Perinatal Infections Fetal Infection

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Perinatal Infections Fetal Infection

• Nabeel BondagjiConsultant perinatologist
• KFSHRC Jeddah

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Infections

• Toxoplasmosis
• Rubella
• Varicella
• Parvovirus
• CMV
• HIV
• Syphilis

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Introduction

• 3 of the perinatal mortalities are related to
  (fetal infection)
• Fetus can be affected at any gestational age
• Most severe affection occurs in the first
  trimester
• Most of the fetal infections are preventable

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Red indicates the most vulnerable period of
development. (Moore 143).
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• First Trimester
• Organogenesis
• Growth restriction
• Second and Third Trimester
• Neuological Impairment
• Growth restriction

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Think of fetal infection

• I.U.G.R
• Hepatic Calcification
• Intracrainal Calcification
• Hydrocephally, Microcephally
• Ascits
• Pericardial,Pleural Effusion
• Non Immune Hydrops Fetalis

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Toxoplasmosis

• - Toxoplasmon gondii (intracellular parasite)
• Trans-placental affect the placenta fetus
• Transmission Rate
• - 10 15 1st trimester
• - 25 2nd trimester
• - 60 3rd trimester

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Toxoplasmosis

• Toxoplasmosis
• - Incidence of congenital toxoplasmosis
• - 0.07 0.5 1000 London
• - 2 1000 Brussels
• - 3.22 1000 Paris

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Risks to the Fetus

• 1st Trimester
• - 55 85 will show sequilie
• - Chrioretinitis severe impairment of vision
• - Hearing loss
• - Mental Retardation
• - Ascits
• - Periventirecular Calcification
• - Hydrocephally

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• Toxoplasmonsis
• Ultra Sound
• - Intracranial, hepatic, calcification
• - Ascitis
• - Hepatosplenomegally
• - Microcephally
• - I.U.G.R
• Diagnosis Fetal Blood Sampling
• - IgM
• - PCR
• - Culture

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Toxoplasmosis

• Treatment
• - Reduce risk of transmission
• Spiramycin
• - If fetal infection documented
• - Pyrimethamine
• - Sulfadiazine.. Folic acid

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• Pyron F, Wallonlion C, Goner P,
• Cochrane Database Review
• January 2005
• Objective
• To assess whether treatment of toxoplasmosis
  reduces the risk of congenital toxoplasmosis
• Selection Criteria
• RCT
• - Antibiotics
• - No treatment
• Proven Infection

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• Look, outcome of the children
• 3332 Papers identified

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• NO Trial fulfill the criteria

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• Conclusion
• We do not know whether antibiotics Treatment
  reduces the congenital transmission or not.
• Screening is Expensive
• Screening is not recommended in countries where
  screening and treatment is not routine.

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Toxoplasmosis

• Prevention to Toxoplasmosis Advice to Pregnant
  Women whose Serological Tests are Negative.
• Cook meat at 60oC (Industrial deep-freezing
  also seems to destroy parasites efficiently).
• When handling raw meat, do not touch eyes or
  mouth.

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Cont.. Prevention of Toxoplasmosis

• Carefully wash hands after handling raw meat,
• dirt, or vegetables soiled by dirt.
• Wash fruit and vegetables before eating
• Wear gloves when gardening
• Avoid all contacts with things that may have
• been contaminated by cat feces
• If the cats litter has to be changed, put on
• gloves and disinfect often with boiling water.
  

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Rubella German Measles

• Rubella
• - 3rd Disease
• RNA Virus
• - Respiratory secretions
• - 2 3 weeks I.P.

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Rubella

• - 0.5 2 Non Immune
• - 0.2 0.5 Congenital Rubella Syndrome
• Risk of Transmission
• - 8 12 weeks 90
• -12 16 weeks 50
• - 16 20 weeks 17

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Rubella

• Ultra Sound - I.U.G.R.
• - Hepto-splenomegally
• Congenital Rubella syndrome
• - Eye
• Cataract, Retinopathy
• Microphthalmia, glaucoma
• - Ear
• Deafness
• -Heart PDA

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Rubella

• Diagnosis
• IgM

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RUBELLA

• Prevention
• Active immunization by vaccination is the only
  efficient way of preventing congenital rubella.

