June 29, 1998
1st-year resident Kyong-bong Cha M.D
I. Instructions
Immunosurveilence decreased during pregnancy
A. Fetal and newborn immunology
① Compromised compared with that of older children and adults
② Begin to develop by 9 to 15 weeks
③ Passive immunity : by IgG transferred actively across the placenta
B. Neonatal infection
① Difficult to diagnosis
② If infected in utero, there may be depression and acidosis at birth
③ Symptoms and signs: suck poorly, vomit, abdominal distension,
? ? ? respiratory difficulty similar to idiopathic respiratory distress syndrome,
? ? ? lethargic or jittery, hypothermia rather than hyperthermia
C. Risk factors of neonatal infection
① Preterm rupture of membrane
② Prolonged labor
③ Manipulations
D. Causes of Fetal and Neonatal Infections
Infection occurring at less than 72hours of age ;caused by bacteria acquired in utero or during delivery
II. Viral Infection
A. Varicella-Zoster
DNA herpesvirus : remains latent in the dorsal root ganglia after primary infection
Most adults have acquired chicken pox during children and are immune
Infection is especially severe during pregnancy
Acyclovir : not teratogenic , but its use is reserved for life-threatening infection
Little evidence that zoster caused congenital malformation
1. Prevention
Varicella-zoster immunoglobulin (VZIG) to exposed susceptible individuals within 96hours
An attenuated live-virus vaccine : not recommended for pregnant woman
2. Fetal effect
when maternal chicken pox during early pregnancy severe congenital malformations including chorioretinitis cerebral cortical atrophy, hydronephrosis and cutaneous and bony leg defects
Varicella infection during pregnancy
During the first 20weeks : absolute risk of embryopathy is about 2%
After 20weeks : no clinical evidence of congenital varicella infection
The highest risk is between 13 and 20weeks : 2 % of congenital varicella
Later in pregnancy : associated with congenital varicella lesions , zoster occasionally develops at several months of age
Fetal exposure to the virus just before or during delivery
(before maternal antibody has been formed)
; serious threat to the newborn
Neonatal varicella infection
⒜ Incubation period : less than 2weeks
⒝ May develop disseminated visceral and CNS disease
? ? : commonly fatal
Varicella-zoster or zoster immunoglobulin (ZIG) should be administered to the neonate whenever the onset of maternal clinical disease was within 5days before delivery or 2days postpartum
B. Influenza
Caused by members of the orthomyxoviridae family
Develops during winter epidemics
Self-limited and not life-threatening for otherwise healthy adults
If pneumonia develops, the prognosis becomes serious
When pneumonia develops , the mortality of pregnancy women is 27-50%
1. Prevention
Vaccination : safe for pregnant women, regardless of the stage of pregnancy
Amantadine : if given prophylactically during epidemics , it is 70 to 90 % effective in preventing influenza
2. Fetal Effect
No congenital malformation
Predispose to schizophrenia in later life : controversial
C. Mumps
Uncommon adult infectious disease caused by an RNA paramyxovirus ; 80-90% seropositive
Infects the salivary glands, the gonads, meninges, pancreas and other organs
During pregnancy : no more severe than in nonpregnant adult
Vaccination : the live attenuated Jeryl-Lynn vaccine is contraindicated
Treatment ; symptomatic
Fetal Effect : no evidence of fetal wastage
D. Rubeola (Measles)
Most adults are immune to measles
Not appear to be teratogenic
Maternal measles : increased frequency of abortion and low birth weight infants
If the woman develops measles shortly before birth : considerable risk of neonatal infection and some risk of death
Passive immunization : immune serum globulin within 3days of exposure
Vaccination is not done during pregnancy
E. Respiratory viruses
Ause the common cold, pharyngitis, laryngotracheobronchitis, bronchitis and pneumonia
Major cause of common cold : Rhinovirus, coronavirus, and adenovirus
Adenovirus ; DNA virus, cough , and lower respiratory tract involvement
Mothers suffering from common cold ; 4-5times increased risk of anencephaly
Adenoviral infection ; common cause of childhood myocarditis
F. Enterovirus infection
Poliovirus, coxsackievirus, and echovirus
Cause CNS ,skin, heart and lung infection
May cause fetal infection
Risk factor for childhood -onset diabetes
1. Coxsackievirus
Usually clinically inapparent but may cause aseptic meningitis, polio-like illness , rashes, respiratory disease , pleuritis, pericarditis and myocarditis
Can be a serious complication of pregnancy : can be fatal to fetus-infant
Viremia may cause hepatitis, myocarditis , and encephalomyelitis : which can cause fetal death
Clinical chorioamnionitis ; fetal ventriculomegaly and cardiomyopathy
2. Poliovirus
Can cause paralytic disease ; poliomyelitis
Pregnant women not only were susceptible to polio but had a higher death rate
With the widespread use of vaccination during child hood, polio has become rare
Vaccination for susceptible pregnant women who must travel to endemic area or in other high risk situations
G. Parvovirus
Causes erythema infectiasum, or fifth disease
Clinical feature ; a bright red macula , rash and erythroderma : slapped cheek
Maternal hydrops syndrome: preeclampsia-like disease related to large placental mass with fetal hydrops
Fetal effect : abortion, fetal death , myocardial damage congenital anomalies by first -trimester pavovirus infection
Diagnosis : confirmed serologically by Ig M-specific Ab
for woman with positive serology, ultrasonic examination is indicated
: if there is hydrops then fetal transfusion should be considered
H. Rubella
Responsible for inestimable pregnancy wastage and severe congenital malformations
1. Prevention ; to eradicate the disease completely
Education of health -care providers and the general public on the danger of rubella infection
Vaccination of susceptible women as as part of routine medical and gynecological
care, including college health service
Vaccination of susceptible women visiting family planning clinics
Identification and vaccination of unimmunized women immediately after childbirth or
abortion
Vaccination of nonpregnant susceptible women identified by premarital serology.
