Perinatal infection

Definition

Perinatal infections are those infections affecting the mother during a pregnancy , and may be transmitted to the fetus during pregnancy, during delivery through the birth canal, or after delivery through the breast milk.

Description

Perinatal infections may be bacterial, fungal, or viral in nature. The degree to which the mother is affected by the infection is not an indication of its impact on the fetus. The mother may have slight or no symptoms, and yet the fetus may be significantly affected by the infection. The woman's sexual partner(s) may also be affected by these infections and should seek medical treatment. The more common perinatal infections significantly affecting the fetus are discussed below.

Causes and symptoms

Chlamydia

According to the Centers for Disease Control (CDC), chlamydia trachomatis is the most frequently reported bacterial sexually transmitted disease in the United States, with about 650,000 cases reported in 1999. It is often referred to as a silent disease, because so many infected individuals are asymptomatic. While about 75% of women are unaware of their infection, symptoms include purulent endocervical discharge, inflammation, edema , and bleeding. Chlamydial infection can permanently damage the reproductive tract. While asymptomatic, women can experience inflammation of the fallopian tubes, chronic pelvic pain , pelvis inflammatory disease, an increased risk for ectopic pregnancy, and infertility . For pregnant woman, chlamydial infection increases the risk for premature rupture of membranes, preterm delivery, and neonatal conjunctival or pneumonic infection. About 65% of infected neonates acquired the disease during a vaginal delivery.

Cytomegalovirus (CMV)

CMV is a common congenital viral infection, belonging to the herpes virus group of infections. Maternal infection usually occurs through sexual intercourse, including kissing, with an infected individual. Maternal infection may be asymptomatic, or the mother may present with mononucleosis-like symptoms, fatigue, lymphadenopathy, or fever . Transmission to the fetus can occur if the mother becomes infected during pregnancy, or if she has a flaring of a pre-exisisting CMV infection. Some immunity is transferred to the fetus if the mother has had a prior CMV infection. Infants infected in utero with CMV may be asymptomatic, or may have a delayed reaction, manifesting as mental retardation or deafness. About 10% of newborns with congenital CMV have evidence of disease at birth. CMV can also be acquired by the newborn through cervical secretions, saliva, urine, or breast milk. It can also be acquired in the newborn nursery by contact with infected individuals. Individuals with a compromised immune system , organ recipients, and those with HIV/AIDS are more likely to suffer severe consequences.

Genital herpes

Genital herpes is a sexually transmitted disease (STD) caused by the herpes simplex virus (HSV), and is considered a life-long infection. It may be contracted in two types, HSV-1 and HSV-2. According to a June 2001 report by the CDC, about 45 million Americans aged 12 and older have contracted HSV-2. The infections may exist subclinically, and later erupt in lesions. The risk of contracting the disease increases with the number of sexual partners. If genital herpes occurs for the first time during pregnancy, first trimester miscarriage and third trimester preterm birth may be the result. The greatest risk for the fetus occurs when genital herpes is contracted near term. Intrauterine transmission does occur, although it is more rare, and can take place across the placenta. After birth, neonates can also contract the disease from an infected newborn in the nursery.

Hepatitis B virus (HBV)

HBV is contracted through direct contact with the blood or other body fluids of an infected individual. It is sexually transmitted, through infected blood or blood products, and to the infant during a vaginal birth. In infants with HBV, 90% contract it at birth. The disease may present in very mild form, with no symptoms and only detected through liver function tests , or may be severe, even fatal, if it has advanced to liver necrosis. Symptoms of HBV infection include:

• jaundice
• fatigue
• rash
• fever that is usually either not present, or very mild
• vague abdominal discomfort
• abdominal pain
• loss of appetite
• nausea
• vomiting
• joint pain

Human immunodeficiency virus (HIV)

HIV is transmitted through direct contact with an infected individual's blood and body fluids (such as semen, amniotic fluid, breast milk, and vaginal and cervical secretions), and leads to the development of acquired immunodeficiency syndrome (AIDS ). The majority of pediatric AIDS cases are due to vertical transmission from the mother to the fetus, and is a leading cause of death in children aged one to four years old. Transmission from the mother to the fetus occurs during pregnancy through the placenta, during a vaginal delivery or with premature rupture of membranes, or through the breast milk. Symptoms of an impaired immune system suspicious of HIV infection include:

• fever
• weight loss
• malaise
• oral candidiasis
• central nervous system dysfunction

Human papillomavirus (HPV)

HPV is a STD than can cause genital warts. However, many infected individuals are asymptomatic. This variability is due to the fact that there are about 30 types of HPV. The CDC estimates about 5.5 million new cases of HPV a year, with about 20 million people infected to date. About 28–46% of women under the age of 25 have HPV. Individuals who are immunocompromised, such as those with HIV, are at higher risk of contracting the disease. This is also true of those who are pregnant. Genital warts appear to grow more quickly during pregnancy, and can be large enough to obstruct the cervix for a vaginal delivery. Disruption to the warts of the genital tract during pregnancy or delivery can lead to significant maternal blood loss.

Rubella

Rubella is a contagious disease, and is spread through the respiratory tract. Because of effective vaccination , it is rare in pregnancy. However, it can be passed to the fetus through the placenta if the mother becomes infected during pregnancy. Maternal symptoms include:

• low-grade fever
• swollen glands
• rash starting at the face and moving down toward the extremities
• joint pain
• conjunctivitis

Streptococcus

Group B streptococcus (GBS) is a contagious, bacterial infection that is particularly harmful to pregnant women, newborns, the elderly, and those who are immunocompromised by other illnesses. According to the CDC, it is the most common cause of life-threatening illness in neonates. In pregnant women it can cause bladder infections, amnionitis, endometritis, and stillbirth. Newborns may develop early-onset disease, from day one to day seven, or late-onset disease, from day seven to several months postpartum. In early-onset disease, infants may present with sepsis, respiratory distress, apnea, pneumonia , shock , or meningitis . Late-onset disease may present as sepsis or meningitis. Individuals may harbor GBS without symptoms, but be able to transmit it to another individual. Premature infants are particularly vulnerable.

Syphilis

Syphilis is a sexually-transmitted disease caused by the bacterium Treponema pallidum. It progresses in three stages. In the primary stage, shortly after infection, a small, round, firm chancre sore develops at the site of transmission. Multiple sores may also exist, usually in the vagina, anus, rectum, lips, or mouth. It heals on its own, and may go unnoticed. Untreated, the disease progresses to the secondary stage. In this stage multiple locations break out in a rash of red or brown spots that do not itch. It may be accompanied by fever, weight loss, fatigue, or muscle pain. If untreated, the disease can progress to late-stage syphilis. In this stage, damage to internal organs, the central nervous system, and body systems develops. This stage can lead to paralysis , numbness, blindness, dementia , and death. A mother can pass the disease on to her fetus, who may be stillborn or die shortly after birth.

Toxoplasmosis

A pregnant woman can become infected with toxoplasmosis either by handling infected cat feces, or by ingesting raw or undercooked infected meat. The risk of maternal to fetal transmission is greater when the mother is suffering from an acute, rather than a chronic, infection of toxoplasmosis.

Diagnosis

Chlamydia

In women, chlamydia is diagnosed by evaluating a sample taken of the cervical secretions. A urine test is also available. The Pap smear does not test for chlamydia. To properly diagnose the disease, the endocervical sample needs to be adequate in amount and contain columnar epithelial cells.

Cytomegalovirus

A blood sample can be evaluated for the presence of a CMV-specific antibody, but about 20% of women will show no antibody presence. Prevalence of CMV among the adult general population is high, in some regions occurring in 40–100% of the population. About 33–66% of pregnant women test positive to the CMV IgG antibody. Ultrasound can detect fetal infection, presenting as intrauterine growth retardation, polyhydramnios, and central nervous system abnormalities.

Genital herpes

When lesions are present, tissue sample scrapings or a biopsy can be taken and cultured to confirm the diagnosis. When the condition is latent, diagnosis is more difficult. Blood tests are available, but accuracy of results is not guaranteed. At the first prenatal visit, mothers should be questioned about a prior history of lesions.

Hepatitis B

Diagnosis for HBV is through evaluation of a blood sample for the presence of antigens or antibodies.

Human immunodeficiency virus (HIV)

The HIV infection affects the immune system, causing progressive deterioration during which the individual becomes susceptible to infections and neoplasms rarely seen in those with an intact immune system, such as wasting syndrome, Pneumocystis carini, and Karposi's sarcoma. The diagnosis of these conditions promotes further evaluation for the presence of HIV/AIDS. The average latency between HIV infection and the development of AIDS is about 11 years. A blood sample is used to detect the presence of HIV infection.

Human papillomavirus

Genital warts are diagnosed during a clinical exam.

Rubella

Because rashes can mimic several diseases, the best diagnostic evaluation for rubella is a blood test for the presence of a rubella-specific IgM antibody. The test can also be performed by evaluating samples of nasal or throat secretions, as well as cerebrospinal fluid.

