jiroveci Respiratory system: Oppertunistic infections -pneumocystis jiroveci -mycobacterium tuberculosis -MAC Cardiovascular system: Pericardial diseases DCM

GI System: Oropharyngeal candidiasis Aphthous ulcer Leukoplakia Esophagitis Hepatobilliary involvement HIV enteropathy with chronic diarrhoea vascular kaposi sarcoma of pharynx

Musculoskeletal system AIDS-related wasting syndrome Renal system FSGS ESRD Immunological system Depressed immunity lymphadenopathy

Hematologica sustem Normocytic normochromic anemia Thrombocytopenia Neutropenia Coagulation abnormality Endocrine system Adrenal insufficiency Hypothyroidism SIADH

anesthetic consideration Anesthetic implication of drugs Thrombocytopenia: -zidovudine -isoniazide -rifampin -phenytoin

Peripheral neuropathy: -didanosine -stavudine -lamivudin -zalcitabin Neutropenia: -ganciclovir -cotrimoxazole

Pentamodine: bronchospasm, Hepatic dysfunction: Phenytoin Ethambutol Others: Pentamodine: bronchospasm, arrythmias, electrolyte abnormalities

Preoperative assesment: -past social/medical history(IV drug abuse) -associated diseases(syphilis, HBV etc.) -carefull physical examination -documentation of any neurological deficits -presence of AIDS-related dementia

-oropharyngeal pathology -oppertunistic pulmonary infections -CVS(subclinical cardiomyopathy) -renal system(nephropathy) -hematological studies

Anesthesia technique: Necessary safety measures Universal/standard precautions Neuroaxial techniques: -Safe -Tailored to individual obstetric indications No evidence of increased infectious complications with neural anesthesia & analgesia Complication of aneuroaxial anesthesia doesn’t differs

GA: Dose adjustment for -h/o drug abuse -compromised liver & kidney function -generalised muscle wasting Higher fraction inspired O2, with lung pathology Increased sensitivity to opioids & BZD

VARICELLA-ZOSTER VIRUS Herpes group virus(I & II) spread by respiratory transmission or direct contact severe maternal varicella cause intrauterine death of fetus Infection in 1st & 2nd trimester lead to congenital varicella syndrome -its risk is 2% in 1st half

Symptoms: -skin lesion in dermatomal distribution -neurologic defecit -eye disease -skeletal anomaly About 30% of infant born with these lesions die in the 1st month of life

primary varicella: -chiken pox -encephalitis -pneumonia -occaissionally with respiratory failure Secondary varicella: -herpes zoster(shingles)

Anesthesia concerns Patient in acute primary varicella at the time of delivery: -current debate about the optimum anesthetic technique GA may exacerbate varicella pneumonia. SAB- theoritical risk of transmitting the virus from skin lesion to the CNS. Epidural may be safer than spinal

Neuraxial anesthesia: A site free of cutaneous lesion should be choosen for needle placement. Maternal risks like bleeding , thrombocytopenia, DIC & hepatitis Pain management is also difficult in these patient Risk of contracting infection

Syphilis Caused by Treponema pallidum. Transmission: -sexual -maternal-fetal -rarely by other means. increases the risk of both transmitting and getting infected with HIV Do HIV testing in all patients with syphilis.

Primary Secondary Latent Late or tertiary STAGES OF SYPHILIS Early latent Late latent Late or tertiary May involve any organ, but main parts are: Neurosyphilis Cardiovascular syphilis Late benign (gumma)

Primary syphilis Incubation period 9-90 days, usually ~21 days. Develops at site of contact/inoculation. Classically: single, painless, clean-based, indurated ulcer, with firm, raised borders. - Atypical presentations may occur.

Mostly anogenital, but may occur at any site (tongue, pharynx, lips, fingers, nipples) Non-tender regional adenopathy Very infectious. May be darkfield positive but serologically negative. Untreated, heals in several weeks, leaving a faint scar.