Vaccination of all susceptible hospital personnel who might be exposed to patients
with rubella or who might have contact with pregnant women
Rubella vaccination should be avoided shortly before or during pregnancy because the vaccine is an attenuated live virus
2. Diagnosis
Abscence of rubella antibody is positive indicates susceptibility
If maternal rubella antibody is positive at the time of exposure to rubellaor before
-> the fetus will not be affected
Antibody response after rubella infection
Peak titer : 1 to 2 weeks after the onset of the rash
Specific IgM antibody by radioimmunoassay : peak at 7 to 10days after onset of clinical disease persist for 4 weeks after appearance of the rash
3. Congenital Rubella Syndrome
Rubella is a potent teratogen
As the duration of pregnancy increased , fetal infections are less likely to cause congenital malformations.
Include one or more of the following
Eyelesions including cataract, glaucoma, microphthalmia and various other abnormalities
Heart disease, including PDA, septal defects and pulmonary artery stenosis
Gensorineural deafness
CNS retarded fetal growth
Thrombocytopenia and anemia
Hepatitis, hepatosplenomegaly, and jaundice
Chronic diffuse interstitial pneumonitis
Osseous changes
Chromosomal abnormalities
Infants born with congenital rubella
-> May shed the virus for many months
-> May be a threat to other infants as well as susceptible adults
I. Cytomegalovirus
Most common cause of perinatal infection
0.5 to 2 percent of all neonates
Transmitted horizontally by droplet infection and contact with saliva and urine. vertically from mother to fetus-infant and as s sexually transmitted disease.
Usually by 2 to 3 years of age children acquire the infection
1. Maternal infection
No evidence that pregnancy increased the risk or clinical severity of maternal cytomegalovirus infection,
Symtomatic among about 15% of adult : fever,pharyngitis, lymphadenopathy, and polyarthritis
When pregnant women is infected ,amnionic fluid culture may be positive and infection can cause fetal death
Management :
Rehydration
Antimicrobials prolong the carrier state and are not given in uncomplicated infection
2. Typhoid fever
Salmonella typhi is spread by oral ingestion of contaminated food, water, or milk
More likely to be encounted in pregnant woman or in those who are HIV infected
⑴ Pregnancy complicated by typhoid fever
① Abortion or preterm labor : 80%
② Fetal mortality : 60%
③ Maternal mortality : 25%
⑵ Treatment : chloramphenicol is the most effective treatment
3. Shigellosis
Common cause of inflammatory exudative diarrhea in adults
Highly contagious with primary attack rates up to 75%, and exposed family members may be infected in over 50% of cases
Self limited
Treatment : trimethoprim- sulfomethoxazole
E. Lyme disease
Caused by the spirochete Borrelia burgdorferi
Most commonly reported vector borne illness in the united states
Result from the bite of ticks of the gennus Ixodes
early local infection : erythema migrans
Multisystemic involvement : skin lesions, arthralgia, and myalgia, carditis, and meningitis
Treatment : doxycycline or ampicllin
for pregnant women ; oral amoxicillin or penicillin for 3 weeks
Neonatal infection: not associated with fetal death ,preterm delivery, or malformation
III. Protozoal Infection
A. Toxoplasmosis
Transmitted through encysted organisms by eating infected raw or undercooked meat and through contact with ooctyes in infected cat feces
Can be acquired congenitally by transplacental transfer
Fatigue ,muscle pains and sometimes lympadenopathy,but most often infection is subclinical
Infection in pregnancy : may cause abortion or result in a live - born infant with evidence of disease
1-5/1000 pregnancies
The risk of fetal infection increased with duration of pregnancy (over all 50%)
The virulence of fetal infection is greater the earlier that infection is acquired
: Fortunately infection is less common earlier in pregnancy
Less than 1/4 of newborns with congenital toxoplasmosis have signs of clinical illness at birth : low birth weight, hepatosplenomegaly, icterus, and anemia, neurologic disease with convulsion, intracranial calcification, mental retardation, and hydrocephaly or microcephaly, chorioretinitis
1. Preconceptional serological screening
① If anti-toxoplasma Ig -G antibody is confirmed before pregnancy
? ? : the woman is not at risk for congenitally infected fetus
? ? : increased microcephaly, deafness, and mental retardation
2. Management
Spiromycin : for the active disease
reduce the incidence of fetal infection
B. Malaria
Four species of plasmodium: vivax, ovale, malarie, and falciparum
->transmitted by the bite of a female Anopheles mosquito
Characterized by fever and flu-like symptoms including chills, headache myalgia and malaise which may occur at intervals
1. Effect on pregnancy
The incidence of abortion and preterm labor is increased
Increased fetal loss : related to placental and fetal infection
-> Parasite have on affinity for decidual vessels and may involve the placenta
Congenital malaria :7% of neonate in nonimmune women
2. Treatment
Commonly used antimalarial drugs are not contraindicate during pregnancy
Chloroquine : the treatment of choice
Quinidine : to treat critically ill persons infected with falciparum malaria
Mefloquine: choloroquine -resistant infections
3. Prophylaxis
Chloroquine 300mg of base given orally once a week in initiated 1 to 2 weeks before the endemic area is entered, and this is continued until 4weeks after return to non endemic areas
C. Amebiasis
Amoebic dysentery may take a fulminant course during pregnancy
If complicated by a hepatic abscess : prognosis is worse