Perinatal infection resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

Synonyms and keywords: Neonatal infection; TORCH infection

Perinatal infection Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Dos
Don'ts

Overview

Most of the perinatal infections in the neonate are bacterial. These infections may be acquired from the mother prior to or at birth or from environmental sources. Premature babies are prone to perinatal infections. Neonates, especially those born prematurely have very limited ability to express symptoms, so, even minor deviations from normal behaviour should suggest bacterial disease. Chronic congenital and perinatal infections are usually asymptomatic in mother and neonate and may remain latent or sub-clinically active in host tissue for prolonged time.It may cause insidious injury to the central nervous and perceptual systems. When noticeable, these infections almost invariably cause mental or perceptual handicaps or both. Cytomegalovirus is the most common cause of congenital infections and the fetal effects of primary maternal infection during gestation can be devastating.Perinatal infection occurring in the 1st few days to 14 days occurs due to contact with the pathogens present in the cervico-vaginal canal during delivery. causes are Escherichia coli, Group B beta haemolytic Streptococci,Gonococci, Listeria monocytogenes ,Bacteroides species, Candida albicans, Cytomegalo virus,Herpes Simplex Virus Type-2.The mortality and morbidity associated with either acute or chronic infections is quite high. So, appropriate diagnosis and treatment is required and should be aggressive.

Causes

Perinatal infection occurring in the 1st few days to 14 days occurs due to contact with the pathogens present in the cervico-vaginal canal during delivery. causes are

• Escherichia coli
• Group B beta haemolytic Streptococci
• Gonococci
• Listeria monocytogenes
• Bacteroides species
• Candida albicans
• Cytomegalo virus
• Herpes Simplex Virus Type-2

Perinatal infections that occurs late, usually 3 to 6 weeks after birth are caused by environmental pathogens. Causes are

• Klebsiella
• Aerobacter
• Proteus species
• Staphylococcus aureus
• Haemophilus influenzae
• Pseudomonas aeruginosa
• Coxsackie B virus
• Candida albicans
• Echovirus
• Influenza virus
• Parainfluenzae virus
• Respiratory syncytial virus

Several vertically transmitted infections are included in the TORCH complex:

1. T – toxoplasmosis from Toxoplasma gondii
2. O – other infections (see below)
3. R – rubella
4. C – cytomegalovirus
5. H – herpes simplex virus-2 or neonatal herpes simplex

Other infections include:

• Parvovirus B19
• Coxsackievirus
• Chickenpox (caused by varicella zoster virus)
• Chlamydia infection
• HIV
• Human T-lymphotropic virus
• Syphilis
• Zika fever, caused by Zika virus, can cause microcephaly and other brain defects in the child.
• Hepatitis B