Secondary syphilis Seen 6 wks to 6 mos after primary chancre Usually w diffuse non-pruritic, indurated rash, including palms & soles. May also cause: Fever, malaise, headache, sore throat, myalgia, arthralgia, generalized lymphadenopathy Hepatitis (10%) Renal: an immune complex type of nephropathy with transient nephrotic syndrome Iritis or an anterior uveitis Bone: periostitis CSF pleocytosis in 10 - 30% (but, symptomatic meningitis is seen in <1%)

Is divided into early and late latency. Latent syphilis Positive syphilis serology without clinical signs of syphilis (& has normal CSF). It begins with the end of secondary syphilis and may last for a lifetime. Pt may or may not have a h/o primary or secondary syphilis. Is divided into early and late latency.

LATE SYPHILIS ‘Tertiary Syphilis’ Is the destructive stage of the disease. Lesions develop in skin, bone, & visceral organs (any organ). The main types are: Late benign (gummatous) Cardiovascular & Neurosyphilis

Can be crippling and life threatening Blindness, deafness, deformity, lack of coordination, paralysis, dementia may occur It is usually very slowly progressive Late syphilis is noninfectious

neurosyphilis Divided into 5 groups, which may overlap: Asymptomatic neurosyphilis Syphilitic meningitis Meningovascular syphilis General paresis Tabes dorsalis

diagnosis Dark field Microscopy VDRL, RPR FTA-ABS, MHA-TP Direct Fluorescent Antibody (DFA)

Pregnancy and syphilis pregnancy usually does not affect the course of syphilis But syphilis may affect pregnancy and can cause: -IUGR -pre term birth -still birth -neonatal death -congenital malformations

Anesthesia concerns Mainly related to late stage syphilis affecting aorta, dorsal column, nerve roots. For aortic involvement: -special care must be taken to minimize aortic wall stress(with beta blocker) For CNS involvement: -neuroaxial analgesia may not be ideal -sensory testing compromised

Hepatitis Acute hepatitis: -one of the most serious infection durig pregnancy -HEV associated with 20% mortaliy -cause: hepatitis virus group EBV HSV CMV rubella

-may be associated with: Chronic hepatitis: -may be associated with: -cirrhosis -hepatic failure -HCC All pregnant woman should undergo screening for hepatitis B, as recommended by CDC

Anesthesia concerns Preoperative assesment: Neuraxial anesthesia: - severity of hepatitis -Coagulation abnormality Neuraxial anesthesia: -no coagulopathy, if present prior replacement of clotting factors -metabolism of local anesthetics is also of concern(amide LA) -decreased hepatic pseudocholinesterase

Theoritical risk of LA toxicity with large dosage in epidural spinal is prefered over epidural GA : indications: -coagulopathy -severe haemorrhage -umbilical cord prolapse Intravascular volume, evaluated with consideration for invasive monitoring when ascitis or CVS compromise are present

Avoid hepatotoxic drugs Judicious use of opioids Avoid hypoxia & reduction in hepatic blood flow RSI can be done with succinylcholine

MALARIA The disease is almost always symptomatic Potentially lethal in non immune, particularly gravid females Possible pregnancy complications: -IUGR -preterm -spontaneous abortion -eclampsia -PPH -puerperal fever

Anesthesia concern Patient may be present with complications of malaria like -pulmonary edema -ARDS -seizure -severe anaemia -ARF

Tuberculosis Pregnancy doesn’t change its course Serious risk to mother, neonate & health care provider Active disease treated with firstline therapy Isoniazide causes hepatitis & risk increased in pregnancy

LFT monitored very closely Precautions: Anesthesia concern LFT monitored very closely Precautions: - placing the patient in negetive pressure room -wearing particulate filter mask Anesthesia technique as per indication

Borreliosis caused by Borrelio burgoderferi Spread by ticks A spirochetal diease Affect cardiovascular & neurological syste

Anesthesia concern: - If there is neurological involvement then avoid neuroaxial anesthesia - Thorough cardiac evaluation

STI in pregnancy Syphilis - 2.4-17% Chlamydia - 5.3-21.5% Gonorrhea - 2.0-20% Bacterial vaginosis - 9-48.5% Trichomoniasis - 9.9-27.5% HSV - 6.7-53.4% HIV - 15- 42.5%

