Congenital and Perinatal Infections Flashcards
What point in pregnancy is the most potentially dangerous for infection ?
- early pregnancy
- fetus is at highest risk from toxins, mutagens, and infections during 1st trimester
- some women don’t know they’re pregnant
- some women don’t act like they’re pregnant
- mother may be exposed to harmful agents and not be aware
What are congenital infections?
- acquired during gestation
- severity: the earlier the mother is infected-> more harm to developing organs; acute maternal infection is worse than reactivation for the fetus-> higher infectious dose causes more harm
What are the manifestations of congenital infections?
- growth retardation- low birth weight
- congenital malformations
- fetal loss- stillbirths
- Rubella, CMV, Toxoplasma gondii, Treponema pallidum, Erythrovirus (parvovirus) B19, HSV, VZV
What are the manifestations of perinatal infections?
- meningitis
- septicemia
- pneumonia
- preterm labor
- Neisseria gonorrhoeae, Chlamydia trachomatis, HSV, Streptococcus agalactiae (Group B Strep), E. coli, Listeria monocytogenes
What are the manifestations of postnatal infections?
- meningitis
- septicemia
- conjunctivitis
- pneumonitis
When do you have a high index of suspicion of congenital infections?
-an infant is born with abnormal head,eyes, blood, liver, spleen, jaundice and/or rash (blueberry muffins)
What are the signs of congenital infection?
- prematurity worsens severity
- intrauterine growth retardation
- congenital defects
- abnormal head size- microcephaly, hydrocephaly
- intracranial calcifications
- eye abnormalities
- hearing loss
- hepatosplenomegaly
- hematologic abnormalities
- bone lesions
- inflammation of CSF
- rash
How do you diagnose congenital infections?
- recognize maternal exposures
- mother often has no symptoms of infection, so few suspicions are raised until the infant is affected
- detect IgM or rising IgG titer in maternal serum
- other specific tests as warranted for mother, neonate, amniotic fluid or fetal blood
- passive transfer of maternal IgG confounds serology on neonate!
- definitive diagnosis: isolate pathogen from infant- sample urine, saliva, CSF, nasopharyngeal swabs
What are the most common congenital infections in the US?
1) CMV
2) Toxoplasmosis
3) Syphilis
4) Rubella
What are the TORCH infections?
- Toxoplasmosis
- Other- Syphilis, VZV, Parvovirus B19, Hep B, HIV, HTLV-1
- Rubella
- CMV
- HSV
may have similar presentations at birth: Rash, Chorioretinitis, Microcephaly, Hepatosplenomegaly, IUGR
How is Toxoplasma gondii transmitted?
- Domestic animals and mice theres encysted bradyzoites
- theres sexual reproduction in the feline definitive host
- there are oocysts in cat feces, and encysted bradyzoites (food and water borne) that infected human
- congenital toxoplasmosis induced by tachyzoites
What are the symptoms of toxoplasmosis?
- most affected infants are asymptomatic
- if symptoms are apparent- classic triad of congenital toxoplasmosis- chorioretinitis, hydrocephalus, intracranial calcifications
How do you diagnose toxoplasmosis?
- laboratory tests:
- serology on mother and infant -> IgM+ infant is diagnostic
- PCR on amniotic fluid, infant samples or placenta
- direct observation of cyst
How do you treat toxoplasmosis?
- Pyrimethamine (Daraprim) + Sulfadiazine + Folinic acid (Leucovorin)
- treat for 1 year
- delaying treatment worsens lon- term outcomes
What is congenital syphilis?
- incidence of congenital reflects the rate in women
- 384 congenital cases in 2013
- Treponema pallidum crosses placenta and infects fetus
- causes miscarriage/stillbirth/neonatal death 40-50%
What are the symptoms of congenital syphilis?
- 2/3 affected infants are asymptomatic
- symptoms usually appear by 5 weeks
- common manifestations of early congenital syphilis- large puffy placenta, hepatomegaly, rhinitis (snuffles), rash, lymphadenopathy
How do you Diagnose and Treat T. pallidum?
- if mother has positive test for syphilis, suspect congenital disease
- test infants <1 month of age
- VDRL or rapid plasma reagin titers
- direct observation of bacteria or DFA staining
- suspicious lesions (rash)
- body fluids (snuffles)
- placenta and umbilical cord
- treat mother and infant with penicillin- IV or IM penicillin G for 10 days
How does Congenital Rubella present?
- infection of the fetus in early pregnancy results in severe disease in 80% of newborns
- symptoms: hearing loss (most common), congenital heart defects, ophthalmic problems, intrauterine growth retardation, neurological problems- mental and psychomotor retardation, microcephaly
- organs: hepatomegaly, splenomegaly, bone lesions, thrombocytopenia purpura, pneumonitis
risk factors for congenital CMV?