Streptococcus

Diagnosis is done through cultures of rectal or vaginal secretions taken during the third trimester. In the neonate, blood samples can be taken.

Syphilis

Syphilis diagnoses are often missed because the signs can mimic other conditions or be so mild in appearance as to go unnoticed. Samples from chancre sores can be evaluated for the presence of syphilis, or a blood test can be run. While antibodies do develop, they diminish as time passes, and the individual may become reinfected.

Toxoplasmosis

Maternal infection with toxoplasmosis may be asymptomatic. About 10–20% of infected women may present with lymphadenopathy. Fatigue and mononucleosis-like symptoms may also be present. A blood sample can be evaluated for the maternal presence of a toxoplasmosis-specific IgM antibody. Amniotic sampling can detect fetal infection. Infected neonates may present with liver or spleen enlargement, jaundice, fever, hydrocephalus, or microcephalus.

Treatment

Chlamydia

The drugs azithromycin, doxycycline, and oflaxacin are the first-choice treatment for chlamydia, but are contraindicated in pregnancy. Erythromycin and amoxicillin are used during pregnancy. Repeat testing is recommended three weeks after the conclusion of treatment.

Cytomegalovirus

Since no fetal treatment exists for CMV, maternal testing is usually not recommended. In affected infants, acyclovir (Zovirax) and ganciclovir have been used to suppress the infection. However, the infection reappears once the medication is discontinued.

Genital herpes

Antiviral medical treatment does not cure herpes, but rather shortens the course of the disease. For severe maternal complications, intravenous acyclovir may be used. Acyclovir should be given to all neonates with the disease. Treatment can prevent disease progression to serious consequences. Even with antiviral treatment, if the HSV has spread throughout the infant, mortality may be as high as 50%.

Hepatitis B

Because HBV affects the liver, alcohol should be avoided. HBV-infected individuals should have their liver evaluated for signs of disease. The CDC reports that the use of alpha interferon and lamivudine are effective for about 40% of patients. The use of these medications in pregnancy is contraindicated.

Human immunodeficiency virus (HIV)

Careful monitoring of the mother's immune status is an essential component of HIV management. For pregnant HIV-positive women, the medical focus is to maximize benefit for the mother herself, while avoiding vertical transmission, if at all possible. The use of zidovudine (ZDV) reduces the incidence of maternal transmission to the fetus. The pregnant state also balances the side effects of treatment on the mother. The use of ritonavir and nelfinavir (Virocept) are first-line protease inhibitor choices for the pregnant woman. The treatment plan of the HIV-infected individual is determined by the amount of virus present in the body, referred to as viral load. The greater the viral load, the greater the degree to which the maternal immune system is compromised, and the higher the risk of transmission to the fetus. During the first trimester of pregnancy, the teratogenic effects of the antiviral agents given to the mother are the greatest for the fetus.

Human papillomavirus

Direct treatment of the warts is done to provide symptomatic relief. However, the nearby normal-looking tissue can also harbor the HPV. The drugs podophyllin, podofilox, and imiquimod are not used during pregnancy. Instead, laser therapy, surgical excision, cryosurgery, or trichloroacetic acid may be used. To avoid transmission of the disease during vaginal delivery, cesarean birth may be performed. Despite the treatment used, the likelihood of recurrence is high.

Rubella

There is no antiviral treatment for rubella. Prevention through vaccination is the best means of avoiding contracting the disease.

Streptococcus

Penicillin or ampicillin are the drugs of choice, but penicillin-resistant strains exist. Severe infection may warrant the use of an aminoglycoside in addition to the penicillin.

Syphilis

If the infection is within a year, a single dose of penicillin can cure the disease, according to the CDC. A greater dose will be needed if the infection has been present for more than a year. The antibiotic will cure the disease, but not any damage that has already occurred. Mothers with syphilis can be treated while pregnant. The infant may require antibiotic treatment as well after birth.

Toxoplasmosis

Pregnant women infected with toxoplasmosis may be treated with pyrimethamine, folinic acid, spiramycin, and sulfonamide. Maternal treatment may prevent transmission to the fetus. Pyrimethamine can be teratogenic if given in the first trimester.

Prognosis

Chlamydia

Chlamydia infection can have serious consequences for the fetus and neonate. These include:

• spontaneous abortion
• premature rupture of membranes
• preterm delivery
• stillbirth
• neonatal death
• pneumonia

The prognosis for the mother depends on the degree of damage to the reproductive tract prior to treatment. Chlamydia responds well to antibiotic treatment.

Cytomegalovirus

Prognosis overall is good, as many infected individuals are asymptomatic. However, fetal death may occur, and infected infants born with mental retardation, chronic liver disease, motor disabilities, or deafness have lifelong consequences.

Genital herpes

About 30–50% of infants exposed to genital herpes near term will contract the disease. This is in comparison to the 3–5% rate of infection for infants exposed to recurrent genital herpes during pregnancy. Infants exposed to the virus during a vaginal birth have higher rates of the disease than those born via cesarean delivery. Infants with HSV localized to the eyes, skin, or mouth have the best outcome. HSV in infants can lead to death through disseminated intravascular coagulation, pneumonitis, or encephalitis.

Hepatitis B

According to the CDC, the number of new infections has declined from 450,000 in the 1980s to 80,000 in 1999. The area of highest growth is in those aged 20 to 49. Because of vaccinations of younger children, those numbers are declining.

Human immunodeficiency virus (HIV)

While long-term prognosis remains poor, short-term prognosis has been improving. Most studies have been done on men, with research focused on women trailing behind. Pregnancy does not appear to alter the course of the disease.

Human papillomavirus

HPV puts women at increased risk for cervical and anal cancer . Infants born via vaginal delivery may also develop papillomas in the larynx or conjunctiva.

Rubella

Rubella is most commonly seen in non-vaccinated children. In children, the disease course is milder than in adults. Fetal contraction of the disease can lead to fetal death, preterm delivery, and congenital defects such as heart anomalies, mental retardation, blindness, and deafness. The stage of gestation is a critical factor in the degree of impairment to the fetus. All fetal body organs and systems can be affected.

Streptococcus

GBS responds well to antibiotic treatment. Unrecognized or untreated, the effect on the neonate can be severe, including sepsis, pneumonia, or meningitis.

Syphilis

Prognosis depends on the stage to which the disease has progressed. Untreated infants may be asymptomatic, and if untreated may have seizures and die soon after birth.

Toxoplasmosis

The later in the pregnancy the infection is contracted, the better the chance of recovery. A chronic infection in which the mother is infected prior to pregnancy is less likely to be transmitted to the fetus. Fetal death may occur in about 10% of cases occurring in the first trimester of pregnancy. Fetal death is rare when the infection occurs in the third trimester. An acute infection is associated with premature birth and stillbirth. Spontaneous abortion is rare.

Health care team roles

Laboratory technicians and phlebotomists need to observe standard universal precautions in drawing and handling blood and other body fluids, as the complete infection status of a patient will not be known. This includes the use of gloves, eye protection such as a face-mask or goggles, and personal protective clothing. Radiology technicians will be involved in ultrasound scanning to detect fetal compromise as a result of infection. Ultrasound-guided sampling of amniotic fluid or fetal tissue may be used to diagnose fetal infection. Through individual discussion, waiting room videos, and pamphlets, nurses can educate pregnant mothers during routine visits about ways to prevent infection by these agents. Nurses can play a significant role in emphasizing the need for retesting after treatment (when required) and discussing the importance of having the woman's sexual partner tested and treated to avoid reinfection.

Prevention

Chlamydia

When a woman has multiple partners, the use of condoms every time a woman has sexual intercourse can decrease the risk of becoming infected. Limiting the number of sexual partners also decreases the risk of chlamydial infection.

Cytomegalovirus

CMV can be shed in body fluids, so care must be taken when handling these substances. This includes the handling of diapers, especially in day care environments. Those working in a hospital environment should always observe universal precautions when handling any body fluid or secretion. Careful hand washing can decrease the risk of transmission. Since CMV is shed in cervical secretions, cesarean birth may decrease the risk of transmission, although infection during the first two trimesters of pregnancy carries the greatest fetal risk. Research is investigating the usefulness of a preconception vaccine.

Genital herpes

Cesarean delivery can substantially reduce disease transmission to the neonate. For mothers with genital herpes, delivery following premature rupture of membranes (PROM) should be considered, as the risk of disease transmission increases by six hours after PROM. If maternal HSV is suspected, a fetal scalp monitor should be avoided, as this creates a direct portal of entry for the infection.

KEY TERMS

Lymphadenopathy —A disorder affecting the lymph nodes or lymphatic vessels.

Perinatal —The time during pregnancy, delivery, and until about one month postpartum.

Sexually transmitted diseases (STDs) —Those diseases transmitted from one individual to another during sexual interaction. They may also be referred to as venereal diseases.

Teratogenic —Tending to produce irregularities of formation.

Vertical transmission —The transmission of a disease or condition from one generation to the next, either through genetics, through the uterine environment, or through the breast milk.