Treatment

Disease	Medical Therapy	Surgery	Prevention
Toxoplasmosis	❑ Mother: Immediate administration of Spiramycin ❑ Fetus and Newborn: Pyrimethamine, Sulfadiazine, and folinic acid.||		❑ Pregnant mother should avoid eating raw, undercooked, and cured meats. ❑ Pregnant mother should avoid contact with cat litter. ❑ Wash hands more frequently, especially after touching soil gardening.
Rubella	❑ Intrauterine rubella infection > 16 weeks: Reassurance. ❑ Congenital rubella syndrome: Supportive care and surveillance. ❑ Live, attenuated rubella vaccine is contraindicated during pregnancy		❑ Immunization of seronegative women before pregnancy. ❑ Nationally notifiable condition: Suspected congenital rubella syndrome must be reported to the local or state health department.
Cytomegalovirus	❑ Fetus: Severe anemia: Intrauterine blood transfusions Thrombocytopenia: Platelet transfusions ❑ Newborn: Supportive therapy of symptoms,Ganciclovir, Valganciclovir, or Foscarnet ❑ Mother: Valacyclovir.		❑ Frequent hand washing. ❑ Pregnant women with risk factors for TORCH infection should avoid potentially contaminated workplaces such as schools, paediatric clinics.
Herpesvirus	❑ Acyclovir 400 mg tablets 3 times daily OR ❑ Acyclovir 200 mg tablets 4 times a day from week 36 until delivery, and viral cultures on cervical-vaginal secretions from 36th week of gestation are required. ❑ Valacyclovir at a dose of 200 mg 2 times a day.		❑ Antiviral therapy (Acyclovir) beginning at 36 weeks of gestation for individuals with a known history of HSV lesions. ❑ Cesarean section in women with active genital lesions or prodromal symptoms such as burning pain.
Parvovirus	❑ Intrauterine fetal blood transfusion in cases of severe fetal anemia.		❑ Hand hygiene (frequent hand washing). ❑ Pregnant women with risk factors for TORCH infection should avoid potentially contaminated workplaces such as schools, paediatric clinics.
Acquired immunodeficiency syndrome (AIDS)	❑ Mother: The US Public Health Servicepublished recommendations for the use of ZDV or AZT to reduce the risk of HIV transmission from infected women to their infants as a result of the AIDS Clinical Trials Group (ACTG) which includes: Antepartum: ZDV, 100 mg orally five times per day, starting at 14–34 weeks. Intrapartum: ZDV, 2 mg/kg intravenously (IV), loading dose, given over 1 hour, followed by 1 mg/kg/hr IV until delivery. ❑ Newborn: ZDV syrup 2 mg/kg orally every 6 hours, beginning 8–12 hours after birth for the first 6 weeks of life	❑ A scheduled cesarean section can reduce vertical transmission to 2%. It is unclear if there is a significant benefit from cesarean delivery in patients who have viral loads of less than 1000 copies/ml who are on HAART.❑ Maternal morbidity is greater with cesarean delivery, particularly in those women with low CD4 cell counts. Therefore, women who are HIV positive must be counseled about the maternal risks and potential benefits of both ZDV prophylaxis and cesarean delivery so that they can make informed choices. ❑ If cesarean delivery is chosen, it should be performed electively at 38 weeks of gestation. ZDV should begin 3 hours prior to delivery. It is important to use perioperative prophylactic antibiotics to reduce maternal infectious morbidity. ❑ The management of labor should include avoidance of scalp electrodes and scalp sampling.	❑ The newborn should be carefully cleaned off maternal blood and secretions. ❑ Breastfeeding is not recommended when there is a suitable alternative. ❑ Even if she is asymptomatic after delivery, she will require support and surveillance for disease progression.
Varicella zoster virus	Pregnant women or newborns with (severe) infection: Acyclovir Administer postexposure prophylaxis in newborns if mother displays symptoms of varicella up to 7 days before delivery or up to 28 days after delivery: IgG antibodies (varicella-zoster immune globulin, VZIG)		Immunization of seronegative women of child breeding age before pregnancy. VZIG in pregnant women without immunity within 10 days of exposure.
Hepatitis			Hepatitis A: ❑ Maintain hygienic practices such as hand washing with safe water, particularly before handling food, avoiding drinking water or using ice cubes of unknown purity, and avoiding eating unpeeled fruits and vegetables. ❑ The HAV vaccine is safe and develops protective levels of antibodies 2 weeks after the first dose of the vaccine and persists at least 10 to 29 years, if not lifelong after receiving the second dose. So, it should be administered before travelling to endemic areas. Hepatitis B: ❑ Testing for HBV surface antigen is recommended as a part of routine prenatal testing. ❑ Infants born to HBV-positive mothers should receive 0.5 mL of hepatitis B immune globulin within 12 hours of birth and simultaneously receive the first dose of HBV vaccine (half the adult dose). The remaining doses should follow the adult schedule. Complete immunization requires the initial dose with repeated doses at 1 and 6 months. Hepatitis C: ❑ At present, no vaccine is available for HCV .
Influenza	❑ Prompt antiviral therapy should be given where the medications reduce the risk of complications in pregnant women and reduce the teratogenic effects of the influenza infection. ❑ Trans placental transfer of oseltamivir to fetus may occur. But there is no evidence of adverse fetal outcomes as of now.		Vaccination is the most effective strategy for preventing influenza infection during pregnancy whereby can protect both mother and the fetus.
