Infection in pregnancy - viral and protozoal

1. Viral and protozoal infection in
pregnancy

2. Viral infection
RUBELLA MEASLES INFLUENZA
CHICKENPOX
CYTOMEGALOVIRUS
(CMV)
PARVOVIRUS
MUMPS
HERPES SIMPLEX
VIRUS (HSV)
HIV

3. RUBELLA
• Rubella or German measles (RNA virus) is
transmitted by respiratory droplet exposure.
• Maternal Rubella features
i. Rash
ii. Malaise
iii. Fever
iv. lymphadenopathy
v. Polyarthritis

4. (CRS)

5. Management
• specific antibody (IgM) should be done within 10
days of the exposure to know whether the patient is
immune or not.
• Rubella specific IgG antibodies are present for life
after natural infection or vaccination.
• If the patient is not immune - therapeutic
termination should be seriously considered.
• PCR - Detection of viral RNA
• Prenatal diagnosis using PCR - chorionic villi, fetal
blood and amniotic fluid samples.

6. • Non-teratogenic.
• However, high fever may lead to
i. Miscarriage, FGR, microcephaly, stillbirth,
preterm baby
• Non-immunized women - IM immune serum globulin
(5 mL) within 6 days of exposure.
• Pneumonia, encephalitis develop  high mortality
• Detection of IgM, detection of viral RNA (RT-PCR)
• Management : supportive care
MEASLES

7. • The course of pregnancy remains unaffected
• if the infection is virulent - abortion or premature
labor.
• There is no evidence of its teratogenic effect even
if it is contracted in the first trimester.
• Outbreak of Asian influenza - increased incidence
of congenital malformation (anencephaly) - first
trimester.
• Influenza (inactivated) vaccine is safe In
pregnancy and also with breastfeeding.
INFLUENZA

8. • Diagnostic test – rapid influenza diagnosic test
• Treatment
– Acetaminophen
– Oseltamivir 75mg PO BID for 5 days
– Inactivated vaccine

9.  encephalitis, bacterial superinfection,
varicella pneumonia (high mortality)
CHICKENPOX (Varicella)

10. Congenital varicella syndrome (CVS)
• Results from transplacental infection during
pregnancy (2%)

11. • Hypoplasia of limbs
• Psychomotor retardation
• IUGR
• Chorioretinal scarring
• Cataracts
• Microcephaly
• Cutaneous scarring

12. • PCR – detect VZV specific DNA
• ELISA – detect IgM and IgG
• Treatment :
– Non immune patients : varicella zoster
immunoglobulin (VZIG), oral acyclovir or
valacyclovir

13. Complication
– Miscarriage
– Stillbirth
– IUGR
– Microcephaly
– intracranial calcification
– Hepatosplenomegaly
– Thrombocytopenia
– Choroidoretinitis
– mental retardation
– deafness.
CYTOMEGALOVIRUS (CMV) INFECTION

14. Congenitally-affected infants may excrete virus (through
urine and nasopharynx) for up to 5–7 years.

15. • Confirmatory test : DNA PCR of urine, blood,
saliva, amniotic fluid or cervical secretion
• CMV specific IgM is present with 80% infected
infants.
• Prenatal diagnosis by amniocentesis sampling
for PCR to detect CMV DNA.

16. • Maternal infection is usually self
limited
• Fetal infection occurs in 33% cases
following maternal infection
• Characterized by cheek slap
appearance
• It mainly affects the erythroid
precursor cells  anemia, aplastic
crises, congenital heart failure,
hydrops
• Fetal loss is more when infection
occurs early(< 10 weeks) in
pregnancy.
PARVO VIRUSES
33% hydrops- resolve
spontaneously
30% mortality rate

17. INVESTIGATION
• Diagnostic test : detection of virus specific IgM.
• PCR amplification of viral DNA from fetal and
maternal blood is more sensitive than IgM
antibody.
• Serial USG - 10 weeks after maternal illness to
detect any fetal hydrops.
• Fetal middle cerebral artery peak Doppler
velocity - to detect fetal anemia before hydrops
develop

18. MUMPS
• A RNA virus
• No ill effects on the course of pregnancy.
• Non-teratogenic.
• Incidence is expected to be low with the
introduction of measles-mumps-rubella
vaccine (MMR) to childhood vaccination
programme
• MMR vaccine (live-attenuated viruses) is
contraindicated in pregnancy

