Perinatal infection resident survival guide

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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

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

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

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

Several vertically transmitted infections are included in the TORCH complex:[1]

  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:

Diagnosis

Shown below is an algorithm summarizing the diagnosis of [[disease name]] according the the [...] guidelines.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Disease Medical Therapy Surgery Prevention
Toxoplasmosis ❑ Mother:

Immediate administration of Spiramycin [2]

❑ Fetus and Newborn:

Pyrimethamine, Sulfadiazine, and folinic acid.[2]||

❑ 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

❑ Immunization of seronegative women before pregnancy.

❑ Nationally notifiable condition: Suspected congenital rubella syndrome must be reported to the local or state health department.[3]

Cytomegalovirus ❑ Fetus:

❑ Newborn:

❑ Mother:

❑ Frequent hand washing.

❑ Pregnant women with risk factors for TORCH infection should avoid potentially contaminated workplaces such as schools, paediatric clinics [4]

Herpesvirus ❑ Acyclovir & Supportive care Only for herpes simplex [5] ❑ 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.[6]

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.[7]

Acquired immunodeficiency syndrome (AIDS) ❑ Mother: The US Public Health Service[8] published 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 not yet known 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 (if the patient chooses this option) should include avoidance of scalp electrodes and scalp sampling.[9] ,[10] The newborn should be carefully cleaned of maternal blood and secretions. There is no evidence that the postpartum course is altered. The virus has been isolated from breast milk, and although the risk of transfer is not known, breastfeeding is not recommended when there is a suitable alternative, as exists in the developed world. A final step in the case of the HIV-infected patient is to see that the patient receives ongoing care. Even if she is asymptomatic after delivery, she will require support and surveillance for disease progression.[11] ,[12]
Varicella zoster virus pregnant women or newborns with (severe) infection: acyclovir

Administer postexposure prophylaxis in newborns if mother displays symptoms of varicella < 5 days before delivery: IgG antibodies (varicella-zoster immune globulin, VZIG)

Immunization of seronegative women before pregnancy

VZIG in pregnant women without immunity within 10 days of exposure.[13]

Hepatitis Hepatitis A:pregnant or not, who is exposed by contact or travel in endemic areas should receive immune serum globulin (0.02–0.05 mL/kg). If exposure is prolonged and close, the higher dose should be used and repeated every 4–6 months. [14] Hepatitis B: infants born to mothers with circulating HBV. These infants, if chronically infected, are at high long-term risk for hepatic cancer. Because of this and because it is possible to prevent perinatal transmission, particularly if infection occurs in late pregnancy, testing for HBV surface antigen is recommended as a part of routine prenatal testing. [15]. 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. There is no reason to modify the obstetric management because cesarean delivery will not modify the risk. The HBV vaccine now in use is a recombinant product, poses no infectious risk, and can be used in pregnancy for women at risk. Complete immunization requires the initial dose with repeated doses at 1 and 6 months. Healthcare workers should know their HBV immune status and, if susceptible, should be vaccinated. Hepatitis C: At present, no vaccine is available for HCV, and there are insufficient data to recommend pregnancy termination. The management of the pregnant woman infected with HCV must be individualized until further evidence is available to make reasonable recommendations.[16]
Influenza Prompt empiric treatment with appropriate neuraminidase inhibitors (oseltamivir and zanamivir) appeared to decrease the risk of severe disease. [17] Preterm delivery and cesarean delivery were commonly associated with maternal illness with preterm birth rates as high as 30% and cesarean section rates of nearly double the current national baseline.[18] Influenza vaccination is now an important component of antenatal care. The CDC recommends that women who will be pregnant during the flu season (October through mid May) be vaccinated. [19] Vaccination may be performed in all three trimesters. Specific vaccines prepared for epidemic strains are more effective than the poly antigenic preparations. Complications of vaccination are generally mild, except for Guillain-Barré syndrome. This is characterized by progressive ascending paralysis but fortunately is usually self-limited and reversible. Evidence from the swine flu epidemic of 1976 suggests that the incidence is approximately 1 in 100,000 vaccinations. The frequency of complications does not appear to be altered by pregnancy. The theoretical risks of vaccination are outweighed by its benefits.
Genital condylomata The treatment of choice for large-volume and symptomatic disease is the carbon dioxide (CO2) laser, [20] and it is suggested that treatment with it be carried out in the third trimester to reduce the chances of recurrence from latent HPV infection at the time of delivery. Interferons have been used successfully [21] but are not yet approved for clinical use.Trichloroacetic acid is the best choice for isolated or small-volume genital disease.[22] There is almost never a reason to perform a cesarean section for condylomata if the patient is seen sufficiently early in pregnancy to accomplish treatment.
Group B streptococci As stated earlier, penicillin is the drug of choice for GBS treatment and prophylaxis. Ampicillin is an acceptable alternative. Penicillin is preferred due to its narrow spectrum of activity. Five million units of penicillin G is given as the loading dose. This is followed with 2.5–3.0 million units every 4 hours until delivery. The dose of ampicillin is 2 g loading followed by 1 g every 4 hours. Increased resistance of GBS isolates to second-line therapies has been noted. Susceptibility testing should be ordered in patients who are allergic to penicillin. Cefazolin is recommended for patients that are not at high risk for anaphylaxis. Two grams are given intravenously followed by 1 g every 8 hours. If the patient is a high risk of anaphylaxis, treatment would depend on the susceptibility of the isolate. Clindamycin (900 mg IV every 8 hours). Erythromycin is no longer an acceptable alternative for penicillin allergic women at high risk for anaphylaxis. Patients at high risk of anaphylaxis with unknown susceptibility or resistance to clindamycin, should be treated with vancomycin. The dose of vancomycin is 1 g every 12 hours until delivery. It must be emphasized that vancomycin is reserved for patients at high risk for anaphylaxis.[23] Women with intact membranes who present with threatened preterm delivery and unknown GBS status should receive IAP until GBS culture results are available. If GBS is negative, or the patient is not in true labor, IAP may be discontinued and re-screening should be done at 35–37 weeks.[24]
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.[25]
Tuberculosis * recent converters should be treated with isoniazid, 300 mg/day, starting after the first trimester and continuing for 6–9 months. Women younger than 35 years of age with a positive PPD of unknown duration should receive isoniazid, 300 mg/day, for 6 months after delivery.
  • Patients with active disease should be started on treatment immediately on diagnosis, with dual-agent therapy for 9 months. Isoniazid 300 mg/day, combined with rifampin, 600 mg/day, is the standard. Ethambutol, 2.5 g/day, may be substituted in case of resistance. Pyridoxine (vitamin B6) supplementation, 50 mg/day, is essential for all patients receiving isoniazid. None of these medications are known to have adverse effects in pregnancy. Breastfeeding is considered safe during maternal treatment as long as the infant is not receiving antituberculous therapy. Infants born to women with active tuberculosis should receive isoniazid prophylaxis (10 mg/kg/day) until maternal disease has been inactive for 3 months. [26]
 Prophylaxis is not recommended for women older than 35 years of age in the absence of active disease because of concern about hepatotoxicity.
Syphilis Therapy is indicated in the gravida with a positive FTA-ABS of recent onset, and the drug of choice is penicillin. [27] 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. [28] *Maternal screening in early pregnancy
  • Nationally notifiable condition: Congenital syphilis and syphilitic childbirth must be reported to local or state health department.[29]
Gonorrhea current recommendations include one of the following regimens:

