Prenatal Prenatal infections infections elaboration: Piotr Uzar Department for Pathology of Pregnancy and Labour PAM
Dec 17, 2015
PrenatalPrenatal infectionsinfections
elaboration: Piotr UzarDepartment for Pathology of Pregnancy and Labour
PAM
Etiology: In prenatal period: viruses, bacteria, treponema, protozoa
In perinatal period: bacteria, viruses
Ways of transmision: ascending - after premature rupture of membranes
blood - by placenta by continuity - from peritoneal cavity
Embryopathy is specific
for moment of infection.
Fetopathy is specific for
etiology of infection.
Most important prenatal infections:
T- toxoplasmosisO- other (syphilis, listeriosis)R- rubellaC- cytomegalyH- herpes simplex, hepatitis,
HIV
Toxoplasmosis frequency: 1-2/1000 newborns etiology: Toxoplasma gondi way of transmision: alimentary,
transfusion, transplantation, by conjunctiva infection of fetus: by placenta (parasite
reservoir) when it is primary infection of pregnant woman
active infection, without treatment: abortion, premature labour, fetal necrosis
Toxoplasmosis fetal symptoms: retinitis, microphthalmia,
anophthalmia, encephalitis (lasting damages of brain: hydrocephalus, abnormal intracranial calcification, dysplasia)
diagnostics: IgG and IgM specific for toksoplasmosis in mother’s blood or IgM in blood of fetus (20- 24Hbd)
treatment: Rovamycine 3x3mln units/d for 3 weeks with break for 2 weeks up to the end of pregnancy
Syphilis etiology: Treponema pallidum infection of fetus: by placenta after
16Hbd mother and fetal symptoms: abortion,
premature labour; fetal maceration and necrosis, non-immunological fetal hydrops, IUGR, low birth-weight
Syphilis newborn symptoms: early syphilis: symptoms 10-14 days after
delivery- coryza, luethic pemphigus, hepatosplenomegaly, jaundice, lymphadenopathy, chorioretinitis and osteitis; without treatment:
late syphilis: symptoms in 6-14 year of lifeHutchinson’s teeth, corneitis, deafness, saddle nose, saber shins
Syphilis diagnostics:
- anamnesis (stillbirth)- skrining of all pregnant women - nontreponemal tests: VDRL and USR - treponemal-specific tests: complement fixation reaction, FTA, FTA-ABS, passive haemagglutination inhibition test , treponema immobilization raection Nelson’s-Mayer - mikroscopical- treponema in dark field of vision
Syphilis treatment:
- if disease of<1-year duration- single 2,4- million unit i.m. Benzathine penicillin - if disease of>1-year duration- 2,4mln/week x3, - if cerebral syphilis- Crystalline penicillin G 2-4mln i.v. every 4h for 10-14days, then like disease of>1-year duration
posttreatment serologic titers partner’s treatment too
Listeriosis etiology: listeria monocytogenes source of infection: raw meat, dairy-goods way of transmision: alimentary, by
conjunctiva, percutaneous, inhalatory, sexual
mother symptoms: parainfluenza, high temperature after latent period and chorioamnionitis
complications: abortion, premature labour
Listeriosis fetal/newborn symptoms:
a) infection by placenta: multisymptomatic sepsis (decreased: muscle tone, appetite; hepatosplenomegaly), internal organs damage, fetal necrosis b) perinatal infection: pneumonia (75% ) or meningitis a few days after birth (25% )
Listeriosis diagnostics: culture of bacteria,
intermediate immunofluorescent reaction or complement fixation reaction from: blood, pharyngeal or vaginal swab, urine, amniotic fluid
treatment: Ampicylina 1,0-2,0 i.v. every 6h + Gentamycyna 2mg/kg i.v. every 8h
Rubella infection to 6Hbd- abortion,
polydysplasia, 7-17Hbd- defect of 1 organ
fetal/newborn symptoms: defects of hearing and sight, congenital heart and vessels disease (e.g. Fallot’s tetralogy), IUGR, psychomotor development’s disorders, hydrocephalus
pathogenesis: genetic material damages
Rubella prophylaxis: check-up IgG level before
pregnancy (titre>1:8- immunity), anergia- vaccination by 3 months at the very latest before planned pregnancy
if direct contact with rubella in pregnancy to check: - passive haemagglutination inhibition test (titre >1:32, testing on 1st and 2nd week of disease) - IgG
Rubella - IgM since third day to 4th week after
contact are (+) treatment: hiperimmunoglobulin
antirubella within 7 days after contact (after appearance rash it’s no use)
infection <17 Hbd - may be indication of termination of pregnancy
Cytomegalia frequency: about 1% primary infection of
pregnant woman (30-40% infection of fetus), 10% seropositive pregnants- secondary infection
way of transmision: kisses, sexual, contact with infants, transfusion, transplantation