19. • Genital tract infection is due to HSV-2.
• Infection may be primary, nonprimary, first
episode and recurrent.
• It is transmitted by sexual contact.
• Primary infection may occur during pregnancy.
• Reactivation or recurrent infection occurs
resulting in virus shedding with or without
symptomatic lesions.
• HSV-1 infection is usually herpes simplex labialis.
HERPES SIMPLEX VIRUS (HSV)

20. Effect on pregnancy
• Increased risk of abortion is inconclusive.
• If the primary infection is acquired in the last trimester there is
chance of premature labor or IUGR.
• The fetus becomes affected by virus shed from the cervix or lower
genital tract during vaginal delivery.
• The baby may be affected in utero from the contaminated liquor
following rupture of the membranes.
• Risk of fetal infection is high in primary genital HSV at term due to
high virus shedding compared to a recurrent infection.
• Cesarean delivery is indicated (ACOG) in an active primary genital
HSV infection where the membranes are intact or recently
ruptured.
• Acyclovir 400 mg three times daily for five days is the drug of choice
when virus culture is positive.

21. • Neonatal infection may be disseminated (fatal) or localized or it
may be asymptomatic.
• Diagnosis is made by detection of the viral DNA by PCR.
• It is manifested as;
i. chorioretinitis
ii. microcephaly
iii. mental retardation
iv. seizures
v. deaths.
• TREATMENT - intravenous acyclovir. Neonatal mortality is high.
• PROPHYLACTIC - acyclovir (400 mg twice daily) is appropriate for
women with recurrent infections particularly near term.
• Breastfeeding is allowed provided the mother avoids any contact
between her lesions, her hands and the baby.

22. • Human immunodeficiency virus (HIV) is an
incurable infection
acquired immunodeficiency syndrome (AIDS)
• Worldwide 25–30% of infected patients are
women and 90% of them are 20–49 years of
age.
HIV and AIDS

23. Modes of transmission

24. • The virus: HIV viruses (HIV 1 and HIV 2) are RNA retroviruses
The virus attaches to T lymphocytes known as CD4+ cells whose
action in the immune system is to combact viruses, bacteria and
certain malignancies.
It produces multiple copies of itself
host cell damage
 There is gradual depletion of CD4+ cells.
 There is also failure of B lymphocytes to produce antibodies to HIV.
These events lead to progressive loss of host immune defence and
development of AIDS.
• Primary infection → 3–6 weeks → Acute syndrome(1 week–3
months) → Immune response to HIV (1–2 weeks) → Clinical
latency—about 10 years → AIDS.

25. Perinatal transmission of HIV
• Vertical transmission to the neonates is about 14–25%.
• Transmission of HIV2 is less frequent (1–4%) than for
HIV 1 (15-40%).
• Transplacental transmission occurs:
a. 20% before 36 weeks
b. 50% before delivery
c. 30% during labor.
• Vertical transmission is more in cases with preterm
birth and with prolonged membrane rupture.

26. Effects
• Pregnancy per se has got no effect on the
disease progression in HIV positive women.
• Increased incidence of abortion, prematurity,
IUGR and perinatal mortality in HIV
seropositive mothers - inconclusive.
• Maternal mortality and morbidity are not
increased by pregnancy.

27. Clinical presentation
Initial presentation
Asymptomatic period
Multiple opportunistic
infection
Neoplasm
Associated constitutional
symptoms
Fever, malaise , headache , Sore throat,
lymphadenopathy ,maculopapular rash
weight loss, lymphadenopathy, protracted diarrhea
Candida, Tuberculosis, pneumocystis and others.
cervical carcinoma, lymphomas, kaposi’ sarcoma
Median time of infection to AIDS 10 years
CD4 count, 200cells/mm – diagnostic of AIDS

28. Diagnosis
• Diagnostic test : HIV RNA PCR
• Screening test HIV antibodies :enzyme
immunoassay (EIA)
• Polymerase chain reaction(PCR) - early
diagnosis.
• Western blot test, immunofluorescence assay
(IFA) or HIV DNA PCR– confirmatory test

29. Management
PRENATAL CARE:
(i) Voluntary serological testing
(ii) In seropositive cases the following additional tests should be done.
• Test for other STDs—such as hepatitis B virus, syphilis, chlamydia, herpes
and rubella,
• Serological testing for cytomegalovirus and toxoplasmosis,
• Tuberculosis,
• Husband should be offered serological testing for HIV.
(iii) Counseling
(iv) Progression of the disease is assessed by—
• CD4+ T lymphocyte counts and
• HIV RNA (viral load).
(v) The patient should have T lymphocyte count in each trimester.
(vi) Highly active antiretroviral therapy (HAART) to HIV 1 positive women is
effective in reducing the viral (HIV RNA) load
(viii) Prophylactic antibiotics should be started when there is opportunistic
infection

30. Anti-HIV 1 drugs
• (A) Nucleoside reverse transcriptase inhibitors
(Zidovudine, Zalcitabine,Lamivudine,
Stavudine).
• (B) Non-nucleoside reverse transcriptase
inhibitors (Nevirapine, Delavirdine).
• (C) Protease inhibitors (Indinavir, Saquinavir,
Ritonavir).
• (D) Entry inhibitors (Enfuvirtide).

