Congenital infections Flashcards
An infection of the fetus typically caused by viruses, or less commonly other infections,that infect the pregnant mother and may be passed to the fetus.
Congenital infections
Congenital infections can be passed on when and how?
Can be before or after delivery
This can be via blood, vaginal secretions or even breast milk.
what are the 2 viruses that can be passed down via breast milk?
- HIV
- CMV
what are the 2 infections that can be passed down through the umbillicus?
- staphlococci
- tetanus
what is TORCH?
- Toxoplasmosis
- Others - HIV, enterovirus, parvovirus, varicella, hepatitis, syphilis
- Rubella
- Cytomegalovirus
- Herpes
Toxoplasmosis is caused by?
Toxoplasma gondii - protozoan parasite (which is typically asymptomatic)
how is toxoplasmosis spread?
Vertical transmission of toxoplasma gondii, that occurs after acute maternal infection
Toxoplasmosis: Frequency of fetal infection increases with?
steeply with advancing gestational age
indications for toxoplasmosis screening
- High index of suspicion with significant cervical LAD, and high fever
- US findings of fetus
- calcifications and or cerebral ventricular dilation - MC
- Placental densities
- Pericardial effusions
- Ascites
- Fetal demise
- Hydrops fetalis
The US, UK, and Canada recommend against universal screening for toxoplasmosis in pregnancy
Toxoplasmosis: Risk Factors for maternal to fetal transmission
- Maternal infection at advanced gestational age
- High Parasite load
- Maternal parasite source
- Higher risk of fetal infection when infected through cat feces than meat - Maternal immunocompromise
s/s of toxoplasmosis
- Cataracts / Chorioretinitis- MC
- Abnormal CSF fluid
- cerebral calcification = convulsion
- Anemia
- Microcephaly / Hydrocephalus
- Hearing loss
- Small for gestational age (SGA)
- Early onset jaundice
- HSM-hepatosplenomegaly
- Generalized maculopapular rash
inflammation of the choroid (thin pigmented vascular coating of the eye) and retina of the eye.
Chorioretinitis
dx for toxoplasmosis
- ELISA - detection of IgM and IgG antibodies
- Skull films and CT head - diffuse cortical calcifications
- acute infection - IgM Ab appear within 1 week - stay elevated for months
- IgG appear in 2 wks, peak @ 8, then persist for life
Toxoplasmosis: How to spot prenatally
- confirmed/strongly suspected primary maternal infection during pregnancy
- abnml US findings
- Testing via amniocentesis after 18 wks preferred
toxoplasmosis tx
- prevent transmission: Treat mom !!!
- < 14 wks gestation - Spiramycin
- > 14 wks - Pyrimethamine + Sulfadiazine + folinic acid until delivery - Infants treated postnatally still - Pyrimethamine + Sulfadiazine + folinic acid until delivery x 1 year
- Repeated eye examinations x q3mo until 18 mo
- Then q6-12mo
toxoplasmosis prevention
- Cook meat until it’s well done
- Peel and wash thoroughly all fruits and vegetables
- Wash all surfaces after contact with raw meat
- Avoid untreated drinking water
- Wear gloves when gardening
- Avoid changing cat litter
rubella: ?% lead to fetal death or premature stillborn delivery
40%
s/s rubella
- “Blueberry Muffin Syndrome” - thrombocytopenia with petechiae or purpura
- Ophthalmologic - cataracts, retinopathy, glaucoma
- Cardiac - PDA and Peripheral pulmonary artery stenosis
- Auditory - sensorineural hearing loss
- Neurologic - behavior disorder, meningoencephalitis and mental retardation
- Microcephaly
work up for rubella
- IgM ab = recent infection
- serial IgG over several months can be confirmation
- CX - blood, urine and CSF are detectable as well
rubella: Tend to shed live virus in ___, ____, and ___ for up to 1 year
urine, stool, and respiratory secretions
Is Rubella worse if mom gets it early or late in pregnancy?
early
MC congenital infection?
CMV
what type of virus is CMV?
Double stranded DNA herpes virus
how is CMV transmitted?
Requires intimate contact: blood, saliva, etc.