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.
Mycoplasmas The treatment for the pregnant woman and the neonate is clindamycin for Mycoplasma hominis and erythromycin for M. pneumoniae and Ureaplasma urealyticum. These associations have not been conclusively established, and, consequently, treatment should be used only if there is reasonable evidence for causality in a given situation.
Chlamydia ❑ Recommended treatment : 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. [30]
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. [31]

Do's

  • The content in this section is in bullet points.

Don'ts

  • The content in this section is in bullet points.

References

  1. ↑ Neu N, Duchon J, Zachariah P (2015). "TORCH infections". Clin Perinatol. 42 (1): 77–103, viii. doi:10.1016/j.clp.2014.11.001. PMID 25677998.
  2. ↑ 2.0 2.1 Paquet C, Yudin MH (January 2013). "Toxoplasmosis in pregnancy: prevention, screening, and treatment". J Obstet Gynaecol Can. 35 (1): 78–81. doi:10.1016/s1701-2163(15)31053-7. PMID 23343802.
  3. ↑ [Centers for Disease Control and Prevention. Three Cases of Congenital Rubella Syndrome in the Post elimination Era: Maryland, Alabama, and Illinois, 2012. MMWR Morb Mortal Wkly Rep. 2013; 62(12): pp. 226–229. url: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6212a3.htm. ], additional text.
  4. ↑ [Julie Johnson, MD, Brenna Anderson, MD, MSc, and Robert F. Pass, MD. Prevention of Maternal and Congenital Cytomegalovirus Infection. Clinical Obstetrics and Gynecology. 2013. url:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3347968/], additional text.
  5. ↑ [ Riley LE, Wald A. Genital herpes simplex virus infection and pregnancy. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/genital-herpes-simplex-virus-infection-and-pregnancy. Last updated June 18, 2016. Accessed March 22, 2017.], additional text.
  6. ↑ [ Demmler-Harrison GJ. Neonatal herpes simplex virus infection: Management and prevention. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/neonatal-herpes-simplex-virus-infection-management-and-prevention. Last updated February 16, 2016. Accessed March 22, 2017. ], additional text.
  7. ↑ [Lamont RF, Sobel JD, Vaisbuch E, et al. Parvovirus B19 infection in human pregnancy. BJOG. 2010; 118(2): pp. 175–186. doi: 10.1111/j.1471-0528.2010.02749.x ], additional text.
  8. ↑ [Centers for Disease Control and Prevention: Recommendations of the US Public Health Service Task Force on use of zidovudine to reduce perinatal transmission of human immunodeficiency virus. MMWR Morb Mortal Wkly Rep 43:1, 1994 ], additional text.
  9. ↑ [ The International Perinatal HIV Group: The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1: a meta-analysis of 15 prospective cohort studies. N Engl J Med 340: 977, 1999 ], additional text.
  10. ↑ [ACOG Committee Opinion no. 234, May 2000 ], additional text.
  11. ↑ [ Ziegler JB, Cooper DA, Johnson RO: Postnatal transmission of AIDS-associated retrovirus from mother to infant. Lancet 1: 896, 1985 ], additional text.
  12. ↑ [Centers for Disease Control: Recommendations for assisting in the prevention of perinatal transmission of human T lymphocyte virus type lymphadenopathy- associated virus and acquired immunodeficiency syndrome. MMWR Morb Mortal Wkly Rep 34: 721, 1985 ], additional text.
  13. ↑ [ Centers for Disease Control and Prevention. 2017 Nationally Notifiable Conditions. https://wwwn.cdc.gov/nndss/conditions/notifiable/2017/. Updated January 1, 2017. Accessed March 22, 2017], additional text.