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• Varicella Zoster Virus DNA Herpes
• - Chickenpox
• - Herpes Zoster
• - Incidence in pregnancy 0.4 0.7 1000
• Maternal
• - Pneumonia increase mortality
• Fetal Congenital Varicella Syndrome in 1st tri
  mester
• - Skin Scar, Limb Hyproplasia
• - Chrioretinitis, Microcephally

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Varicella

• Neonatal Infection
• Increase in Mortality
• - 5 days before delivery 48 hours post partum
• - Avoid delivery if possible in this period

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Diagnosis

• Viral Culture
• - PCR
• Presence of infection does not predicate the
  severity of the disease

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VARICELLA

• Prevention
• Passive immunization is currently available
• and should be administered within 24-72
• hours to sero-negative pregnant patients who
• have been exposed to varicella.

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Varicella

• Treatment
• - Oral cyclovir to improve sysmatic I.V. to
  treat pneumonia
• - Safe in Pregnancy
• - Does not prevent or decrease the fetal effect
• - VZIG to be given to the neonate 5 days before
  delivery 2 days postpartum

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Varicella

• Screening
• - Not Recommended

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Parvovirus B.19 the fifth disease

• Infectious period 5 10 days after exposure
• Mode of transmission
• - Transplacental 33 transmission risk
• - Fetal effect abortion lt20 weeks
• - Hydrops fetalis 18 of all non immune

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Intrauterine fetal infection

• Fetal effect of B19 - A symptomatic -
  IUGR - Congenital anomalies - Hydrops
  fetalis - IUFD
• Parvovirus B 19 pathogenesis a)
  Anemia b) Fetal myocardium and hepatic
  affection c) Vasculitis

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Diagnosis

• Parpovirus
• - ELISA
• -Western blot test
• IGM Diagnosis of Primary Infection
• Elect Microscopy
• - Direct Visualization of the virus or viral
  particles

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Parvovirus

• Fetal Diagnosis
• PCR in A.F., Placenta Blood
• Ultra Sound
• Hydropy Fetalis

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Parvovirus

• Prognosis and therapy
• Survivor recovers normal
• Fetal Therapy
• Intravascualr Intrauterine Blood Transfusion

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CMV

• DNA Herpes Virus
• Most common perinatal infection
• 0.2 2 of all newborns
• Leading cause of hearing loss
• Mode of transmission
• Contact with infected
• -Blood
• -Urine
• -Salvia
• -Sexual contact

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CMV

• I.P 28 60 days
• Viremia 2 3 weeks
• Maternal effect
• Asympathic, mild fever, malaise myalgia
• Primary infection 0.7 4
• Recurrent infection 13.5

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• Epidimulogical Facts
• Primary Infection
• -Risk of Transmission 30 40
• -10 Seguilie of the infected
• -30 Prenatal Mortality
• -Of the survivor 80will have neurological
  damage

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• Recurrent Infection
• Transmission 0.1 2 Mostly a symptomatic most
  of the sequilie occurs as hearing loss

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Diagnosis

• CMV
• Diagnosis Culture or PCR
• blood, urine salvia
• IgG Serial Measurements 3 4 weeks
• Diagnosis either by seroconversion
• Or increase titer by more than 4 folds
• -1 4 1 16
• -1 16 1 256

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• IGM is not reliable as it may be negative even in
  the right phase and may persist for months after
  infections

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Diagnosis

• Fetal Diagnosis Ultra Sound System
• - Intracrainal or hepatic calcification
• - Echogenic bowel
• - Ascits
• A.F.
• - Culture
• - PCR

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• CMV
• Treatment
• - Not available
• - Neonatal therapy ganciclovir may decrease
  neonatal infections
• Vaccine
• - May Reactivate A previous infection
• CMV
• Screening
• Not Recommended

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Human immunodeficiency virus (HIV) Infection

• This is the major cause of congenital
• infection in the developing world.
• Over one million children had been
• infected from their mother by the end of
  1998.