CMV: Severe problems can occur at any trimester but greater if exposed when?
first trimester
congenital CMV is 3-7x greater in what type of pregnancies
hint: age group
adolescent pregnancies
Leading cause of non-hereditary sensorineural hearing loss
CMV
presentation of CMV
- sensorineural hearing loss
- Microcephaly
- Intracranial calcifications / periventricular
- Hepatosplenomegaly / Jaundice
- Mental Retardation
- Retinal Disease
- Cerebral Palsy
- Thrombocytopenia / Petechiae
how to dx CMV?
- DX: Clinically
- Elevated liver transaminases, thrombocytopenia, bilirubin
- CMV detection in urine or saliva (within first 3 wks of life)
- CT: intracranial lesions - usually periventricular
- IgM and IgG
- PCR studies (check viral load)
- Detection of CMV w/n first 3 wks after birth = congenital CMV infection; after first 3 wks = perinatal exposure
CMV tx
- No antivirals currently approved
- Very symptomatic - ganciclovir and valganciclovir - NEED APPROVAL
- Long term tx - PT, Birth to Three, Children with Special Health Care Needs, Hospice.
?% pregnant women have evidence of past HSV infection
30-60%
which HSV type accounts for 70% or more of neonatal herpes infections or congenital cases
HSV 2
Primary genital herpes infection and vaginal birth: ?% risk of infecting baby
25-50
HSV: Highest risk intrauterine is during what trimester
3rd trimester
?% infants who acquire HSV infection are born to mothers with no previous hx or clinical findings consistent with HSV infection
75
HSV: Disseminated infection should be considered in any infant and neonatal with symptoms of ?
sepsis, liver dysfunction and negative bacteriologic cultures.
neonate - fever, irritability and / or abnml CSF findings and seizures
Congenital HSV - Triad of symptoms:
- Skin vesicles
- Ulcerations
- Scarring eye damage
additional HSV presentations
- Organomegaly (usually liver and lungs)
- CNS abnormalities
- Prematurity (< 36 wks gestation)
- Localized infections of skin, eyes and mouth is usually first indication of infection (45%)
how to DX HSV?
- Specimen CX - vesicles, eyes, urine, nasopharynx, blood, CSF, stool or rectum
- PCR - sensitive for detecting HSV DNA in blood, urine and CSF
HSV tx
**IV Acyclovir **
given to all infants suspected to have infection or dx of HSV.
recommendations for HSV
- USPSTF does not recommend screening asx mothers
- ACOG recommends c-section delivery for ALL mothers with active genital lesions
- DO NOT KISS THE BABIES
if mom is infected with VZV during the first half of pregnancy, what are the chances for transmission?
low
Congenital Varicella syndrome s/s
- Cicatricial skin lesions (zig zag skin scarring and limb atrophy)
- Ocular defects - cataracts, retinitis
- CNS - hydrocephalus, microcephaly, seizures, mental retardation
- Death 20-30% for a child of a mother who develops varicella 5-7 days after delivery
how to dx varicella?
- Usually based upon the characteristic appearance of skin lesions
- Scraping of vesicle base and testing PCR for varicella
- IgM may be detected 3 d after sx appear
- IgG increased in serum confirms dx and may be present as early as 7 d after sx appear
Varicella : treatment? can you breastfeed?
-
VariZIG - varicella zoster immune globulin (IVIG)
- Prophylaxis Exposure
- Given to any infant with perinatal exposure
- Given to all infants < 28 wks gestation following postnatal exposure - Isolation
- Acyclovir - 30 mg/kg per day TID IV
- Breastfeeding encouraged in exposed newborns d/t antibodies in breast milk
3 ways Parvo B19 is known as:
- Human Parvovirus B19
- Fifth’s Disease
- Erythema Infectiosum
what type of virus is Parvo B19
Single-stranded DNA virus
Parvo B19 has highest infection rates in what professions?
teachers and daycare workers
s/s of parvo B19?
- Mild systemic sx - fever, lacy rash, slapped cheeks
- Fetal anemia
- Myocarditis
- Hydrops fetalis
- Children infected have 1-4 days of systemic sx before the appearance of rash.
