Perinatal Infections Fetal Infection Nabeel Bondagji Consultant perinatologist KFSH&RC Jeddah
Dec 22, 2015
Perinatal Infections Fetal Infection
Nabeel BondagjiConsultant perinatologist
KFSH&RC Jeddah
Infections
Toxoplasmosis
Rubella
Varicella
Parvovirus
CMV
HIV
Syphilis
Introduction
3% of the perinatal mortalities are related to (fetal infection)Fetus can be affected at any gestational ageMost severe affection occurs in the first trimesterMost of the fetal infections are preventable
Red indicates the most vulnerable period of development. (Moore 143).
•First Trimester
Organogenesis
Growth restriction
•Second and Third Trimester
Neuological Impairment
Growth restriction
Think of fetal infection
I.U.G.R Hepatic Calcification Intracrainal Calcification Hydrocephally, Microcephally Ascits Pericardial,Pleural Effusion Non Immune Hydrops Fetalis
Toxoplasmosis
- Toxoplasmon gondii (intracellular parasite)
Trans-placental affect the placenta fetus
Transmission Rate
- 10 –15% 1st trimester
- 25% 2nd trimester
- 60% 3rd trimester
Toxoplasmosis
Toxoplasmosis
- Incidence of congenital toxoplasmosis
- 0.07 – 0.5 : 1000 London
- 2 : 1000 Brussels
- 3.22 : 1000 Paris
Risks to the Fetus
1st Trimester
- 55 – 85% will show sequilie
- Chrioretinitis severe impairment of vision
- Hearing loss
- Mental Retardation
- Ascits
- Periventirecular Calcification
- Hydrocephally
ToxoplasmonsisUltra Sound- Intracranial, hepatic, calcification- Ascitis- Hepatosplenomegally- Microcephally- I.U.G.R
Diagnosis Fetal Blood Sampling- IgM- PCR- Culture
Toxoplasmosis
Treatment
- Reduce risk of transmission
Spiramycin
- If fetal infection documented
- Pyrimethamine
- Sulfadiazine….. Folic acid
Pyron F, Wallonlion C, Goner P,Cochrane Database ReviewJanuary 2005
ObjectiveTo assess whether treatment of toxoplasmosis reduces the risk of congenital toxoplasmosis
Selection CriteriaRCT- Antibiotics- No treatment
Proven Infection
Look, outcome of the children
3332 Papers identified
NO Trial fulfill the criteria
ConclusionWe do not know whether antibiotics Treatment reduces the congenital transmission or not.Screening is ExpensiveScreening is not recommended in countries where screening and treatment is not routine.
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.
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 cat’s litter has to be changed, put on
gloves and disinfect often with boiling water.
Rubella German Measles
Rubella
- 3rd Disease
RNA Virus
- Respiratory secretions
- 2 – 3 weeks I.P.
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%
Rubella
Ultra Sound - I.U.G.R. - Hepto-splenomegally
Congenital Rubella syndrome- Eye
Cataract, Retinopathy Microphthalmia, glaucoma- Ear
Deafness-Heart PDA
Rubella
Diagnosis IgM
RUBELLA
Prevention Active immunization by vaccination is
the only efficient way of preventing congenital rubella.
Varicella Zoster Virus DNA Herpes- Chickenpox- Herpes Zoster- Incidence in pregnancy 0.4 – 0.7 : 1000 Maternal- Pneumonia increase mortalityFetal Congenital Varicella Syndrome in 1st tri mester- Skin Scar, Limb Hyproplasia- Chrioretinitis, Microcephally
Varicella
Neonatal Infection
Increase in Mortality
- 5 days before delivery – 48 hours post partum
- Avoid delivery if possible in this period
Diagnosis
Viral Culture
- PCR
Presence of infection does not predicate the severity of the
disease
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.
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
Varicella
Screening
- Not Recommended
Parvovirus B.19 the fifth disease
Infectious period 5 – 10 days after exposure
Mode of transmission
- Transplacental 33% transmission risk
- Fetal effect – abortion <20 weeks
- Hydrops fetalis 18% of all non immune
Intrauterine fetal infection Fetal effect of B19 : - A symptomatic -
IUGR - Congenital anomalies- Hydrops fetalis - IUFD
Parvovirus B 19 pathogenesis:a) Anemiab) Fetal myocardium
and hepatic affection c) Vasculitis
Diagnosis
Parpovirus
- ELISA
-Western blot test
IGM Diagnosis of Primary Infection
Elect Microscopy
- Direct Visualization of the virus or viral particles
Parvovirus
Fetal Diagnosis- PCR in A.F., Placenta & Blood
Ultra Sound- Hydropy Fetalis
Parvovirus
Prognosis and therapy
Survivor recovers normal
Fetal Therapy
Intravascualr Intrauterine Blood Transfusion
CMVDNA Herpes VirusMost common perinatal infection 0.2 – 2% of all newbornsLeading cause of hearing lossMode of transmissionContact with infected-Blood-Urine-Salvia-Sexual contact
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%
Epidimulogical Facts
Primary Infection
-Risk of Transmission 30 – 40%
-10% Seguilie of the infected
-30% Prenatal Mortality
-Of the survivor 80%will have neurological damage
Recurrent Infection
Transmission 0.1 – 2% Mostly a symptomatic most of the sequilie occurs as hearing loss
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
IGM is not reliable as it may be negative even in the right phase and may persist for months after infections
Diagnosis
Fetal Diagnosis Ultra Sound System
- Intracrainal or hepatic calcification
- Echogenic bowel
- Ascits
A.F.
- Culture
- PCR
CMVTreatment- Not available- Neonatal therapy ganciclovir may decrease neonatal infectionsVaccine- May Reactivate A previous infectionCMVScreening
Not Recommended
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.
Mother child in utero at birth breast milk
Organ/tissue donation Semen Kidneys Skin, bone marrow, corneas, heart
valves, tendons, etc.
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.
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.
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
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
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
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
Treatment with zidovudine appears to be safe in pregnancy.
Elective caesarean section may decrease mother-to-child transmission.
HIV
Chochrane Database 2002
Objective to assess what intervention will decrease the risk of mother to children transmission of HIV
AZT4 trials decrease 1585 patientsNeviropine compared AZT 626 decrease transmissionC/S one trial 436 patients decrease risk of transmissionImmunoglbullinDoes not decrease the risk
Conclusion
Zidoridine, Nevirpine
C/S decreases the transmission significantly.
Syphilis
- T.P.
- Increase HIV
Transmission all through
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
Diagnosis
Screening Non SpecificVDALRPRSpecific
TPHAF.T.A. becomes …..
3 – 4 weeks
Treatment
- Penicillin
- Benzathin Penicillin 2.4 million unit
- Erythpromycine
Thank You..Thank You..