Hepatitis B

The HBV vaccine is considered the best prevention. It is a series of three injections over seven months. It is not contraindicated in pregnancy. Use of latex condoms will help reduce the risk of transmission. Avoiding high-risk contact, such as contact with blood and other body fluids, will also lessen the risk of HBV. The CDC recommends that newborns born to HBV-infected mothers receive hepatitis B immune globulin after birth as well as the first dose of the vaccine within 12 hours postpartum.

Human immunodeficiency virus (HIV)

In the early 1990s, studies of ZDV used during pregnancy and given to the neonate for six weeks postpartum resulted in a 70% decrease in maternal HIV transmission to the infant. Cesarean birth also reduces transmission, as compared with vaginal birth. Knowledge of the mother's HIV status during pregnancy is therefore important in reducing the transmission risk. Testing for HIV status should be offered to all pregnant women. Avoidance of breast-feeding can also decrease the risk of transmission. If untreated, about 20% to 30% of infants born to HIV-positive women will be infected. Treatment with ZDV and avoidance of breast-feeding has been reported to lower transmission to about 2% to 3%. In 1999, a Ugandan study reported that a single dose of nevirapine given to infected mothers during labor in addition to a single dose given to the neonate within three days of birth cut the transmission rate in half, as compared with those treated with AZT throughout pregnancy and during the first six weeks of life.

Human papillomavirus

Use of a condom and limiting the number of sexual partners decreases the risk of contracting the disease.

Rubella

Women in childbearing age should have a titer draw to test for immune status. If they have not been exposed to rubella, they can be vaccinated against the disease, but should not become pregnant for three months following the vaccination, due to potential devastating effects on the fetus.

Streptococcus

Prevention of transmission of GBS from the mother to the infant can be enhanced by careful monitoring of the mother during labor for potential signs of infection such as fever, urinary tract infection, or PROM before 37 weeks or 18 hours or more before delivery. Treating the mother with IV antibiotics during labor limits the risk of transmission.

Syphilis

Use of a latex condom can reduce the risk of contracting the disease. However, the condom may not cover the area of infection. A blood test is the best way of finding out if one has syphilis, as the sores may be in hidden areas.

Toxoplasmosis

Prevention of infection through cat feces is best done by having someone other than the mother clean the cat litter, and to avoid inhalation of airborne oocytes. If this is not possible, cat litter should be changed daily, as spores develop in one to five days in the litter. Cats become infected by eating contaminated wildlife, so keeping the cat completely indoors significantly reduces the risk of contagion. Infection through meat can be avoided by avoiding raw meat and by cooking meat to at least 159°F (71°C). Garden soil can be contaminated, so the use of gloves when gardening with thorough hand washing afterwards can decrease infection. Outdoor sandboxes should be covered to avoid contamination by stray cats.

Resources

BOOKS

Burrow, Gerard N., and Thomas P. Duffy. Medical Complications during Pregnancy, 5th Edition. Philadelphia: W. B. Saunders Company, 1999.

Chin, James, ed. Control of Communicable Diseases Manual. Washington, DC: American Public Health Association, 2000.

Scott, James. Danforth's Obstetrics and Gynecology, 8th ed. Philadelphia: Lippincott Williams & Wilkins, 1999.

ORGANIZATIONS

Centers for Disease Control. <http://www.cdc.gov>.

Esther Csapo Rastegari, R.N., B.S.N., Ed.M.

Perinatal Infection

Definition

Perinatal infections are those infections affecting the mother during a pregnancy, and may be transmitted to the fetus during pregnancy, during delivery through the birth canal, or after delivery through the breast milk.

Description

Perinatal infections may be bacterial, fungal, or viral in nature. The degree to which the mother is affected by the infection is not an indication of its impact on the fetus. The mother may have slight or no symptoms, and yet the fetus may be significantly affected by the infection. The woman's sexual partner(s) may also be affected by these infections and should seek medical treatment. The more common perinatal infections significantly affecting the fetus are discussed below.

Causes and symptoms

Chlamydia

According to the Centers for Disease Control (CDC), chlamydia trachomatis is the most frequently reported bacterial sexually transmitted disease in the United States, with about 834,555 cases reported in 2002. It is often referred to as a silent disease, because so many infected individuals are asymptomatic. While about 75% of women are unaware of their infection, symptoms include purulent endocervical discharge, inflammation, edema, and bleeding. Chlamydial infection can permanently damage the reproductive tract. While asymptomatic, women can experience inflammation of the fallopian tubes, chronic pelvic pain, pelvis inflammatory disease, an increased risk for ectopic pregnancy, and infertility. For pregnant woman, chlamydial infection increases the risk for premature rupture of membranes, preterm delivery, and neonatal conjunctival or pneumonic infection. About 65% of infected neonates acquired the disease during a vaginal delivery.

Cytomegalovirus (CMV)

CMV is a common congenital viral infection, belonging to the herpes virus group of infections. Maternal infection usually occurs through sexual intercourse, including kissing, with an infected individual. Maternal infection may be asymptomatic, or the mother may present with mononucleosis-like symptoms, fatigue, lymphadenopathy, or fever. Transmission to the fetus can occur if the mother becomes infected during pregnancy, or if she has a flaring of a pre-exisisting CMV infection. Some immunity is transferred to the fetus if the mother has had a prior CMV infection. Infants infected in utero with CMV may be asymptomatic, or may have a delayed reaction, manifesting as mental retardation or deafness. About 10% of newborns with congenital CMV have evidence of disease at birth. CMV can also be acquired by the newborn through cervical secretions, saliva, urine, or breast milk. It can also be acquired in the newborn nursery by contact with infected individuals. Individuals with a compromised immune system, organ recipients, and those with HIV/AIDS are more likely to suffer severe consequences.

Genital herpes

Genital herpes is a sexually transmitted disease (STD) caused by the herpes simplex virus (HSV), and is considered a life-long infection. It may be contracted in two types, HSV-1 and HSV-2. According to a June 2001 report by the CDC, about 45 million Americans aged 12 and older have contracted HSV-2. The infections may exist subclinically, and later erupt in lesions. The risk of contracting the disease increases with the number of sexual partners. If genital herpes occurs for the first time during pregnancy, first trimester miscarriage and third trimester preterm birth may be the result. The greatest risk for the fetus occurs when genital herpes is contracted near term. Intrauterine transmission does occur, although it is more rare, and can take place across the placenta. After birth, neonates can also contract the disease from an infected newborn in the nursery.

Hepatitis B virus (HBV)

HBV is contracted through direct contact with the blood or other body fluids of an infected individual. It is sexually transmitted, through infected blood or blood products, and to the infant during a vaginal birth. In infants with HBV, 90% contract it at birth. The disease may present in very mild form, with no symptoms and only detected through liver function tests, or may be severe, even fatal, if it has advanced to liver necrosis. Symptoms of HBV infection include:

• jaundice
• fatigue
• rash
• fever that is usually either not present, or very mild
• vague abdominal discomfort
• abdominal pain
• loss of appetite
• nausea
• vomiting
• joint pain

Human immunodeficiency virus (HIV)

HIV is transmitted through direct contact with an infected individual's blood and body fluids (such as semen, amniotic fluid, breast milk, and vaginal and cervical secretions), and leads to the development of acquired immunodeficiency syndrome (AIDS ). The majority of pediatric AIDS cases are due to vertical transmission from the mother to the fetus, and is a leading cause of death in children aged one to four years old. Transmission from the mother to the fetus occurs during pregnancy through the placenta, during a vaginal delivery or with premature rupture of membranes, or through the breast milk. Symptoms of an impaired immune system suspicious of HIV infection include:

• fever
• weight loss
• malaise
• oral candidiasis
• central nervous system dysfunction

Human papillomavirus (HPV)

HPV is a STD than can cause genital warts. However, many infected individuals are asymptomatic. This variability is due to the fact that there are about 30 types of HPV. The CDC estimates about 5.5 million new cases of HPV a year, with about 20 million people infected to date. About 28-46% of women under the age of 25 have HPV. Individuals who are immunocompromised, such as those with HIV, are at higher risk of contracting the disease. This is also true of those who are pregnant. Genital warts appear to grow more quickly during pregnancy, and can be large enough to obstruct the cervix for a vaginal delivery. Disruption to the warts of the genital tract during pregnancy or delivery can lead to significant maternal blood loss.

Rubella

Rubella is a contagious disease, and is spread through the respiratory tract. Because of effective vaccination, it is rare in pregnancy. However, it can be passed to the fetus through the placenta if the mother becomes infected during pregnancy. Maternal symptoms include:

• low-grade fever
• swollen glands
• rash starting at the face and moving down toward the extremities
• joint pain
• conjunctivitis

Streptococcus

Group B streptococcus (GBS) is a contagious, bacterial infection that is particularly harmful to pregnant women, newborns, the elderly, and those who are immunocompromised by other illnesses. According to the CDC, it is the most common cause of life-threatening illness in neonates. In pregnant women it can cause bladder infections, amnionitis, endometritis, and stillbirth. Newborns may develop early-onset disease, from day one to day seven, or late-onset disease, from day seven to several months postpartum. In early-onset disease, infants may present with sepsis, respiratory distress, apnea, pneumonia, shock, or meningitis. Late-onset disease may present as sepsis or meningitis. Individuals may harbor GBS without symptoms, but be able to transmit it to another individual. Premature infants are particularly vulnerable.