- no prior infection with CMV
- pregnancy at a younger age
- first pregnancy
- new sex partner during pregnancy
- frequent contact with babies and toddlers
- mothers illness may be subclinical and she may be unaware that problems exist
- primary infection during early pregnancy has the worst prognosis
- spread through saliva
symptoms of congenital CMV
- chorioretinitis
- small size for gestational age
- microcephaly
- petichiae, purpura, jaundice
- hepatosplenomegaly
- 15% develop progressive hearing loss
incidence of congential CMV
- 4 million/year of all pregnancies in the US
- 99% of fetuses not affected
- 1% affected-40,000
- of those, 90% asymptomatic at birth and 85% of those remain normal, 15% develop late disabilities
- 10% are symptomatic at birth, with the most severe neurologic complications
diagnosis of congenital CMV
- PCR on urine or blood
- serology on infant not recommended because maternal IgG can confound results
- culture virus from urine or saliva
treatment of congenital CMV
- ganciclovir IV
- valganciclovir PO
congenital HSV infections
-many different presentations, ranging over all severities
variables for HSV in mother
- virus type, HSV2 worse than 1
- primary infection is worse than reactivation
- visible lesions worse than subclinical reactivation
variables for HSV in child
- intrauterine worse than perinatal
- disseminated worse than encephalitis, which is worse than skin lesions
neonatal HSV infections
- rare
- most freq-mom has recurrent HSV2 during birth, neonate acquires virus at full term. prognosis is good, rare severe infections
- most severe- mom has primary HSV 2 during pregnancy. fetus born with disseminated virus, prognosis poor- severe mental impairment, death
- treatment is IV acyclovir
- prevention- C section birth, antiviral prophylaxis during pregnancy
congenital VZV
- very rare
- primary infection in mom damages fetus
- limbs and brain development are impaired, outcome is poor
- treatment- acyclovir and derivatives for mom
- vaccinate all seronegative women
- advise seronegative pregnant women to avoid children with chicken pox or anyone with shingles
parvovirus B19
-5th disease
-most common in school age children during winter/spring
-biphasic disease
febrile illness without rash 1st,
then rash- slapped cheek on face. erythematous, maculopapular rash, arthralgia, arthritits
-seronegative pregnant women at risk for fetal death
-no treatment or prevention
perinatal infections
- acquired during or shortly after birth
- many routes of transmission
- exchange of maternal and fetal blood
- fetal monitors attached to scalp break the skin
- vaginal and skin flora colonize neonate during birth
- many viruses secreted in breast milk
- relatives and visitors can transmit infections to neonate- don’t kiss the baby!
Hep B global distribution
- up to 50% seropositive (?rebeccas lecture said 1/3)
- HBV easily transmitted during birth
- 15% of babies infected at birth without intervention
- prevention- vaccinate all neonates, ad HBIG at birth if mom is HBV+
perinatal transmission of retroviruses
-HTLV type 1 can cause adult T cell leukemia or tropical spastic paraparesis
-HIV can be transmitted
-transplacental passage of infected maternal lymphocytes, infected lymphocytes in breast milk
Risk groups:
-IVDA, sex with many people, prostitutes, newborns of virus positive mothers, people who aren’t vaccinated
managing HIV mothers
- combined ante/intrapartum and infant antiretroviral prophylaxis
- recommendations updated frequently
- 3 part zidovudine regimen- before, during, after birth
- with treatment, only 2% transmission rate to neonate, without rate is 30%
GBS
- encapsulated gram positive
- strep agalactiae
- 25% of women are asymptomatic carriers
- risk factors for early onset disease:
- previous baby with GBS, GBS in urine
- fever during labor
- heavy maternal colonization
- delivery before 37 weeks
- premature or prolonged ROM
- intrapartum antibiotics reduce risk
early onset GBS
-0-7 days
-sepsis, possible bone foci, CNS involvement
-pneumonia
tachypnea, grunting, hypoxia
-appears ill
-poor feeding, lethargic, irritable
-temperature instability, HoTN, shock
late onset GBS
- 7-89 days
- sepsis, bone, CNS
- pneumonia or meningitis
- sepsis-fever, irritability, lethargy, poor feeding, tachypnea, grunting, apnea
- meningitis-bulging fontanel, nuchal rigidity, focal neuro findings
late late onset GBS
- > 3 mo
- sepsis, bones, CNS
- meningitis
diagnosis of GBS
- culture bacteria from normally sterile site
- GBS sensitive to penicillin
maternal management of GBS
- intrapartum antibiotic prophylaxis (IAP)
- penicillin G, IV
empirical therapy for GBS
- give when GBS is suspected but not confirmed
- if IAP was given, suspect resistance
- vanco + penicillin G or ampicillin
important points about congenital/perinatal infections
- prevention measures are most effective before pregnancy
- vaccination and antimicrobials
- 1st trimester is worst time for infections
- maternal infection is often asymptomatic or missed
- infections are not always transmitted to baby
- TORCH panel not a routine screen in US