C=cytomegalovirus (CMV) H=herpes simplex (HSV) TORCH Infections T=toxoplasmosis O=other (syphilis) R=rubella C=cytomegalovirus (CMV) H=herpes simplex (HSV)

Caused by protozoan – Toxoplasma gondii TOXOPLASMOSIS Caused by protozoan – Toxoplasma gondii Domestic cat is the definitive host with infections via: Ingestion of cysts (meats, garden products) Contact with oocysts in feces Much higher prevalence of infection in European countries

Acute infection usually asymptomatic 1/3 risk of fetal infection with primary maternal infection in pregnancy Infection rate higher with infxn in 3rd trimester Fetal death higher with infxn in 1st trimester

Clinical Manifestations Most (70-90%) are asymptomatic at birth Classic triad of symptoms: Chorioretinitis Hydrocephalus Intracranial calcifications Other suggestive symptoms: - fever, -rash, -HSM, -microcephaly,

-seizures, -jaundice, -thrombocytopenia, -lymphadenopathy Initially asymptomatic infants are still at high risk of developing abnormalities, especially chorioretinitis

Diagnosis Toxoplasma serology Maternal IgG indicates past infection Can be isolated in culture from placenta, umbilical cord, infant serum PCR testing on WBC, CSF, placenta Not standardized Newborn serologies with IgM/IgA

Prevention and Treatment Treatment for pregnant mothers diagnosed with acute toxo Spiramycin daily Macrolide antibiotic Small studies have shown this reduces likelihood of congenital transmission (up to 50%) If infant diagnosed prenatally, treat mother with Spiramycin, pyrimethamine and sulfadiazine Leucovorin rescue with pyrimethamine

Rubella Single-stranded RNA virus Vaccine-preventable disease Mild, self-limiting illness Infection earlier in pregnancy has a higher probability of affected infants

Clinical menifestations Sensorineural hearing loss (50-75%) Cataracts and glaucoma (20-50%) Cardiac malformations (20-50%) Neurologic (10-20%) Others to include growth retardation, bone disease, HSM, thrombocytopenia, “blueberry muffin” lesions

Diagnosis: -serology -PCR Treatment: -immunization -supportive care

Cytomegalovirus (CMV) Most common congenital viral infection Mild, self limiting illness Transmission can occur with primary infection or reactivation of virus 40% risk of transmission in primary infection Studies suggest increased risk of transmission later in pregnancy However, more severe sequalae associated with earlier acquisition

Typical clinical symptoms: -IUGR -microcephally -hepatosplenomegally -petechiae -jaundice -thrombocytopenia -anemia -chorioretinitis

long-term neurodevelopmental sequelae include: -mental retardation -motor impairment -SNHL -visual impairment Primary maternal CMV infection during gestation poses a 40% risk of intra uterine transmission

Diagnosis and treatment -serology -PCR Treatment: -Once the diagnosis of congenital CMV infection is confirmed, (i)one option is pregnancy termination.  (ii) second proposed antiviral agents such as ganciclovir, foscarnet, and cidofovir

-These drugs are of moderate effectiveness in treating CMV infection in the adult, particularly the immunocompromised patient -they are not of proven value in preventing or treating congenital CMV infection (iii) hyperimmune globulin (iv)A live attenuated vaccine using the Towne 125 strain has been developed, and appears to be safe

Anesthesia concerns No specific consideration Patients with chronic CMV infection, AIDS related may have polyradiculopathy - it improves with antiCMV therapy

Primarily transmitted through infected maternal genital tract Herpes Simplex (HSV) HSV1 or HSV2 Primarily transmitted through infected maternal genital tract Rationale for C-section delivery prior to membrane rupture Primary infection with greater transmission risk than reactivation

diagnosis Culture of maternal lesions if present at delivery Cultures in infant: Skin lesions, oro/nasopharynx, eyes, urine, blood, rectum/stool, CSF CSF PCR Serologies again not helpful given high prevalence of HSV antibodies in population

High dose acyclovir 60mg/kg/day divided q8hrs treatment High dose acyclovir 60mg/kg/day divided q8hrs X21days for disseminated, CNS disease X14days for SEM Ocular involvement requires topical therapy as well

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