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• Mother ? child
• in utero
• at birth
• breast milk
• Organ/tissue donation
• Semen
• Kidneys
• Skin, bone marrow, corneas, heart valves,
  tendons, etc.

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TO SCREEN OR NOT TO SCREEN?

• The best defense is a strong offense.
• The American Academy of Paediatrics and the ACOG
  issued a Joint Statement on HIV Screening in
  Pregnancy (1999) (2001).
• A pregnant women should receive HIV counseling as
  part of their routine ANC.
• A pregnant women should have HIV testing with
  their consent.

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PRE-TEST COUNSELING

• Risks of transmission (including Mode)
• Risks of perinatal transmission
• Potential social and psychological implication of
  Positive test.
• The availability of Agents that may reduce the
  risk of neonatal infection.
• Clarify the difference between HIV infection and
  disease.

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Timing of Perinatal HIV Transmission

• Cases documented intrauterine, intrapartum, and
  postpartum by breastfeeding
• In utero - 25 40 of cases
• Intrapartum- 60 75 of cases
• Addition risk with breastfeeding
• 14 ?risk with established infection
• 29 ?risk with primary infection
• Current evidence suggests most transmission
  occurs during the intrapartum period

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Factors Influencing Perinatal Transmission

• Maternal Factors
• HIV-1 RNA levels (viral load)
• Low CD4 lymphocyte count
• Other infections, Hepatitis C, CMV, bacterial
  vaginosis
• Maternal infection drug use
• Lack of ZDV during pregnancy
• Obstetrical Factors
• Length of ruptured membranes/chorioamnionitis
• Vaginal delivery
• Invasive procedures
• Infant Factors
• Prematurity

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Reducing HIV Transmission with Suboptimal
Regimens

• Partial ZDV regimens ( New York cohort)
• Transmission rates
• 6.1 with prenatal, intrapartum, and infant ZDV
• 10 with only intrapartum ZDV
• 9.3 if only infant ZDV started within first 48
  hours
• 26.6 with no ZDV

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Reducing Intrapartum HIV Transmission
Studies of Short Course Therapy

• Oral ZDV in a non-breastfeeding population
  (Thailand) from 36 weeks and during labor
• Transmission rate 9.4 ZDV vs. 18.9 placebo
• PETRA study intrapartum/postpartum oral ZDV/3TC
  in a breast-feeding population (Uganda, S.
  Africa, Tanzania)
• Transmission rate 10 ZDV/3TC vs. 17 placebo
• HIV Net 012 intrapartum/postpartum/neonatal
  Nevirapine (NVP) vs. short course/neonatal ZDV in
  a breast-feeding population (Uganda)
• Transmission rate 12 NVP vs. 21 ZDV

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• Treatment with zidovudine appears
  to be safe in pregnancy.
• Elective caesarean section may decrease
  mother-to-child transmission.

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• HIV
• Chochrane Database 2002
• Objective to assess what intervention will
  decrease the risk of mother to children
  transmission of HIV

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• AZT
• 4 trials decrease 1585 patients
• Neviropine compared AZT 626 decrease transmission
• C/S one trial 436 patients decrease risk of
  transmission
• Immunoglbullin
• Does not decrease the risk

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• Conclusion
• Zidoridine, Nevirpine
• C/S decreases the transmission significantly.

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• Syphilis
• - T.P.
• - Increase HIV
• Transmission all through

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• Manifestation
• Ultra Sound
• Thick Placenta
• Hydrops fetalis
• I.U.G.R
• Hydroamnios Hepato-splenomegaly
• Risk of Transmission
• 90 primary
• 50 secondary
• 6 14 Latent Syphillis

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• Diagnosis
• Screening Non Specific
• VDAL
• RPR
• Specific
• TPHA
• F.T.A. becomes ..
• 3 4 weeks

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• Treatment
• - Penicillin
• - Benzathin Penicillin 2.4 million unit
• - Erythpromycine

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