Syphilis

Syphilis is a sexually-transmitted disease caused by the bacterium Treponema pallidum. It progresses in three stages. In the primary stage, shortly after infection, a small, round, firm chancre sore develops at the site of transmission. Multiple sores may also exist, usually in the vagina, anus, rectum, lips, or mouth. It heals on its own, and may go unnoticed. Untreated, the disease progresses to the secondary stage. In this stage multiple locations break out in a rash of red or brown spots that do not itch. It may be accompanied by fever, weight loss, fatigue, or muscle pain. If untreated, the disease can progress to late-stage syphilis. In this stage, damage to internal organs, the central nervous system, and body systems develops. This stage can lead to paralysis, numbness, blindness, dementia, and death. A mother can pass the disease on to her fetus, who may be stillborn or die shortly after birth.

Toxoplasmosis

A pregnant woman can become infected with toxoplasmosis either by handling infected cat feces, or by ingesting raw or undercooked infected meat. The risk of maternal to fetal transmission is greater when the mother is suffering from an acute, rather than a chronic, infection of toxoplasmosis.

Diagnosis

Chlamydia

In women, chlamydia is diagnosed by evaluating a sample taken of the cervical secretions. A urine test is also available. The Pap smear does not test for chlamydia. To properly diagnose the disease, the endocervical sample needs to be adequate in amount and contain columnar epithelial cells.

Cytomegalovirus

A blood sample can be evaluated for the presence of a CMV-specific antibody, but about 20% of women will show no antibody presence. Prevalence of CMV among the adult general population is high, in some regions occurring in 40-100% of the population. About 33-66% of pregnant women test positive to the CMV IgG antibody. Ultrasound can detect fetal infection, presenting as intrauterine growth retardation, polyhydramnios, and central nervous system abnormalities.

Genital herpes

When lesions are present, tissue sample scrapings or a biopsy can be taken and cultured to confirm the diagnosis. When the condition is latent, diagnosis is more difficult. Blood tests are available, but accuracy of results is not guaranteed. At the first prenatal visit, mothers should be questioned about a prior history of lesions.

Hepatitis B

Diagnosis for HBV is through evaluation of a blood sample for the presence of antigens or antibodies.

Human immunodeficiency virus (HIV)

The HIV infection affects the immune system, causing progressive deterioration during which the individual becomes susceptible to infections and neoplasms rarely seen in those with an intact immune system, such as wasting syndrome, Pneumocystis carini, and Karposi's sarcoma. The diagnosis of these conditions promotes further evaluation for the presence of HIV/AIDS. The average latency between HIV infection and the development of AIDS is about 11 years. A blood sample is used to detect the presence of HIV infection.

Human papillomavirus

Genital warts are diagnosed during a clinical exam.

Rubella

Because rashes can mimic several diseases, the best diagnostic evaluation for rubella is a blood test for the presence of a rubella-specific IgM antibody. The test can also be performed by evaluating samples of nasal or throat secretions, as well as cerebrospinal fluid.

Streptococcus

Diagnosis is done through cultures of rectal or vaginal secretions taken during the third trimester. In the neonate, blood samples can be taken.

Syphilis

Syphilis diagnoses are often missed because the signs can mimic other conditions or be so mild in appearance as to go unnoticed. Samples from chancre sores can be evaluated for the presence of syphilis, or a blood test can be run. While antibodies do develop, they diminish as time passes, and the individual may become reinfected.

Toxoplasmosis

Maternal infection with toxoplasmosis may be asymptomatic. About 10-20% of infected women may present with lymphadenopathy. Fatigue and mononucleosis-like symptoms may also be present. A blood sample can be evaluated for the maternal presence of a toxoplasmosis-specific IgM antibody. Amniotic sampling can detect fetal infection. Infected neonates may present with liver or spleen enlargement, jaundice, fever, hydrocephalus, or microcephalus.

Treatment

Chlamydia

The drugs azithromycin, doxycycline, and oflaxacin are the first-choice treatment for chlamydia, but are contraindicated in pregnancy. Erythromycin and amoxicillin are used during pregnancy. Repeat testing is recommended three weeks after the conclusion of treatment.

Cytomegalovirus

Since no fetal treatment exists for CMV, maternal testing is usually not recommended. In affected infants, acyclovir (Zovirax) and ganciclovir have been used to suppress the infection. However, the infection reappears once the medication is discontinued.

Genital herpes

Antiviral medical treatment does not cure herpes, but rather shortens the course of the disease. For severe maternal complications, intravenous acyclovir may be used. Acyclovir should be given to all neonates with the disease. Treatment can prevent disease progression to serious consequences. Even with antiviral treatment, if the HSV has spread throughout the infant, mortality may be as high as 50%.

Hepatitis B

Because HBV affects the liver, alcohol should be avoided. HBV-infected individuals should have their liver evaluated for signs of disease. The CDC reports that the use of alpha interferon and lamivudine are effective for about 40% of patients. The use of these medications in pregnancy is contraindicated.

Human immunodeficiency virus (HIV)

Careful monitoring of the mother's immune status is an essential component of HIV management. For pregnant HIV-positive women, the medical focus is to maximize benefit for the mother herself, while avoiding vertical transmission, if at all possible. The use of zidovudine (ZDV) reduces the incidence of maternal transmission to the fetus. The pregnant state also balances the side effects of treatment on the mother. The use of ritonavir and nelfinavir (Virocept) are first-line protease inhibitor choices for the pregnant woman. The treatment plan of the HIV-infected individual is determined by the amount of virus present in the body, referred to as viral load. The greater the viral load, the greater the degree to which the maternal immune system is compromised, and the higher the risk of transmission to the fetus. During the first trimester of pregnancy, the teratogenic effects of the antiviral agents given to the mother are the greatest for the fetus.

Human papillomavirus

Direct treatment of the warts is done to provide symptomatic relief. However, the nearby normal-looking tissue can also harbor the HPV. The drugs podophyllin, podofilox, and imiquimod are not used during pregnancy. Instead, laser therapy, surgical excision, cryosurgery, or trichloroacetic acid may be used. To avoid transmission of the disease during vaginal delivery, cesarean birth may be performed. Despite the treatment used, the likelihood of recurrence is high.

Rubella

There is no antiviral treatment for rubella. Prevention through vaccination is the best means of avoiding contracting the disease.

Streptococcus

Penicillin or ampicillin are the drugs of choice, but penicillin-resistant strains exist. Severe infection may warrant the use of an aminoglycoside in addition to the penicillin.

Syphilis

If the infection is within a year, a single dose of penicillin can cure the disease, according to the CDC. A greater dose will be needed if the infection has been present for more than a year. The antibiotic will cure the disease, but not any damage that has already occurred. Mothers with syphilis can be treated while pregnant. The infant may require antibiotic treatment as well after birth.

Toxoplasmosis

Pregnant women infected with toxoplasmosis may be treated with pyrimethamine, folinic acid, spiramycin, and sulfonamide. Maternal treatment may prevent transmission to the fetus. Pyrimethamine can be teratogenic if given in the first trimester.

Prognosis

Chlamydia

Chlamydia infection can have serious consequences for the fetus and neonate. These include:

• spontaneous abortion
• premature rupture of membranes
• preterm delivery
• stillbirth
• neonatal death
• pneumonia

The prognosis for the mother depends on the degree of damage to the reproductive tract prior to treatment. Chlamydia responds well to antibiotic treatment.

Cytomegalovirus

Prognosis overall is good, as many infected individuals are asymptomatic. However, fetal death may occur, and infected infants born with mental retardation, chronic liver disease, motor disabilities, or deafness have life-long consequences.

Genital herpes

About 30-50% of infants exposed to genital herpes near term will contract the disease. This is in comparison to the 3-5% rate of infection for infants exposed to recurrent genital herpes during pregnancy. Infants exposed to the virus during a vaginal birth have higher rates of the disease than those born via cesarean delivery. Infants with HSV localized to the eyes, skin, or mouth have the best outcome. HSV in infants can lead to death through disseminated intravascular coagulation, pneumonitis, or encephalitis.

Hepatitis B

According to the CDC, the number of new infections has declined from 450,000 in the 1980s to 80,000 in 1999. The area of highest growth is in those aged 20 to 49. Because of vaccinations of younger children, those numbers are declining.

Human immunodeficiency virus (HIV)

While long-term prognosis remains poor, short-term prognosis has been improving. Most studies have been done on men, with research focused on women trailing behind. Pregnancy does not appear to alter the course of the disease.

Human papillomavirus

HPV puts women at increased risk for cervical and anal cancer. Infants born via vaginal delivery may also develop papillomas in the larynx or conjunctiva.