- Arthropathy - joints of hands, wrists, knees and ankles; lasts 1-2 wks.
a serious fetal condition defined as abnormal accumulation of fluid in 2 or more fetal compartments, including ascites, pleural effusion, pericardial effusion, and skin edema.
Hydrops fetalis (fetal hydrops)
how to dx parvo B19
- Pregnant women exposed - IgG + IgM; US; percutaneous umbilical cord blood sampling
- Positive IgM test result indicates that infection probably occurred within the past 2-4 mo
tx for Parvo B19
- acute infection > 20 wks gestation - US weekly looking for signs of fetal hydrops
- Infants who survive - supp on management of hydrops.
- Aplastic crisis - blood transfusions
what is syphilis caused by?
Spirochete Treponema pallidum
Syphilis is MC transmitted by ?
transplacental infection of fetus
- nearly 100% chance of passage to fetus if active primary or secondary infection, but can be acquired by contact with chancre
syphilis: ?% result in spontaneous abortion
40%
how many infants are born with congenital syphilis asx at birth but will manifest sx by 3 months of age?
2/3
s/s syphilis
not transferred through breast milk
- Before 2 y/o
- Hepatomegaly
- Nasal Discharge - “Snuffles” (persistent) - White and may be bloody
- Rash
- Generalized LAD
- Skeletal abnormalities - After 2 y/o
- CNS abnormalities
- Abnormalities to bones, teeth, eyes, skin
late s/s of syphilis
- Hutchinson’s Triad: interstitial keratitis, CNVIII deafness and Hutchinson’s teeth
- Rhagades - cracks and fissures around mouth and chin
- Bowing shins
- Saddle nose
- Mulberry molars: round cusps on enamel on permanent first molars
- Clutton Joints: symmetrical joint edema/synovial inflammation
What conditions would require further evaluation in regards to mom’s syphilis status?
- Any child born to a mother with positive testing w/o adequate tx with PCN
- infants whose mothers were treated < 1 mo prior to delivery
- should not be DC w/o knowing mom’s syphilis status
how to dx syphilis
- Serum quantitative nontreponemal titer > fourfold mother’s titer
- Direct visualization of T. Pallidum by dark field exam from bodily fluids
syphilis tx
-
Parenteral PCN
- aq PCN G x 10 d - 50,000 U/kg q12h IV
- Procaine PCN G x 10 d - 50,000 U/kg QD IM - Repeat antibody titers at 3, 6, 12 mo to document falling titers
MCC of sexually transmitted genital infections in the US
chlamydia
chlamydia is transmitted to newborns via ?
exposure to an infected mother’s genital flora during vaginal birth
how are mothers screened for chlamydia?
via vaginal swab or first pass urine specimen
s/s chlamydia
- Conjunctivitis - incubation 5-14 days post delivery - Both eyes
- Pneumonia
chlamydia should be suspected in any infant how old and with what sign?
under a month of age with conjunctivitis if possibility of exposure
gold standard of dx chlamydia
isolation of C trachomatis by cx
Swabs of both conjunctival and nasopharyngeal samples
tx chlamydia
- Topical therapy not effective
- Erythromycin PO x 14 d
- All pregnant women should be screened at the first pregnancy visit
what pathogen causes gonorrhea
Neisseria Gonorrhoeae - G- diplococci
s/s gonorrhea
- Eye MC frequent site of infection (BL)
- Purulent conjunctivitis
- Profuse exudate and swelling of eyelid
- May also present as scalp abscesses, vaginitis and bacteremia
who to screen for gonorrhea
Screening for those at increased risk for infection:
* previous STD infection
* multiple sexual partners
* inconsistent condom use
* commercial sexual partners
* drug use
* in communities with high prevalence of disease
Neonatal prophylaxis gonorrha
Erythromycin ophthalmic ointment
dx for gonorrhea
Gram stain of conjunctival exudate
tx gonorrhea
- Single dose of Ceftriaxone
- asx infants whose mothers have untreated disease should receive the same tx
- Test for the others
how can HIV be transmitted?
from mother to baby transplacentally in utero, during birth or by breastfeeding
ways to decrease the risk of HIV transmission
- antiretroviral tx of mother before and during delivery
- tx of infant first 6 wks of life
- C-section
- avoidance of breastfeeding
what increases the risk of HIV transmission by 30-50%?