mother symptoms: fever, lymphadenopathy
complications: abortion, polydysplasia, fetal necrosis
Cytomegalia fetal symptoms: microcephalia,
encephalitis and meningitis, abnormal intracranial calcification, hepatosplenomegaly, anaemia, IUGR, interstitial pneumonia, miocarditis, chorioretinitis
newborns who survive: psychomotor development’s disorders, mental retardation, cerebral atrophy, epilepsy, deafness, microphthalmia, cataract, hemolytic anaemia
Cytomegalia diagnostics:
- culture of viruses from: urine, uterine cervix secretion, saliva, blood, faeces, pharyngeal swab, amniotic fluid- check IgM and IgG in mother’s blood; IgM in blood of fetus
trial therapy- Gancyklowir intrafetally
Herpes simplex frequency: carrier state HSV-2 - 1% pregnants way of transmision: sexual mother symptoms: rarely; vesicles of mucous
membrane or skin of external genitals area infection of fetus: by placenta, after
premature rupture of membranes or intra partum
complications: abortion, premature labour, fetal necrosis
Herpes simplex primary infection of pregnant- 5%
infection of fetus to 32Hbd then increase to 50% before labour
newborn symptoms: vesicles of mucous membrane or skin and eyes, disseminated form (liver, spleen, bone marrow, central nervous system), 30% infected newborns die
Herpes simplex diagnostics:
- cytological smear from female genitals - viruses in fluid from vesicles- serological investigations from mother’s blood: IgG and IgM
prophylaxis: monitoring of infection in pregnancy
Herpes simplex treatment: primary infection-
hospitalization and Acyklowir 5x0,2/d p.o. or i.v. for 10 days; secondary infection- symptomatic treatment and locally Acyklowir
if there are symptoms of infection- caesarean section to 4h after premature rupture of membranes
if there are not symptoms of infection- delivery through natural passages
Hepatitis Hepatitis A- infection HAV in II, III
trimester of pregnancy (damage liver of fetus) or at delivery; protective action- human gamma-globulin
Hepatitis B- infection HBV anti-HBs and anti-HBe passing by
placenta protect fetus against infection or relieve course of disease
Hepatitis prophylaxis: screening of all pregnant
patients for the presence of hepatitis B surface antigen (HBsAg)
diagnostics: immunological testing treatment: newborn should receive
hepatitis B immunoglobulin and hepatitis B vaccine within 48h after labour, II vaccination after 1 m-th, III vaccination after 6 m-th
HIV risk of infection: by placenta (15%);
perinatal- with blood and secretions (30%); after labour- with milk
fetal symptoms: IUGR, microcephalia, wide mouth, short nose with flat root of the nose, oblique eyelid
if HIV(+): prenatal care in specialistic outpatient clinic in secound half of pregnancy; observation of intrauterine development of fetus; check-up nontreponemal tests, CMV Ig, Toxo Ig
HIV every 2m-th check lymphocytes
CD4+ level- if <200/mm3 then antiviral treatment (Azotymidyna-AZT, Retrovir, Zidovudine-ZDV)+ prophylactic antibiotic treatment
termination of pregnancy by caesarean section reduce the risk of infection to 50%
breast-feeding should be forbiden specialistic neonatal care
Premature rupture of membranes
definition: rupture of the chorioamniotic membrane with flowing away the amniotic fluid before the onset of labour
most often- rupture of the inferior pole of the chorioamniotic membrane, seldom- high or sham rupture
quantity of the flowing away fluid is depend on: quantity of amniotic fluid, intrauterine pressure and presetation of fetus
PROM prophylaxis: diagnostics and treatment
of local colpitis, smoking prohibition etiology: isthmocervical insufficiency,
hydramnion, premature uterine contraction, intrauterine infection, situs and malformations of fetus, abnormal structure of chorioamniotic membrane
diagnosis: flowing away of the amniotic fluid, amnioscopy, AFI
PROM complications:
- mother- infection-> generalization-> septic schock-> death- fetal/newborn- infection, prematurity, intrauterine fetal anoxia, perinatal injury, development’s disorders
procedure: - transport „in utero” - labour in top references centres - check-up parameters of infection (clinical, laboratory, biophysical of fetus: CTG, USG)
PROM treatment: conservative therapy
(tocolysis, steroidotherapy<34Hbd, antibiotic treatment, amnioinfusion) or termination of pregnancy
clinical observation of women in puerperium (infections, bleeding, thrombotic complications)
clinical observation of newborn (infections)