Rubella

Rubella is most commonly seen in non-vaccinated children. In children, the disease course is milder than in adults. Fetal contraction of the disease can lead to fetal death, preterm delivery, and congenital defects such as heart anomalies, mental retardation, blindness, and deafness. The stage of gestation is a critical factor in the degree of impairment to the fetus. All fetal body organs and systems can be affected.

Streptococcus

GBS responds well to antibiotic treatment. Unrecognized or untreated, the effect on the neonate can be severe, including sepsis, pneumonia, or meningitis.

Syphilis

Prognosis depends on the stage to which the disease has progressed. Untreated infants may be asymptomatic, and if untreated may have seizures and die soon after birth.

Toxoplasmosis

The later in the pregnancy the infection is contracted, the better the chance of recovery. A chronic infection in which the mother is infected prior to pregnancy is less likely to be transmitted to the fetus. Fetal death may occur in about 10% of cases occurring in the first trimester of pregnancy. Fetal death is rare when the infection occurs in the third trimester. An acute infection is associated with premature birth and stillbirth. Spontaneous abortion is rare.

Health care team roles

Laboratory technicians and phlebotomists need to observe standard universal precautions in drawing and handling blood and other body fluids, as the complete infection status of a patient will not be known. This includes the use of gloves, eye protection such as a facemask or goggles, and personal protective clothing. Radiology technicians will be involved in ultrasound scanning to detect fetal compromise as a result of infection. Ultrasound-guided sampling of amniotic fluid or fetal tissue may be used to diagnose fetal infection. Through individual discussion, waiting room videos, and pamphlets, nurses can educate pregnant mothers during routine visits about ways to prevent infection by these agents. Nurses can play a significant role in emphasizing the need for retesting after treatment (when required) and discussing the importance of having the woman's sexual partner tested and treated to avoid reinfection.

Prevention

Chlamydia

When a woman has multiple partners, the use of condoms every time a woman has sexual intercourse can decrease the risk of becoming infected. Limiting the number of sexual partners also decreases the risk of chlamydial infection.

Cytomegalovirus

CMV can be shed in body fluids, so care must be taken when handling these substances. This includes the handling of diapers, especially in day care environments. Those working in a hospital environment should always observe universal precautions when handling any body fluid or secretion. Careful hand washing can decrease the risk of transmission. Since CMV is shed in cervical secretions, cesarean birth may decrease the risk of transmission, although infection during the first two trimesters of pregnancy carries the greatest fetal risk. Research is investigating the usefulness of a preconception vaccine.

Genital herpes

Cesarean delivery can substantially reduce disease transmission to the neonate. For mothers with genital herpes, delivery following premature rupture of membranes (PROM) should be considered, as the risk of disease transmission increases by six hours after PROM. If maternal HSV is suspected, a fetal scalp monitor should be avoided, as this creates a direct portal of entry for the infection.

Hepatitis B

The HBV vaccine is considered the best prevention. It is a series of three injections over seven months. It is not contraindicated in pregnancy. Use of latex condoms will help reduce the risk of transmission. Avoiding high-risk contact, such as contact with blood and other body fluids, will also lessen the risk of HBV. The CDC recommends that newborns born to HBV-infected mothers receive hepatitis B immune globulin after birth as well as the first dose of the vaccine within 12 hours postpartum.

Human immunodeficiency virus (HIV)

In the early 1990s, studies of ZDV used during pregnancy and given to the neonate for six weeks postpartum resulted in a 70% decrease in maternal HIV transmission to the infant. Cesarean birth also reduces transmission, as compared with vaginal birth. Knowledge of the mother's HIV status during pregnancy is therefore important in reducing the transmission risk. Testing for HIV status should be offered to all pregnant women. Avoidance of breast-feeding can also decrease the risk of transmission. If untreated, about 20-30% of infants born to HIV-positive women will be infected. Treatment with ZDV and avoidance of breast-feeding has been reported to lower transmission to about 2-3%. In 1999, a Ugandan study reported that a single dose of nevirapine given to infected mothers during labor in addition to a single dose given to the neonate within three days of birth cut the transmission rate in half, as compared with those treated with AZT throughout pregnancy and during the first six weeks of life.

Human papillomavirus

Use of a condom and limiting the number of sexual partners decreases the risk of contracting the disease.

Rubella

Women in childbearing age should have a titer draw to test for immune status. If they have not been exposed to rubella, they can be vaccinated against the disease, but should not become pregnant for three months following the vaccination, due to potential devastating effects on the fetus.

Streptococcus

Prevention of transmission of GBS from the mother to the infant can be enhanced by careful monitoring of the mother during labor for potential signs of infection such as fever, urinary tract infection, or PROM before 37 weeks or 18 hours or more before delivery. Treating the mother with IV antibiotics during labor limits the risk of transmission.

Syphilis

Use of a latex condom can reduce the risk of contracting the disease. However, the condom may not cover the area of infection. A blood test is the best way of finding out if one has syphilis, as the sores may be in hidden areas.

KEY TERMS

Lymphadenopathy— A disorder affecting the lymph nodes or lymphatic vessels.

Perinatal— The time during pregnancy, delivery, and until about one month postpartum.

Sexually transmitted diseases (STDs)— Those diseases transmitted from one individual to another during sexual interaction. They may also be referred to as venereal diseases.

Teratogenic— Tending to produce irregularities of formation.

Vertical transmission— The transmission of a disease or condition from one generation to the next, either through genetics, through the uterine environment, or through the breast milk.

Toxoplasmosis

Prevention of infection through cat feces is best done by having someone other than the mother clean the cat litter, and to avoid inhalation of airborne oocytes. If this is not possible, cat litter should be changed daily, as spores develop in one to five days in the litter. Cats become infected by eating contaminated wildlife, so keeping the cat completely indoors significantly reduces the risk of contagion. Infection through meat can be avoided by avoiding raw meat and by cooking meat to at least 159 °F (71 °C). Garden soil can be contaminated, so the use of gloves when gardening with thorough hand washing afterwards can decrease infection. Outdoor sandboxes should be covered to avoid contamination by stray cats.

Resources

BOOKS

Burrow, Gerard N. and Thomas P. Duffy. Medical Complications during Pregnancy, 5th Edition. Philadelphia: W. B. Saunders Company, 1999.

Chin, James, ed. Control of Communicable Diseases Manual. Washington, DC: American Public Health Association, 2000.

Scott, James. Danforth's Obstetrics and Gynecology, 8th ed. Philadelphia: Lippincott Williams & Wilkins, 1999.

ORGANIZATIONS

Centers for Disease Control. 〈http://www.cdc.gov〉.

Perinatal infection

Definition

An infection caused by a bacteria or virus that can be passed from a mother to her baby during pregnancy or delivery is called a perinatal infection.

Description

Perinatal infections include bacterial or viral illnesses that can be passed from a mother to her baby either while the baby is still in the uterus or during the delivery process. Maternal infection can, in some cases, cause complications at birth. The mother may or may not experience active symptoms of the infection during the pregnancy. Some perinatal infections are sexually transmitted.

Transmission

Transmission of many perinatal infections occurs during childbirth , particularly in cases when invasive techniques such as episiotomy or artificial rupture of membranes are employed. In other cases, transmission may occur during pregnancy, if the infectious agent can cross the placental barrier, and it may occur during breastfeeding, if the infectious agent can be found in breast milk.

Demographics

The incidence of perinatal infection depends on the causative agent of infection. For example, perinatal transmission of cytomegalovirus occurs in two to 24 out of every 1,000 live births. The rate of transmission of genital herpes during pregnancy is one to two out of every 2,000 pregnancies; the rate of transmission during childbirth changes to one out of every 2,000 to 5,000 live births. Perinatal transmission of group beta streptococcus causes neonatal infection in one to five out of every 1,000 live births, and rubella (German measles ), 0.02 out of every 1,000 live births. HIV is transmitted from untreated mother to child in 25 to 40 percent of cases, but in only 1 percent of cases if mother receives treatment and the infant receives prophylaxis.

Causes and symptoms

The following represent some of the more common infections that can be transmitted perinatally.

Chlamydia

The bacterium Chlamydia trachomatis is the cause of the most common bacterial sexually transmitted disease in the United States, causing more than 4 million infections each year. The majority of women with chlamydial infection experience no obvious symptoms. The infection affects the reproductive tract and causes pelvic inflammatory disease, infertility, and ectopic pregnancy (when the fertilized egg implants somewhere other than in the uterus). This infection can cause premature rupture of the membranes and early labor. It can be passed to the infant during delivery and can cause ophthalmia neonatorum (an eye infection) within the first month of life and pneumonia within one to three months of age. Symptoms of chlamydial pneumonia are a repetitive cough and rapid breathing. Wheezing is rare and the infant is usually without a fever .

