Perinatal infection 2

Congenital infections associated with pregnancy loss and preterm

birth

there are other types of infection which is occur during pregnancy

leading to pregnancy loss &preterm birth like parvovirus, malaria
&listeria.

Parvovirus

Infective organism

Parvovirus B19 (PVB19) is a relatively common infection in pregnancy,

and is transmitted through respiratory droplets.

It occurs most commonly in those pregnant women who work with

young children, for example teachers.

Routine screening in pregnancy is not currently recommended as

there are currently no agreed treatment or prevention methods to
protect the baby from being infected.

Clinical features

In adults, many cases are asymptomatic or produce symptoms of a

mild

flu-like illness and/or arthropathy. In children it usually causes a

characteristic rash (slapped cheek syndrome).

There is a transplacental
transmission. In most fetuses infected with PVB19, there will be

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spontaneous resolution with no longterm consequences, but the
infection can cause an aplastic anaemia.

The anaemic fetus may then become hydropic due to high output
cardiac failure and liver congestion. This is the most common
presentation during pregnancy and is seen on ultrasound scan. If a
fetus is hydropic, the velocity of blood flow in the fetal middle cerebral
artery can be measured. If the velocity is high, it is suggestive of
anaemia, and PVB19 would be one of several differential diagnoses.

Management

The diagnosis is made by demonstrating seroconversion of the

mother, who develops IgM antibodies to PVB19, having previously
tested negative. A hydropic fetus may :

recover spontaneously as the mother and fetus recover from the virus,
or may require treatment by in utero transfusion.

Infection in the first 20 weeks of pregnancy can lead to hydrops fetalis

and intrauterine death, as treatment by intrauterine transfusion is not
possible at early gestations. Prior to 20 weeks the fetal loss rate is
approximately 10%. If the anaemia is treated by in utero transfusion,
the fetus can make a complete recovery. Parvovirus does not cause
neurological damage, and if the fetus survives the anaemia, the
outcome is usually normal. After 20 weeks gestation the

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fetal loss rate is estimated to be approximately 1%.

Infections acquired around the time of delivery with

serious neonatal consequences
(like herpes , group B streptococcus ,gonorrhea &chlamydia)

Herpes simplex virus (HSV)

- There are two viral types, HSV- type1 and HSV-type2 .

-The majority of orolabial infections are caused by HSV-1.

-Genital herpes is a sexually transmitted infection and is most

commonly caused by HSV- type2. Neonatal herpes is a viral infection
with a high morbidity and mortality, and is most commonly acquired at
or near the time of delivery due to contact with infected secretions.

Factors influencing transmission include:

1. The type of maternal infection (primary or recurrent).

2. The presence of transplacental maternal antibodies.
3. The duration of rupture of membranes before delivery, the use
of fetal scalp electrodes .
4. The mode of delivery.

The risks are greatest when a woman acquires a new infection

(primary genital herpes) in the third trimester

Neonatal herpes can be life threatening, the virus is able to enter the
brain and spinal fluid and can cause seizures and even death.
Neonatal herpes is classified into three subgroups: disease localized
to skin,eye and/mouth;

local central nervous system (CNS) disease (encephalitis alone);

and disseminated infection with multiple organ involvement

Diagnosis

1. Usually from appearance of the typical rash

2. PCR testing of vesicular fluid (most sensitive—gold standard)
3. Culture of vesicular fluid.

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Treatment
1. -screen for other sexually transmitted infections.
2. -The use of aciclovir is associated with a reduction in the
duration and severity of symptoms and a decrease in the
duration -of viral shedding.

-Caesarean section should be recommended to all women presenting

with primary episode genital herpes lesions at the time of delivery, or
within 6 weeks of the expected date of delivery.

-For women who develop primary genital herpes lesions within 6

weeks of delivery and who opt for a vaginal birth, rupture of
membranes should be avoided and invasive procedures fetal blood
sampling should not be used. Intravenous aciclovir given intrapartum
to the mother and subsequently to the neonate

Recurrent episodes

-A recurrent episode of genital herpes occurring during the antenatal

period is not an indication for delivery by Caesarean section.

-For these women, daily suppressive aciclovir given from 36 weeks of

gestation until delivery may reduce the likelihood of active HSV lesions

at term.

-the risk to the baby of neonatal herpes is very small (1–3 per cent).

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Group B streptococcus

Infective organism

Group B streptococcus (Streptococcus agalactiae) (GBS) is a gram-

positive coccus frequently found as a vaginal commensal. It can cause
sepsis in the neonate and transmission can occur from the time the
membranes are ruptured until delivery.GBS is recognized as the most
frequent cause of severe early-onset (less than 7 days of age)
infection in newborn infants.

Clinical features

The mother will not have symptoms as GBS is a common vaginal

commensal. An infected neonate may demonstrate signs of neonatal
sepsis including sudden collapse, tachypnoea, nasal flaring, poor
tone, jaundice, etc

fetal risks

Associated with preterm pre labour rupture of membranes and

preterm delivery.

Diagnosis

Culture from a lower vaginal swab (LVS) and perianal swab.

Management

Antenatal

If GBS is detected incidentally, antenatal treatment is not

recommended as it does not reduce the likelihood of GBS colonization
at the time of delivery.

