Birth Defects Surveillance

& Zika virus in pregnancy

Dr Gehanath Baral gehanath@gmail.com

Paropakar Maternity and Women’s Hospital

Thapathali, Kathmandu Nepal

Dr Gehanath Baral 1

Birth defect ?

Any

• Structural or functional abnormality

That • Exists since intrauterine life

And

• Can be identified prenatally, at birth or later in life

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What are structural birth defects?

– Major: Significant medical or cosmetic consequence – Spina bifida, hydrocephalus, cleft lip, heart

defects, hypospadias, limb deficiency, clubfoot, hip dislocation, omphalocele, Down syndrome (trisomy 21), achondroplasia, Di George syndrome (del 22q11.2)

– Minor: Medically insignificant and suspicious of a major problem

Any anatomical abnormality of a body structure “Malformation”

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– Inborn errors of metabolism (e.g., phenylketonuria, mucopolysaccharidosis)

– Haematologic diseases (e.g., sickle cell anemia, thalassemia, glucose-6-phosphate dehydrogenase [G-6-PD]deficiency)

– Endocrine system diseases (e.g., hypothyroidism, congenital adrenal hyperplasia)

– Other molecular anomalies (e.g., cystic fibrosis, oculocutaneous albinism)

– Developmental disabilities (e.g., some types of cerebral palsy, deafness, cognitive and/or behavioral anomalies including autism)

Any altered function of a molecule or an organ

What are functional birth defects?

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Congenital/Genetic defects

Congenital: Existing since birth or “existing since intrauterine life”

Genetic: caused by a genetic anomaly

– Genetic does not necessarily mean “hereditary”

– The majority of genetic diseases are not transmitted by parents but occur as a new event

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– Major cause of SBs and NNDs

– Incidence =6% of births

– Birth defects may result in long-term disability

– Disability rate= 3% (1 in 33 infants)

– Annual neonatal death= 270,000

– The most common and severe birth defects are

– Heart defects (1%),

– Neural tube defects and

– Down syndrome

Birth Defects Facts

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Birth Defects Facts

– Causes difficult to identify exactly, may be

– Idiopathic (70%),

– Genetic (Heart defect and cleft lip/palate),

– Infectious or

– Environmental in origin

– Many birth defects can be prevented

– Rubella vaccination,

– Adequate intake of folic acid and iodine, and

– Adequate preconception and antenatal care

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Birth Defects Surveillance Project

Project Title: Expansion of strengthening

national network for newborn and birth

defects in Nepal

Duration: December 2014-November 2015

Support: WHO-SEARO

Nodal Institute: Paropakar Maternity and

Women’s Hospital

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Hospitals in the network

1. Paropakar Maternity and Women’s Hospital, Kathmandu

2. TU Teaching Hospital, Kathmandu

3. Western Regional Hospital, Pokhara

4. BP Koirala Institute of Medical Sciences, Dharan

5. Nepal Medical College, Kathmandu

6. Kathmandu Medical College, Kathmandu

7. Koshi Zonal Hospital, Biratnagar

8. Patan Academy of Medical sciences, Lalitpur

9. Bharatpur Hospital, Chitawan

10.Dhulikhel Hospital, Dhulikhel

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Role of National Nodal Center

1. Support capacity building of member institutions

2. Consolidate and analyze the data

3. Monitoring visits for improving quality of data

4. Providing periodic feedbacks for improvement

5. Dissemination and publication of reports

6. Co-ordinate activities of the members of network

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Database on Newborn and Birth Defects web site

(http://apps.searo.who.int/npn)

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Database on Newborn and Birth Defects web site

• Click on Yahoo Icon

• Provide Email ID and password

• Click on “Sign in” button

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Database on Newborn, Still birth and Birth Defects web

site

• Birth Defects (BD) Form

• Newborn (NB) Form

• Stillbirth (SB) Form

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Hospital based gross prevalence in live birth