Cytomegalovirus

Cytomegalovirus (CMV) is a common virus in the herpes virus family. It is found in saliva, urine, and other body fluids and can be spread through sexual contact or other more casual forms of physical contact such as kissing. In adults, CMV may cause mild symptoms of swollen lymph glands, fever, and fatigue. Many people who carry the virus experience no symptoms at all. Infants can become infected with CMV while still in the uterus if the mother becomes infected or develops a recurrence of the infection during pregnancy. Although most infants exposed to CMV before birth develop normally and do not show any symptoms, as many as 6,000 infants who were exposed to CMV before birth are born with serious complications each year. CMV interferes with normal fetal development and can cause mental retardation , blindness, deafness, or epilepsy in these infants.

Genital herpes

Genital herpes, which is usually caused by herpes simplex virus type 2 (HSV-2), is a sexually transmitted disease that causes painful sores on the genitals. Women who have their first outbreak of genital herpes during pregnancy are at high risk of miscarriage or delivering a low birth weight baby. The infection can be passed to the infant at the time of delivery if the mother has an active sore. The most serious risk to the infant is the possibility of developing HSV-2 encephalitis , an inflammation of the brain, with symptoms of irritability and poor feeding.

Hepatitis B

Hepatitis B is a contagious virus that causes liver damage and is a leading cause of chronic liver disease and cirrhosis. Approximately 20,000 infants are born each year to mothers who test positive for the hepatitis B virus. These infants are at high risk for developing hepatitis B infection through exposure to their mothers blood during delivery.

Human immunodeficiency virus (HIV)

Human immunodeficiency virus (HIV) is a serious, contagious virus that causes acquired immunodeficiency syndrome (AIDS ). About 25 to 40 percent of untreated pregnant women pass the infection on to their newborn infants, while only 1 percent of treated pregnant women transmit the virus. There are often no symptoms of HIV in infants, but within a few months most infants who are infected show signs of opportunistic infections such as failure to thrive , chronic thrush, and persistent diarrhea .

Human papillomavirus

Human papillomavirus (HPV) is a sexually transmitted disease that causes genital warts and can increase the risk of developing some cancers. HPV appears to be transferred from the mother to the infant during the birth process and can cause tracheal narrowing due to lesions (warts) from the virus.

Rubella (German measles)

Rubella is a virus that causes German measles, an illness that includes rash, fever, and symptoms of an upper respiratory tract infection. Most people are exposed to rubella during childhood and develop antibodies to the virus so they never get it again. Rubella infection during early pregnancy can pass through the placenta to the developing infant and cause serious birth defects, including heart abnormalities, mental retardation, blindness, and deafness.

Group beta streptococcus

Group beta streptococcus (GBS) infection is the most common bacterial cause of infection and death in newborn infants. Although rates have declined in the United States since the introduction of antibiotics to at-risk women during labor in the 1980s, about 1,600 cases and 80 newborn deaths still occur each year. In women, GBS can cause vaginitis and urinary tract infections. Both infections can cause premature birth, and the bacteria can be transferred to the infant in the uterus or during delivery. GBS causes pneumonia, meningitis , and other serious infections in infants.

Syphilis

Syphilis is a sexually transmitted bacterial infection that can be transferred from a mother to an infant through the placenta before birth. Up to 50 percent of infants born to mothers with syphilis are premature or stillborn or die shortly after birth. Infected infants may have severe birth defects. Those infants who survive infancy may develop symptoms of syphilis up to two years later.

When to call the doctor

Pregnant women who exhibit symptoms of infection should contact their healthcare provider to determine if the infection can be passed vertically to the child during pregnancy, childbirth, and/or breastfeeding. In some cases, early detection and treatment of infection can minimize the risk of perinatal transmission.

Diagnosis

How a bacterial or viral infection is diagnosed depends on the causative agent. Examples include the following:

• Chlamydia can be diagnosed by taking a cotton swab sample of the cervix and vagina during the third trimester of the pregnancy. Chlamydial cell cultures take three to seven days to grow. DNA probes are available for more rapid diagnosis.
• Past or recent infection with cytomegalovirus (CMV) can be identified by antibody tests and CMV can be grown from body fluids.
• Genital herpes is suspected with the outbreak of a particular kind of genital sore. The sore can be cultured and tested to confirm that HSV-2 is present.
• Hepatitis B can be identified through a blood test for the hepatitis B surface antigen (HBsAg) in pregnant women. The test is part of prenatal health programs.
• Human immunodeficiency virus (HIV) can be detected using a blood test and is part of most prenatal screening programs.
• Human papillomavirus (HPV) causes the growth of warts in the genital area. The wart tissue can be removed with a scalpel and tested to determine what type of HPV virus caused the infection.
• Pregnant women are usually tested for antibodies to rubella, which would indicate that they have been previously exposed to the virus and, therefore, would not develop infection during pregnancy if exposed.
• Group beta streptococcus (GBS) can be detected by a vaginal or rectal swab culture and sometimes from a urine culture. Blood tests can be used to confirm GBS infection in infants who exhibit symptoms.
• Pregnant women are usually tested for syphilis as part of the prenatal screening, generally with a blood test.

Treatment

Methods of treating some of the more common causes of perinatal infection include:

• Chlamydia: Pregnant women can be treated during the third trimester with oral erythromycin, for seven to 14 days depending on the dose used. Newborn infants can be treated with erythromycin liquid for ten to 14 days at a dosage determined by their body weight.
• Cytomegalovirus (CMV): No drugs or vaccines were as of 2004 available for prevention or treatment of CMV except in immunocompromised persons.
• Genital herpes: The antiviral drugs acyclovir or famciclovir can be administered to the mother during pregnancy. Little is known about the risks of these drugs to the fetus; however, the risk of birth defects does not seem to be any higher than for women who do not take these medications. Infants with suspected HSV-2 can be treated with acyclovir. Delivery of the infant by cesarean section is recommended if the mother has an active case of genital herpes.
• Hepatitis B: Infants born to mothers who test positive to the HBsAg test should be treated with hepatitis B immune globulin at birth to give them immediate protection against developing hepatitis B. All infants should also receive a series of three hepatitis B vaccine injections as part of their routine immunizations.
• Human immunodeficiency virus (HIV): Recent studies have shown that prenatal care and HIV testing before delivery are major opportunities for preventing perinatal HIV infection . Pregnant women with HIV should be treated as early in the pregnancy as possible with zidovudine (AZT). Other newer drugs designed to treat HIV/AIDS also may be used during pregnancy with the knowledge that these drugs may have unknown effects on the infant. Infants born with HIV should receive aggressive drug treatment to prevent development of AIDS. Most of the drugs designed to treat HIV are routinely used during pregnancy because of the mother's health needs and because transmission rate is directly related to the mother's viral load. Teratogenicity is not fully established for some of the subsequent HIV medications.
• Human papillomavirus: Genital warts are very difficult to treat and frequently recur even after treatment. They can be removed by cryotherapy (freezing), laser or electrocauterization (burning), or surgical excision (cutting). Some medications (imiquimod 5% cream, podophyllin, trichloroacetic acid, or topical 5-fluorouracil) can be applied to help dissolve genital warts. Cesarean delivery rather than vaginal delivery reduces the risk of transmission of HPV from mothers to infants.
• Rubella (German measles): No treatment is available. Some healthcare providers may recommend giving the mother an injection of immune globulin (to boost the immune system to fight off the virus) if she is exposed to rubella early in the pregnancy. However, no evidence to support the use of these injections existed as of 2004. Exposure to rubella early in pregnancy poses a high risk that the infant will have serious birth defects. Termination of the pregnancy may be considered. Women who have not been previously exposed to rubella are usually vaccinated immediately after the first pregnancy to protect infants of future pregnancies.
• Group beta streptococcus (GBS): Pregnant women diagnosed with GBS late in the pregnancy should be treated with antibiotics injected intravenously to prevent premature labor. In 2003, the Centers for Disease Control and Prevention (CDC) issued revised guidelines for preventing perinatal GBS disease. They began recommending that women not only be tested as soon as they learn of their pregnancy, but again at 35 to 37 weeks of gestation. The CDC also recommended updated prophylaxis regimens for women with penicillin allergies , as well as other guidelines for patients with threatened preterm deliveries and other recommendations. If transmission of GBS to the newborn infant already is suspected or if the baby develops symptoms of infection, infants often are treated with antibiotics.
• Syphilis: Antibiotic therapy, usually penicillin, given early in the pregnancy can be used to treat the infection and may prevent transmission to the infant.

