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)