Group B streptococci	❑ Intravenous penicillin G is the treatment of choice for intrapartum antibiotic prophylaxis against Group B Streptococci. ❑ Penicillin G 5 million units intravenous is administered as a loading dose, followed by 2.5 to 3 million units every 4 hours during labor until delivery. ❑ Ampicillin is a reasonable alternative to penicillin G, which is administered as a 2 gm intravenous loading dose followed by 1 gm intravenous every 4 hours during labor until delivery. ❑ Antibiotic prophylaxis in patients with a history of anaphylaxis, angioedema, respiratory distress, or urticaria following penicillin or cephalosporin is guided by antibiotic susceptibility testing. If GBS is sensitive to both clindamycin and erythromycin, then clindamycin 900 mg intravenous every 8 hours is recommended for GBS prophylaxis during labor until delivery. ❑ If the culture returns resistant to erythromycin, vancomycin 1 gm intravenously every 12 hours is recommended for GBS prophylaxis. ❑ If patient is penicillin allergic, vancomycin is the choice of treatment. ❑Cefazolin 2 gram intravenous loading dose followed by 1 gm every 8 hours may be used in patients without a history of anaphylaxis, angioedema, respiratory distress, or urticaria following penicillin or cephalosporin administration.		Initiating antibiotic prophylaxis greater than 4 hours before delivery is considered to be adequate antibiotic prophylaxis and is effective in the prevention of transmission of GBS to the fetus.
Listeriosis	IV ampicillin and gentamicin (for both mother and newborn)		*Avoidance of soft cheeses Avoidance of potentially contaminated water and food: See “Food and water safety” in food poisoning. Nationally notifiable condition: Listeriosis must be reported to the local or state health department.
Syphilis	Therapy is indicated in the gravida with a positive FTA-ABS of recent onset, and the drug of choice is penicillin. The regimen recommended is the same as in the nonpregnant woman. For early syphilis, a single dose of 2.4 million units of benzathine penicillin G is recommended. Some recommend a follow-up dose 1 week later, particularly in the third trimester. For late-stage syphilis (more than 1 year of duration), three doses are recommended. For the patient allergic to penicillin, treatment with penicillin after oral desensitization is recommended. This should be done in a facility that has appropriate provisions for resuscitation, if needed.		*Maternal screening in early pregnancy Nationally notifiable condition: Congenital syphilis and syphilitic childbirth must be reported to local or state health department.
Gonorrhea	current recommendations include one of the following regimens: Ceftriaxone, 125 mg IM, single dose Cefixime, 400 mg orally, single dose Spectinomycin, 2 g IM, single dose (for patients who cannot tolerate a cephalosporin). In addition, treatment for Chlamydia should be administered because of the likelihood of coinfection. Disseminated infection in the newborn requires high-dose treatment, and ophthalmic infection should be treated both locally and systemically.		Prevention of perinatal infection is best accomplished by careful maternal screening and treatment.
Chlamydia	❑ Recommended treatment : Erythromycin base, 500 mg,or erythromycin ethylsuccinate, 800 mg orally four times daily for 7 days Amoxicillin, 500 mg orally three times daily for 7 days Azithromycin, 1 g orally as a single dose		The question of maternal screening and prophylactic treatment to prevent neonatal infection is unsettled. As diagnostic studies have become more readily available, screening has become more practical. The decision to routinely screen a prenatal population should probably be based on a determination of the specific population prevalence.
Salmonella	❑ chloramphenicol ❑ Alternate antibiotics are ampicillin or amoxicillin ❑ Combination of trimethoprim and sulfamethoxazole is useful for resistant strains but avoided in pregnancy if possible. ❑ Aspirin should be avoided because patients with typhoid are extremely sensitive and severe hypothermia may occur.		❑ Sanitation and hygienic processes and the control of faulty food processing.
Trichomonas vaginalis			Vaginal trichomoniasis has adverse pregnancy outcomes, so metronidazole, 2 g orally as a single dose, can be given after the first trimester.
Malaria			❑ Pregnant woman who must travel to an endemic area should take Chloroquine phosphate, 500 mg once a week starting 1 week before the trip and continuing for 6 weeks. This is safe for pregnant women.
Zika virus			❑ Avoidance of travel to ZIKv endemic areas during pregnancy. ❑ The use of N,N-Diethyl-meta-toluamide, which has been recommended in pregnancy to prevent ZIKA infection. ❑ Long sleeves and pants or permethrin-treated clothing. ❑ Use of mosquito nets and window screens if living in or traveling to an endemic area. ❑ If the pregnant woman is living in an endemic area, areas of standing water such as tires, buckets, planters should be eliminated because they are a breeding area for mosquitoes. ❑ All pregnant women and their partners should receive counseling on prevention measures including avoidance of mosquito bites and sexual transmission. ❑ If a couple has a male partner and he travels to an area with ZIKA Virus, they should use condoms or abstain from sexual activity for 6 months (even if there is no symptoms). ❑ If a female travels to an area with risk of ZIKV, condoms or abstinence from sexual activity for 8 weeks (even in the absence of symptoms) is recommended. ❑ If a pregnant patient and her partner travel to or live in an area with Zika virus, condoms should be used each time the couple has sex for the remainder of pregnancy, or they should abstain from sexual activity.

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References

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