Prognosis

The prognosis of a neonate who has contracted an infection perinatally depends on the specific infection. Examples include the following:

• Chlamydia: Without treatment, the most serious consequences of chlamydial infection are related to complications of premature delivery. Treatment of the mother with antibiotics during the third trimester can prevent premature delivery and the transfer of the infection to the baby. Infants treated with antibiotics for eye infection or pneumonia generally recover.
• Cytomegalovirus: The chance for recovery after exposure to CMV is very good for both the mother and the infant. Exposure to CMV can be serious and even life threatening for mothers and infants whose immune systems are compromised, for example, those receiving chemotherapy or who have HIV/AIDS. Those infants who develop birth defects after CMV exposure may have serious, lifelong complications.
• Genital herpes: Once a woman or infant is infected, outbreaks of genital herpes sores can recur at any point during their lifetimes.
• Hepatitis B: Infants treated at birth with immune globulin and the series of vaccinations are protected from development of hepatitis B infection. Infants infected with hepatitis B develop a chronic, mild form of hepatitis and are at increased risk for developing liver disease.
• Human immunodeficiency virus (HIV): A combination of treatment with highly active antiretroviral therapy during pregnancy, zidovudine (AZT) during delivery, and AZT to the baby for six weeks after birth significantly reduces the chance that the infant will be infected with HIV from the mother.
• Human papillomavirus: Once infected with HPV, there is a lifelong risk of developing warts and an increased risk of some cancers.
• Rubella (German measles): Infants exposed to rubella virus in the uterus are at high risk for severe birth defects, including heart defects, blindness, and deafness.
• Streptococcus: Infection of the urinary tract or genital tract of pregnant women can cause premature birth. Infants infected with GBS can develop serious, life-threatening infections.
• Syphilis: Premature birth, birth defects, or the development of serious syphilis symptoms is likely to occur in untreated pregnant women.

Prevention

Use of a barrier method of contraceptive (e.g. condom ) can prevent transmission of some sexually transmitted infections during intercourse. Intravenous drug use and sexual intercourse with infected partners increase the risks of exposure to most of these infections. Pregnant women can be tested for many of the bacterial or viral infections described; however, effective treatment may not be available to protect the infant.

In some cases, the method of childbirth may impact the chance of passing an infection from mother to child. For instance, research has shown that delivering a baby by caesarian section over vaginal delivery reduces the risk of transmitting HIV from mother to child.

Nutritional concerns

A woman's nutritional status may contribute to her ability to fight off infections, particularly in cases of malnutrition . A well-balanced diet rich in nutrients such as folic acid , calcium, iron, zinc, vitamin D, and the B vitamins is recommended for pregnant women. Mothers are recommended to eat approximately 300 additional calories day (above and beyond a normal nonpregnancy diet) to support the fetus's growth and development.

KEY TERMS

Cesarean section —Delivery of a baby through an incision in the mother's abdomen instead of through the vagina; also called a c-section, cesarean birth, or cesarean delivery.

Ectopic pregnancy —A pregnancy that develops outside of the mother's uterus, such as in the fallopian tube. Ectopic pregnancies often cause severe pain in the lower abdomen and are potentially life-threatening because of the massive blood loss that may occur as the developing embryo/fetus ruptures and damages the tissues in which it has implanted.

Encephalitis —Inflammation of the brain, usually caused by a virus. The inflammation may interfere with normal brain function and may cause seizures, sleepiness, confusion, personality changes, weakness in one or more parts of the body, and even coma.

Episiotomy —An incision made in the perineum (the area between the vulva and the anus) during labor to assist in delivery and to avoid abnormal tearing of the perineum.

Perinatal —Referring to the period of time surrounding an infant's birth, from the last two months of pregnancy through the first 28 days of life.

Pneumonia —An infection in which the lungs become inflamed. It can be caused by nearly any class of organism known to cause human infections, including bacteria, viruses, fungi, and parasites.

Parental concerns

Minimizing the risk of transmitting a maternal infection to a fetus is often a major concern for parents. The first step is identifying possible maternal infections. Proper prenatal care in many cases allows for early diagnosis and thus early treatment of certain infections, thus improving the newborn's prognosis.

Resources

BOOKS

Ford-Jones, E. Lee, and Greg Ryan. "Implications for the Fetus of Maternal Infections in Pregnancy." In Infectious Diseases, 2nd ed. Edited by Jonathan Cohen et all. New York: Mosby, 2004.

PERIODICALS

Cline, Matthew K., Chasse Bailey-Dorton, and Maria Cayelli. "Update in Maternity Care: Maternal Infections." Clinics in Office Practice 27, no. 1 (March 2000): 13–33.

Goldenberg, Robert L. "The Plausibility of Micronutrient Deficiency in Relationship to Perinatal Infection." The Journal of Nutrition (May 2003): 1645S.

Morantz, Carrie A. "CDC Updates Guidelines for Prevention of Perinatal Group B Streptococcal Disease." American Family Physician (March 1, 2003): 1121.

Peters, Vicki, et al. "Missed Opportunities for Perinatal HIV Prevention Among HIV-exposed Infants Born 1996–2000, Pediatric Spectrum of HIV Disease Cohort." Pediatrics (May 2003): S1186.

ORGANIZATIONS

American College of Obstetricians and Gynecologists. 409 12th St., SW, PO Box 96920, Washington, DC 20090–6920. Web site: <www.acog.com>.

March of Dimes Birth Defects Foundation. 1275 Mamaroneck Ave., White Plains, NY 10605. Web site: <www.marchofdimes.com>.

WEB SITES

Alter, Sherman. "Herpes Simplex Virus Infection." eMedicine, August 11, 2004. Available online at <www.emedicine.com/ped/topic995.htm> (accessed January 16, 2005).

Frye, Richard E., and Delia M. Rivera-Hernandez. "Human Immunodeficiency Virus Infection." eMedicine, December 14, 2004. Available online at <www.emedicine.com/ped/topic1027.htm>.

Kessler, Alexander T., and Athena P. Kourtis. "Hepatitis B." eMedicine, August 16, 2004. Available online at <www.emedicine.com/ped/topic978.htm> (accessed January 16, 2005).

Schleiss, Mark R. "Cytomegalovirus Infection." eMedicine, December 1, 2004. Available online at <www.emedicine.com/ped/topic544.htm> (accessed January 16, 2005).

Altha Roberts Edgren Teresa G. Odle Stephanie Dionne Sherk

Perinatal Infection

Definition

An infection caused by a bacteria or virus that can be passed from a mother to her baby during pregnancy or delivery is called a perinatal infection.

Description

Perinatal infections include bacterial or viral illnesses that can be passed from a mother to her baby either while the baby is still in the uterus, during the delivery process, or shortly after birth. Maternal infection can, in some cases, cause complications at birth. The mother may or may not experience active symptoms of the infection during the pregnancy. The most serious and most common perinatal infections, and the impact of these diseases on the mother and infant, are discussed below in alphabetical order. It is important to note that men can become infected and can transmit many of these infections to other women. The sexual partners of women who have these infections also should seek medical treatment.

Causes and symptoms

Chlamydia

Chlamydia trachomatis is the most common bacterial sexually transmitted disease in the United States, causing more than 4 million infections each year. The majority of women with chlamydial infection experience no obvious symptoms. The infection affects the reproductive tract and causes pelvic inflammatory disease, infertility, and ectopic pregnancy (the fertilized egg implants somewhere other than in the uterus). This infection can cause premature rupture of the membranes and early labor. It can be passed to the infant during delivery and can cause ophthalmia neonatorum (an eye infection) within the first month of life and pneumonia within one to three months of age. Symptoms of chlamydial pneumonia are a repetitive cough and rapid breathing. Wheezing is rare and the infant does not develop a fever.

Cytomegalovirus

Cytomegalovirus (CMV) is a common virus in the herpes virus family. It is found in saliva, urine, and other body fluids and can be spread through sexual contact or other more casual forms of physical contact like kissing. In adults, CMV may cause mild symptoms of swollen lymph glands, fever, and fatigue. Many people who carry the virus experience no symptoms at all. Infants can become infected with CMV while still in the uterus if the mother becomes infected or develops a recurrence of the infection during pregnancy. Most infants exposed to CMV before birth develop normally and do not show any symptoms. As many as 6,000 infants who were exposed to CMV before birth are born with serious complications each year. CMV interferes with normal fetal development and can cause mental retardation, blindness, deafness, or epilepsy in these infants.

Genital herpes

Genital herpes, which is usually caused by herpes simplex virus type 2 (HSV-2), is a sexually transmitted disease that causes painful sores on the genitals. Women who have their first outbreak of genital herpes during pregnancy are at high risk of miscarriage or delivering a low birth weight baby. The infection can be passed to the infant at the time of delivery if the mother has an active sore. The most serious risk to the infant is the possibility of developing HSV-2 encephalitis, an inflammation of the brain, with symptoms of irritability and poor feeding.

Hepatitis B

Hepatitis B is a contagious virus that causes liver damage and is a leading cause of chronic liver disease and cirrhosis. Approximately 20,000 infants are born each year to mothers who test positive for the hepatitis B virus. These infants are at high risk for developing hepatitis B infection through exposure to their mothers blood during delivery.

Human immunodeficiency virus (HIV)

Human immunodeficiency virus (HIV) is a serious, contagious virus that causes acquired immunodeficiency syndrome (AIDS ). About one-fourth of pregnant women with HIV pass the infection on to their newborn infants. An infant with HIV usually develops AIDS and dies before the age of two.