  14. ↑ [ Amstey MS: Treatment and prevention of viral infections. Clin Obstet Gynecol 31: 501, 1988 ], additional text.
  15. ↑ [ American College of Obstetricians and Gynecologists: Guidelines for Hepatitis B Virus Screening and Vaccination During Pregnancy. ACOG Committee Opinion 78. Washington DC, ACOG, 1990 ], additional text.
  16. ↑ [ Duff P. Hepatitis in pregnancy. Semin Perinatol 1998; 22: 277-83 ], additional text.
  17. ↑ [Mosby LG, Ellington SR, Forhan SE, Yeung LF, Perez M, Shah MM, MacFarlane K, Laird SK, House LD, Jamieson DJ. The Centers for Disease Control and Prevention's maternal health response to 2009 H1N1 influenza. Am J Obstet Gynecol. 2011 Jun;204(6 Suppl 1):S7-12. Epub 2011 Mar 31], additional text.
  18. ↑ [ Mosby LG, Ellington SR, Forhan SE, Yeung LF, Perez M, Shah MM, MacFarlane K, Laird SK, House LD, Jamieson DJ. The Centers for Disease Control and Prevention's maternal health response to 2009 H1N1 influenza. Am J Obstet Gynecol. 2011 Jun;204(6 Suppl 1):S7-12. Epub 2011 Mar 31. ], additional text.
  19. ↑ [ Harper SA, Fukuda K, Uyeki TM, Cox NJ, Bridges CB. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization practices (ACIP) MMWR. Recomm Rep 2004; 53(RR-6): 1-40 ], additional text.
  20. ↑ [Ferenczy A: Treating genital condyloma during pregnancy with the carbon dioxide laser. Am J Obstet Gynecol 148: 9, 1989], additional text.
  21. ↑ [ Friedman-Kien AE, Eron LJ, Conant M: Natural interferon alfa for treatment of condylomata acuminata. JAMA 259: 533, 1988], additional text.
  22. ↑ [Choo QL, Kuo G, Weiner, AJ et al: Isolation of a DNA clone derived from blood-borne non-A, non-B viral hepatitis genome. Science 244: 359, 1989 ], additional text.
  23. ↑ [Verani JR, McGee L, Schrag SJ; Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease--revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010 Nov 19;59(RR-10):1-36], additional text.
  24. ↑ [ Verani JR, McGee L, Schrag SJ; Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease--revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010 Nov 19;59(RR-10):1-36. ], additional text.
  25. ↑ [ Janakiraman V. Listeriosis in pregnancy: diagnosis, treatment, and prevention. Rev Obstet Gynecol. 2008; 1(4): pp. 179–85. pmid: 19173022. ], additional text.
  26. ↑ [ Ricci JM, Fojaco RM, Fojaco RM, O'sullivan MJ: Congenital syphillis: The University of Miami/Jackson Memorial Medical Center Experience, 1986-1988. Obstet Gynecol 74: 687, 1989 ], additional text.
  27. ↑ [ Centers for Disease Control: Syphilis: CDC recommended treatment schedules. J Infect Dis 134: 97, 1976], additional text.
  28. ↑ [ ACOG Educational Bulletin No 245, March 1998, American College of Obstetricians and Gynecologists ], additional text.
  29. ↑ [Centers for Disease Control and Prevention. 2017 Nationally Notifiable Conditions. https://wwwn.cdc.gov/nndss/conditions/notifiable/2017/. Updated January 1, 2017. Accessed March 22, 2017. ], additional text.
  30. ↑ [ Sever JL, Larsen JN, Grossman JH: Toxoplasmosis. In: Handbook of Perinatal Infections, pp 157–163. Boston, Little, Brown, 1979 ], additional text.
  31. ↑ [ Centers for Disease Control and Prevention (CDC). Zika virus prevention. Available at: https://www.cdc.gov/zika/prevention/index.html. Accessed April 24,2017], additional text.


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