Breastfeeding
HIV presentation
Newborns are typically asx
HIV dx
HIV DNA PCR
< 48 hrs of age, 2 wks, 1-2 mo, and at 2-4 mo
If 4 months and older with a neg PCR - HIV excluded
tx HIV
Antiretroviral prophylaxis (Zidovudine) for 6 wks for infants born to HIV-infected mothers
type of virus Hep C
HCV - small, single stranded RNA virus
primary source of pediatric infection of Hep C
Vertical transmission
Hep C: 5% transmission rate from mother to baby; what other condition increases risk?
HIV
RF for Hep C
- IV drug use
- tattoos (of the at-home or prison variety)
can you breastfeed while having Hep C?
yes, not CI
how to dx Hep C
- Anti-HCV (HCV antibody testing) present in blood after 18 mo of age is indicator
- confirmed with HCV RNA test, then HCV Genotyping
tx Hep C
decided by GI- interferon and ribavirin
presentation of Hep C
MC asx
presentation HPV
hoarseness in children later on in life
prevention of HPV
HPV or Gardasil vaccine
Congenital Zika Syndrome is caused by what
Arthropod-borne flavivirus transmitted by mosquitoes
pathway of infection of Zika
- Maternal infection
- placental transmission
- virus targets neural progenitor cells in fetal brain
- kills progenitor cells
presentation Zika syndrome
asx or sx
* Fetal growth restriction
* Fetal demise - 5-10%
* Ventriculomegaly
* Microcephaly
* Ocular - Optic nerve and retinal pathology; Retinal scarring
* Hearing loss - sensorineural, possibly delayed
* Arthrogryposis - Congenital joint contracture; Congenital club foot
* Cardiac - ASD, VSD, PFO
* Neurogenic - Hypertonia; Spasticity; Hyperreflexia; Seizures / Epilepsy
* SGA
describe the microcephaly in Zika
- Severe with partial skull collapse
- Thin cerebral cortices with subcortical calcifications
- Craniofacial disproportion
- Craniosynostosis
how to eval Zika
- H&P - Head circumference / development
- Lab studies
- Cranial U/S (primary screening tool)
- Hearing Assessment
- Radiologic findings
what lab shows definitive infection of Zika
(+) Serum + Urine for Zika RNA via PCR
what two labs show probable Zika infection
- Serum Zika IgM
- CSF for RNA and IgM
If both of these negative = Likely negative
tx Zika syndrome
- No specific tx - multifaceted
- Referrals
- Ophthalmology w/in 1 month of birth
- Hearing screen - newborn (ABR preferred)
- Neurology, ID, Genetics, Development
- Labs - Zika detection, CBC, CMP, genetics - Infants born to Zika (+) mothers w/o clinical findings
- Head US and ophthalmologic exam and ABR hearing test by 1 mo of age
Newborn is considered any child within the first ? days of life
28
Three major routes of perinatal infection
- Bloodborne transplacental - CMV, etc.
- Ascending with disruption of the amniotic barrier (PRM) - Bacterial infections after 12-18 hrs of ruptured membranes
- Infection via passage through birth canal - HSV, HIV, GBS, etc.
Most with early-onset sepsis will present at what age
< 24 hrs of age
presentation of sepsis
- Resp distress MC
- hypotension, acidemia, and neutropenia
- Range from subtle to profound septic shock
- Temperature instability
- Irritability
- Lethargy
- Poor feeding
- Respiratory sx
- Tachycardia
- Poor perfusion
- hypotension
MC pathogen to cause sepsis
group B strep
newborn sepsis w/u for how long?
(__ days of age)
7-90 days of age
rectal temp considered sepsis
100.4
Medical emergency, specifically ? days or under requiring a full work-up and hospital admission
60
work-up for newborn sepsis
- CBC
- BMP
- Urine cath and culture
- CXR
- CRP and Procalcitonin
- Blood cultures
- NP swab
- LP cultures
tx for newborn sepsis
- hospital admission with empiric abx until all cultures return
- Ampicillin + Cefotaxime/Gentamicin
- Questionable Acyclovir
- Close follow-up by PCP after discharge