Human papillomavirus

Human papillomavirus (HPV) is a sexually transmitted disease that causes genital warts and can increase the risk of developing some cancers. HPV appears to be transferred from the mother to the infant during the birth process.

Rubella (German measles)

Rubella is a virus that causes German measles, an illness that includes rash, fever, and symptoms of an upper respiratory tract infection. Most people are exposed to rubella during childhood and develop antibodies to the virus so they will never get it again. Rubella infection during early pregnancy can pass through the placenta to the developing infant and cause serious birth defects including heart abnormalities, mental retardation, blindness, and deafness.

Streptococcus

Group B streptococcus (GBS) infection is the most common bacterial cause of infection and death in newborn infants. Although rates have declined in the United States since the introduction of antibiotics to at-risk women during labor in the 1980s, about 1,600 cases and 80 newborn deaths still occur each year. In women, GBS can cause vaginitis and urinary tract infections. Both infections can cause premature birth and the bacteria can be transferred to the infant in the uterus or during delivery. GBS causes pneumonia, meningitis, and other serious infections in infants.

Syphilis

Syphilis is a sexually transmitted bacterial infection that can be transferred from a mother to an infant through the placenta before birth. Up to 50% of infants born to mothers with syphilis will be premature, stillborn, or will die shortly after birth. Infected infants may have severe birth defects. Those infants who survive infancy may develop symptoms of syphilis up to two years later.

Diagnosis

Chlamydia

Chlamydial bacteria can be diagnosed by taking a cotton swab sample of the cervix and vagina during the third trimester of the pregnancy. Chlamydial cell cultures take three to seven days to grow but many laboratories are not equipped to run the tests necessary to confirm the diagnosis.

Cytomegalovirus

Past or recent infection with CMV can be identified by antibody tests and CMV can be grown from body fluids.

Genital herpes

The appearance of a genital sore is enough to suspect an outbreak of genital herpes. The sore can be cultured and tested to confirm that HSV-2 is present.

Hepatitis B

A blood test can be used to screen pregnant women for the hepatitis B surface antigen (HBsAg) in prenatal health programs.

Human immunodeficiency virus (HIV)

HIV can be detected using a blood test and is part of most prenatal screening programs.

Human papillomavirus

HPV causes the growth of warts in the genital area. The wart tissue can be removed with a scalpel and tested to determine what type of HPV virus caused the infection.

Rubella (German measles)

Pregnant women are usually tested for antibodies to rubella, which would indicate that they have been previously exposed to the virus and therefore would not develop infection during pregnancy if exposed.

Streptococcus

GBS can be detected by a vaginal or rectal swab culture, and sometimes from a urine culture. Blood tests can be used to confirm GBS infection in infants who exhibit symptoms.

Syphilis

Pregnant women are usually tested for syphilis as part of the prenatal screening.

Treatment

Chlamydia

Pregnant women can be treated during the third trimester with oral erythromycin, for seven-14 days depending on the dose used. Newborn infants can be treated with erythromycin liquid for 10-14 days at a dosage determined by their body weight.

Cytomegalovirus

No drugs or vaccines are currently available for prevention or treatment of CMV.

Genital herpes

The antiviral drugs acyclovir or famciclovir can be administered to the mother during pregnancy. Little is known about the risks of these drugs to the fetus, however, the risk of birth defects does not seem to be any higher than for women who do not take these medications. Infants with suspected HSV-2 can be treated with acyclovir. Delivery of the infant by cesarean section is recommended if the mother has an active case of genital herpes.

Hepatitis B

Infants born to mothers who test positive to the HBsAg test should be treated with hepatitis B immune globulin at birth to give them immediate protection against developing hepatitis B. These infants, as well as all infants, should also receive a series of three hepatitis B vaccine injections as part of their routine immunizations.

Human immunodeficiency virus (HIV)

Recent studies have shown that prenatal care and HIV testing before delivery are major opportunities to prevent perinatal HIV infection. Pregnant women with HIV should be treated as early in the pregnancy as possible with zidovudine (AZT). Other newer drugs designed to treat HIV/AIDS also may be used during pregnancy with the knowledge that these drugs may have unknown effects on the infant. The risks and benefits of such treatments need to be discussed. Infants born with HIV should receive aggressive drug treatment to prevent development of AIDS.

Human papillomavirus

Genital warts are very difficult to treat and frequently recur even after treatment. They can be removed by cryotherapy (freezing), laser or electrocauterization (burning), or surgical excision (cutting) of the warts. Some medications (imiquimod 5% cream, podophyllin, trichloroacetic acid or topical 5-fluorouracil) can be applied to help dissolve genital warts. Cesarean delivery rather than vaginal delivery seems to reduce the risk of transmission of HPV from mothers to infants.

Rubella (German measles)

No treatment is available. Some health care providers may recommend giving the mother an injection of immune globulin (to boost the immune system to fight off the virus) if she is exposed to rubella early in the pregnancy. However, no evidence to support the use of these injections exists. Exposure to rubella early in pregnancy poses a high risk that the infant will have serious birth defects. Termination of the pregnancy may be considered. Women who have not been previously exposed to rubella will usually be vaccinated immediately after the first pregnancy to protect infants of future pregnancies.

Streptococcus

Pregnant women diagnosed with GBS late in the pregnancy should be treated with antibiotics injected intravenously to prevent premature labor. In 2003, the Centers for Disease Control and Prevention (CDC) issued revised guidelines for preventing perinatal GBS disease. They began recommending that women not only be tested as soon as they learn of their pregnancy, but again at 35 to 37 weeks gestation. The CDC also recommended updated prophylaxis regimens for women with penicillin allergies, as well as new guidelines for patients with threatened preterm deliveries and other new recommendations. If transmission of GBS to the newborn infant already is suspected or if the baby develops symptoms of infection, infants often are treated with antibiotics.

Syphilis

Antibiotic therapy, usually penicillin, given early in the pregnancy can be used to treat the infection and may prevent transmission to the infant.

Prognosis

Chlamydia

Without treatment, the most serious consequences of chlamydial infection are related to complications of premature delivery. Treatment of the mother with antibiotics during the third trimester can prevent premature delivery and the transfer of the infection to the baby. Infants treated with antibiotics for eye infection or pneumonia generally recover.

Cytomegalovirus

The chance for recovery after exposure to CMV is very good for both the mother and the infant. Exposure to CMV can be serious and even life threatening for mothers and infants whose immune systems are compromised, for example those receiving chemotherapy or who have HIV/AIDS. Those infants who develop birth defects after CMV exposure may have serious, lifelong complications.

Genital herpes

Once a woman or infant is infected, outbreaks of genital herpes sores can recur at any point during their lifetimes.

Hepatitis B

Infants treated at birth with immune globulin and the series of vaccinations will be protected from development of hepatitis B infection. Infants infected with hepatitis B develop a chronic, mild form of hepatitis and are at increased risk for developing liver disease.

Human immunodeficiency virus (HIV)

Treatment with AZT during pregnancy significantly reduces the chance that the infant will be infected with HIV from the mother.

Human papillomavirus

Once infected with HPV, there is a lifelong risk of developing warts and an increased risk of some cancers.

Rubella (German measles)

Infants exposed to rubella virus in the uterus are at high risk for severe birth defects including heart defects, blindness, and deafness.

Streptococcus

Infection of the urinary tract or genital tract of pregnant women can cause premature birth. Infants infected with GBS can develop serious, life-threatening infections.

Syphilis

Premature birth, birth defects, or the development of serious syphilis symptoms is likely to occur in untreated pregnant women.

Prevention

Use of a barrier method of contraceptive (condom ) can prevent transmission of some of the infections. Intravenous drug use and sexual intercourse with infected partners increases the risks of exposure to most of these infections. Pregnant women can be tested for many of the bacterial or viral infections described; however, effective treatment may not be available to protect the infant. New studies show that a woman's nutritional status may contribute to her ability to fight off infections, particularly in cases of malnutrition. Proper prenatal care may improve outcomes and prevent some infections.

KEY TERMS

Cesarean section— A surgical procedure in which an incision is made in a woman's abdomen to deliver the infant from the uterus.

Ectopic pregnancy— A condition that ends in miscarriage, in which the fertilized ovum attaches somewhere other than in the uterus (for example in the fallopian tube or abdomen).

Encephalitis— Inflammation or swelling of the brain.

Perinatal— The period of time around the time of pregnancy and delivery.

Pneumonia— An infection and inflammation of the lungs that usually causes shortness of breath, cough, fever, and chest pain.

Resources

PERIODICALS

Goldenberg, Robert L. "The Plausibility of Micronutrient Deficiency in Relationship to Perinatal Infection." The Journal of Nutrition May 2003: 1645S.

Morantz, Carrie A. "CDC Updates Guidelines for Prevention of Perinatal Group B Streptococcal Disease." American Family Physician March 1, 2003: 1121.

Peters, Vicki, et al. "Missed Opportunities for Perinatal HIV Prevention Among HIV-exposed Infants Born 1996–2000, Pediatric Spectrum of HIV Disease Cohort." Pediatrics May 2003: S1186.