%37.0

10078766

295

100Birth Live Total

DefectsBirth with BabiesDefectBirth

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Hospital based gross prevalence in still birth

%1.3

1001159

36

100Birth Still Total

DefectsBirth with BabiesDefectBirth

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Hospital based gross prevalence in total birth

%41.0

10079925

331

100Birth Total

DefectsBirth with BabiesDefectBirth Total

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Types of birth defects

Number of babies with Birth Defects

331

Types of birth defects

Neural Tube Defects 46

Orofacial Cleft 68

Hypospadias 14

Talipes Equinavarus 32

Limb Reduction Defects 17

Abdominal Wall Defects 10

Others 245

Number of Visible Birth Defects

432

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New born admission and morbidities

Birth trauma 0.8% Respiratory Upto 7%

Hypoglycemia 4.4% CNS Upto 8%

Meconeum aspiration 8.2% Systemic infection

39%

Hypothermia 5.6% Therapeutic intervention

Upto 61%

Hyperbilirubinemia 24.1% NND 4.03‰

Rhesus isoimmunization

1.6%

LBW 33.1%

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Microcephaly=2-12‰0

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What is ZIKA virus?

– ssRNA/Flavi virus : 1947 (RhMonkey)/1952 (human)

– Aedes aegipti/albopictus mosquito bite,

– Vertical tansmission,

– Sexual transmission

– Symptoms

– 20% symptomatic,

– Acute fever, maculopapular rash, arthralgia and conjunctivitis

– Myalgia, headache

– Complication: GB Syndrome

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Prevention of ZIKA virus?

– Neither a vaccine nor prophylactic medications available to prevent Zika virus infection

– Mosquito prevention strategies:

– Wearing long-sleeved shirts and long pants

– Using insect repellents

– DEET, picaridin, and IR3535 are safe for pregnant women

– Using permethrin-treated clothing

– Staying and sleeping in screened-in or air-conditioned rooms

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ZIKA virus test In Pregnancy

– RT-PCR

– Serology: IgM + neutralizing Ab by PRNT (plaque reduction neutralization test)

– X-reactive results:

– Dengue

– Yellow fever

– JE vaccination

– NO test if NO travel history to risk area

– Do test if ≥2 symptoms during or within 2 weeks of travel

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What to test?

– Maternal serum/plasma

– Amniotic fluid

– HPE/immunostain of Placenta/cord

– Zika test for frozen placental/cord tissue

– Serology of cord blood

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Which specimen?

– Maternal serum/plasma

– Amniotic fluid: RT-PCR

– HPE/immunostain of Placenta/cord

– Zika test for frozen placental/cord tissue

– Serology of cord blood

Amniocentesis

• ≥15 weeks gestation

• Do test if ≥2 symptoms during or within 2 weeks of travel

• USG: microcephaly or calcification (sensitivity=57%)

What to test in pregnancy?

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Zika Virus treatment In pregnancy

1. No specific antiviral treatment

2. Supportive

– Rest, fluids, and use of analgesics /antipyretics

– Fever should be treated with acetaminophen

– Avoid aspirin and other nonsteroidal anti-inflammatory drugs until dengue can be ruled out to reduce the risk for hemorrhage

3. If +ve Zika virus test in serum or amniotic fluid

– Serial USG for fetal anatomy and growth q 3–4 weeks

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Neonatal screening

Measure head circumference after

24 hours of birth

Compare with standard nomogram

If microcephaly USG/CT/MRI of

brain

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References

– World Health Organization Fact sheet N°370 Updated April 2015. http://www.who.int/mediacentre/factsheets/fs370/en/

– Questions and Answers for Obstetrical Healthcare Providers. http://www.cdc.gov/zika/hc-providers/qa-pregnant-women.html

– Interim Guidelines for Pregnant Women during a Zika Virus Outbreak. http://www.cdc.gov/mmwr/volumes/65/wr/mm6502e1.htm

– Steps to prevent bug bites. http://wwwnc.cdc.gov/travel/page/avoid-bug-bites

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