31. INTRAPARTUM CARE
• Zidovudine is given IV infusion starting at the onset of labor (vaginal
delivery) or 4 hours before cesarean section.Loading dose 2 mg/kg/hr,
maintenance dose 1 mg/kg/hr until cord clamping is done.
• A single dose Nevirapine at the onset of labor and a single dose of it to the
newborn at age 48 hours is an effective alternative requirement for
women who had no prior therapy.
• Women taking HAART can have planned vaginal delivery when plasma
viral load is < 50 copies/mL (RCOG 2010).
• Elective cesarean delivery reduces the risk of vertical transmission by
about 50%. Avoidance of breastfeeding,HAART therapy and appropriate
mode of delivery has reduced MTCT rates from 25-30% to < 1%. Baby
should be bathed immediately.
• High viral load (> 10000 copies/mL), lower CD 4 count, rupture of
membranes > 4 hrs and breastfeeding double the risk of MTCT. A maternal
sample for plasma viral load should be taken at delivery.

32. • Invasive procedures that might result in break in the skin or mucous
membrane of the infants (procedures like attachment of scalp
electrode and determination of scalp blood pH) are contraindicated.
Instrumentation (ventouse) is avoided.
• Amniotomy and oxytocin augmentation for vaginal delivery should
be avoided whenever possible.
• Caps, masks, gowns and double gloves should be worn. Protective
eye wear (goggles) should be used.
• Mechanical suctioning devices should be used to remove secretions
from the neonates airways.
• Blunt tipped needles should be used to avoid needle stick injury
and washing on any blood contamination from the skin
immediately. Appropriate sterilization of instruments and linens
should be done.
• Factors for increased perinatal transmission: Previous child with HIV
infection, mother with AIDS, preterm delivery, decreased maternal
CD 4+ count, high maternal viral load, chorioamnionitis,
intrapartum blood exposure (vaginal laceration, forceps delivery).
• Elective cesarean delivery is recommended (RCOG-2010) at 38
weeks for women taking HAART who have plasma viral load > 50
copies/mL.

33. • Health care workers should be protected from contact
with potentially infected body fluids. Estimated risk of
infection after parenteral or mucous membrane
exposure is 0.36%.
• Post exposure prophylaxis with triple therapy for 4
weeks, reduces the risk of seroconversion by more
than 80%. (ZDV 200 mg tid + Lamivudin 150 mg bid +
Indinavir 800 mg tid).
• Disposable syringes and needles are used and they are
deposited in the puncture proof containers.
• Long-term safety of anti-retroviral drugs is unknown.
Neuropathy, myopathy, lactic acidosis, pancreatitis,
hepatitis and mitochondrial toxicity have been
observed.

34. POSTPARTUM CARE
• — Breastfeeding—Doubles the risk of MTCT
(from 14% –28%) but where alternative forms of
infant nutrition are not safe, the risks associated
with breastfeeding may be accepted. Mother is
helped to make an informed choice.
• — Zidovudine syrup – 2 mg/kg, is given to the
neonate 4 times daily for first 6 weeks of life.
High risk neonate should be treated with HAART.
The infant is tested at D1, weeks 6, 12 and at 18
months of age.

35. CONTRACEPTION
• Barrier methods of contraception (condom or
female condom) is effective in preventing
transmission of the virus.
• The disease could be prevented
predominantly by health education and by
practice of safer sex.

36. COUNSELING
• Pre-pregnancy and early pregnancy counseling
for HIV infected patient is essential.
• The counsellor must provide up to date
knowledge which enables the patient to make
an informed choice.