Intrapartum antibiotic prophylaxis

Antibiotics (penicillinor clindamycin) given in labour are estimated to

be 60–80% effective in reducing early-onset neonatal GBS infection.
It is recommended that intravenous penicillin 3 g be given as soon as
possible after the onset of labour (or after development of a risk
factor) and 1.5 g fourhourly until delivery. Clindamycin 900 mg should
be given intravenously 8-hourly to those allergic to penicillin.

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There is no good evidence to support the administration of
intrapartum

antibiotic prophylaxis to women in whom GBS carriage was detected

in a

previous pregnancy.

Risk factors requiring prophylaxis for GBS

Intrapartum fever (>38C).

Prolonged rupture of membranes greater than 18 hours.

Prematurity less than 37 weeks.

Previous infant with GBS.

Incidental detection of GBS in current pregnancy.

GBS bacteruria.

Treatment of the neonate

Neonatal sepsis can progress rapidly to death. Whether they received

intrapartum antibiotics or not, any newborn infant with clinical signs
compatible with infection should be treated promptly with broad-
spectrum antibiotics.

Blood cultures should always be obtained before antibiotic treatment

is commenced, and CSF cultures should be considered.

Neonatal risks

Early-onset GBS infection has about a 20% mortality rate and may
present with :

1. Pneumonia •
2. Septicaemia •
3. Meningitis •
Late-onset infection (>7 days) is not associated with maternal GBS carriage .

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Perinatal infection causing long term disease
Like HIV, hepatitis B and C.

Human immunodeficiency virus

The HIV virus is a ribonucleic acid (RNA) retrovirus transmitted through

sexual contact; blood and blood products; shared needles for IV drug
users; or vertical (mother to child) transmission, which mainly occurs
in the late third trimester, during labour, delivery or breast feeding.

Screening

In the UK, all pregnant women should be offered screening for HIV
early in pregnancy because appropriate antenatal interventions can
reduce maternal-tochild transmission of HIV infection from 25–30% to
less than 2%

Management

Antiretroviral therapy, given antenatally and intrapartum to the mother

and to the neonate for the first 4–6 weeks of life.

Delivery by elective caesarean section in the presence of a high viral

load.

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 Planned vaginal delivery is recommended (in the absence of other
obstetric contraindications) in women with an undetectable viral load
(<50 copies/ml)

Management of infants

The cord should be clamped as early as possible after delivery and the
baby should be bathed immediately after the birth.

Avoidance of breastfeeding.(regardless of viral load at delivery)

Infants born to women with HIV should be treated with antiretroviral

medications and follow routine newborn vaccination programmes.

Hepatitis B
is a DNA virus that is transmitted mainly in blood, other body fluids
such as saliva, semen and vaginal fluid. Drug users who share
needles

Incubation period is 6weeks to 6months.

Clinical features

Hepatitis B is a virus that infects the liver, but many people with
hepatitis B viral infection have no symptoms or may be present
with non-specific systemic and gastrointestinal symptoms
followed by an episode of jaundice.

Screening

Serological screening for HBV 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.

Diagnosis

Based on clinical picture and serological detection of:

HB surface antigen (HBsAg) ———current infection .

HB E antigen (HBeAg) ———active viral replication .

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Anti-HBsAg antibodies ———indicates immunity from either infection
or Vaccination.

Management if the women is HBV positive shoud be referred to

a hepatologist for ongoing monitoring for the long-term
consequences of chronic infection, for example hepatocellular
carcinoma.

-To prevent vertical transmission of hepatitis B a combination of

hepatitis B immunoglobulin and hepatitis B vaccine may be
given(within 24 hours of delivary) ,This is thought to be up to 95%
effective at preventing neonatal HBV infection.

-The passive immunoglobulin provides immediate protection

against any virus transmitted to the baby from contact with blood
during delivery and should be given immediately after delivery.

- The active vaccine is given in three doses: at birth, at one

month and at six months of age.

Hepatitis C
The hepatitis C virus (HCV) is an RNA virus .Transmission of the
virus occurs predominantly through infected blood products and
injection of drugs.. Sexual transmission is extremely rare.

Mother to-child transmission can occur due to contact with

infected maternal blood around the time of delivery .

Screening

Current recommendations are that pregnant women should not be

offered routine screening for HCV. This is because there is a lack
of effective interventions for the treatment of HCV in pregnancy, to
reduce vertical transmission of HCV from mother to child.

Clinical feature

It is one of the major causes of liver cirrhosis, hepatocellular

carcinoma and liver failure. Following initial infection, only 20 per
cent of women will have hepatic symptoms 80 % being
asymptomatic.

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diagnosis-

-detection of anti-HCV antibodies in serum.

-PCR for the virus.

Management:

-woman should be offered post-test counseling and referral to a

hepatologist for management and treatment.

-In non-pregnant adults, interferon and ribavirin can be used to

treat hepatitis C infection, but these are contraindicated in
pregnancy.

- regarding mode of delivery do not recommend elective

Caesarean section for all women with hepatitis C.

BY DR.Sawsan ghazi

2023- 2024

Infective organism

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The hepatitis B virus (HBV) is a DNA virus that is
transmitted mainly in blood,

but also in other body fluids such as saliva, semen and

vaginal fluid. Drug users

who share needles are at high risk. In some areas in the

world (e.g. China),

chronic hepatitis B is prevalent and vertical

transmission is very common.

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