37. Parasitic and protozoal infection
MALARIA TOXOPLASMOSIS
LISTERIOSIS
INTESTINAL
WORMS

38. MALARIA
• Malaria is predominantly a tropical disease.
• In India and other south east Asian countries
there is resurgence of malaria.
• The diagnosis is confirmed by the detection of
malarial parasites in peripheral thick blood
smear.
MALARIA

39. Pathogenesis

40. • Hemolytic anemia
• Maternal HIV or tuberculosis causes intense
parasitization of the placenta
• The fetal effects are due to high fever or due to
placental parasitization.
• The intervillous spaces become blocked with
macrophages and parasites and there is
diminished placental blood flow. This is mostly
seen with P. falciparum infection and in the
second half of pregnancy.
• Congenital malaria is rare (< 5%) unless the
placenta is damaged.

41. Severity of infection depends on
immunity state
Complications are high

42. Management
• Prevention from mosquito bites is done using
pyrethroid-impregnated mosquito nets and
electrically heated mats.
• Chemoprophylaxis:
– Chloroquine 300 mg/weekly, 2 weeks before
travel and covering the period of exposure and 4
weeks after leaving the endemic zone.
– Mefloquine 250 mg/week : alternative drug for
chloroquine-resistant.

43. • Rapid antigen detection test
– Parasite F-test
– Dual antigen test
• Molecular diagnosis
– DNA probe
– PCR –for species specification
Investigation

44. Treatment
• Chloroquin—10 mg base/kg p.o. followed by 10 mg/kg at
24 hours and 5 mg/kg at 48 hours.
• For radical cure - primaquin should be postponed until
pregnancy is over.
• Parasites resistant to chloroquin - quinine (10 mg salt/kg
p.o. every 8 hours for 7 days) under supervision.
• Patients with severe anemia may need blood transfusion.
• The antimalarial drugs - no effect on uterine contraction
unless the uterus is irritable.
• Folic acid 10 mg should be given daily to prevent
megaloblastic anemia.
• Complicated anemia : artesunate

45. • Caused by Toxoplasma gondii.
• Infection is transmitted through encysted
organism by eating infected raw or uncooked
meat or through contact with infected cat
feces.
• It can also be acquired across the placenta.
TOXOPLASMOSIS

46. • During parasitemia, transplacental infection to
the fetus occurs.
• The affected baby may develop :
i. hydrocephalus,
ii. chorioretinitis
iii. cerebral calcification
iv. microcephaly
v. mental retardation

47. • Acute infection is diagnosed by:
i. detecting IgM specific antibody,
ii. High level of IgG antibody titre
iii. detection of seroconversion for IgG from negative to
positive.
• Chronic maternal toxoplasmosis is not
considered to be a significant cause of
recurrent abortion as parasitemia will not be
repeated in subsequent pregnancies

48. • If current infection is confirmed the following
tests are carried out:
• (1) Amniocentesis and cordocentesis for
detection of IgM antibody in the amniotic fluid
and fetal blood. PCR for T. gondii gene is also
done
• (2) Ultrasonography at 20–22 weeks for
ventricular dilatation. If the fetus is infected and
hydrocephalus is present, counseling for
termination is to be done.

49. Treatment
• Toxoplasmosis is a self limited illness in an immunocompetent
adult and does not require any treatment.
• Pyrimethamine - 25 mg orally daily and oral sulfadiazine 1 gm four
times a day is effective.
*Pyrimethamine is not given in the first trimester
• Leucovorin is added to minimize toxicity. Four to six weeks course is
usually given.
• Spiramycin (3 gm orally daily) has also been used as an alternative.
• Acute toxoplasmosis during pregnancy is treated with spiramycin.
• Extended courses may be needed in an immunocompromised
patient to cure infection.
• Treatment to the mother reduces the risk of congenital infection
and the late sequelae.

50. Prevention
NO
• Uncooked meat
• unpasteurized milk
• contact with stray cat or cat litter are to be
avoided.

51. LISTERIOSIS
• Listeria monocytogenes (LM) is an intracellular
gram-positive bacillus.
• Found in soil and vegetation. It can grow and
multiply in temperature as low of 0.5°C.
• Infection is caused by eating infected food or
through contact with infected miscarried
products of animals.
• Maternal symptoms are ‘flu-like’ or “food
poisoning”.
• No reliable serological test for it except the blood
culture during septicemia.
LISTERIOSIS

52. • Neonatal death due to septicemia is also high
(10%).
• Overall perinatal mortality is 50%.
• Obstetric complications are:
i. Late miscarriage
ii. preterm labor
iii. delivery
iv. stillbirth

53. Treatment
• Ampicillin + gentamicin
• Trimethoprim and sulfamethoxazole
Prevention of listeriosis during pregnancy
according to FDA includes
• Not to drink or take—
• unpasteurized milk
• Soft cheese
• refrigerated smoked seafood (salmon, trout, cod).

54. Summary