Common Fetal Infections

Shanojan Thiyagalingam, Obstetrics & Gynaecology

Outline
1 Overview of Fetal Infections
2. TORCH Infections
A. Toxoplasma gondii
B. Treponema pallidum
C. Rubella
D. Cytomegalovirus
E. Human Immunodeciency Virus
F. Herpes Simplex Virus
Overview: Common Pathogens Affecting Fetus
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Toxoplasma gondii (1/10,000 live births)
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Treponema pallidum (4/1000 pregnant mothers)
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Rubella (3/year)
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Cytomegalovirus (1/100 births)
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Human Immunodeciency Virus (<200 births)
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Herpes Simplex Virus (9.6/10,000 live births)
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Listeria monocytogenes
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Escherichia coli
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Streptococcus agalactiae
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Hepatitis
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Parvovirus B19

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Neisseria meningitidis
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Enteroviruses
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Varicella Zoster Virus
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Coxsackievirus
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Parvovirus
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Malaria
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Group B Streptococcus
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Papillomavirus
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Neisseria gonorrhoea
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Tuberculosis
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Chlamydia trachomatis
Outline
1 Overview of Fetal Infections
2. TORCH Infections
A. Toxoplasma gondii
B. Treponema pallidum
C. Rubella
D. Cytomegalovirus
E. Human Immunodeciency Virus
F. Herpes Simplex Virus
Toxoplasma gondii
Transmission:
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To mom: raw meat, unpasteurized goats milk, cat feces/urine
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To baby: transplacental

Greatest Transmission Risk To Fetus:
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T3 (most severe if infected in T1)

E!ect on Fetus
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Congenital Toxoplasmosis
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Triad: chorioretinitis, hydrocephaly, intracranial calcication; MR, microcephaly
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75% of neonates initially asymptomatic at birth; severity depends on gestations age at time
of primary infection

E!ect on Mother
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mostly subclinical or u-like symptoms

Toxoplasma gondii
Diagnosis
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Serology
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IgM (persists for years so cannot conrm acute
infection),
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IgG serology
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Amniotic PCR

Management
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Maternal
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infection confers immunity; pre-pregnancy
infection eliminates vertical transmission
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Spiramycin (doesnt cross placenta; !fetal
morbidity but not rate of transmission)
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Fetal
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pyrimethamine, sulfadiazine, folic acid
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if untreated ! long term sequelae

Prevention
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no vaccine
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avoid: cat litter boxes, gardening without glove/
mask d/t organism in cat feces
Outline
1 Overview of Fetal Infections
2. TORCH Infections
A. Toxoplasma gondii
B. Treponema pallidum
C. Rubella
D. Cytomegalovirus
E. Human Immunodeciency Virus
F. Herpes Simplex Virus
Treponema pallidum
Transmission
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To mom: sexual contact
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To baby: transplacental

Greatest Transmission Risk To Fetus
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T1-T3

E!ect on Fetus
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stillbirth, hydrops fetalis; if child survives: facial abnormalities (Hutchinsons teeth, saddle nose,
short maxilla), saber shins, CN 8 deafness
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early (<2 y/o) vs late (>2 y/o) congenital syphilis
Treponema pallidum
Diagnosis
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IgM antitreponemal antibodies (dont cross placenta)
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Screening:
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VDRL/RPR for all pregnancies
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Conrmation:
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FTA-ABS/MHA-TP
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Dark eld microscopy if primary
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U/S: edema, ascites, hydrops, thickened placenta

Management
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Penicillin G 2.4 million units IM
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1 dose if early syphillis
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3 dose if late syphillis
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if allergic ! desensitization
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Jarisch-Herxheimer reaction (uterine contractions and fetal heart late decel)
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if positive "VDRL monthly

Prevention
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if untreated mother ! atleast >70% risk for infant infection (vs. 1-2% if treated)
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check titre in T1
Outline
1 Overview of Fetal Infections
2. TORCH Infections
A. Toxoplasma gondii
B. Treponema pallidum
C. Rubella
D. Cytomegalovirus
E. Human Immunodeciency Virus
F. Herpes Simplex Virus
Rubella
Transmission:
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To mom: respiratory droplets (highly contagious)
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To baby: transplacental

Greatest Transmission Risk To Fetus:
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highest in T1

E!ect on Fetus
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Congenital Rubella Syndrome
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Triad: PDA (or pulmonary artery hypoplasia),
cataracts and deafness +/- blueberry mufn rash
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Other: mental retardation, impacts organs during
organogenesis; latent onset: thyroid/ocular/growth
hormone/diabetic diseases, HSM, thrombocytopenia,
hyperbilirubinemia

E!ect on Mother
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rash (50%), fever, posterior auricular or occipital
lymphadenopathy, arthralgia
Rubella
Diagnosis
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serology: all pregnant women screened
(immune if titre >1:16)
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Neonate: chorionic villi, amniotic uid,
fetal blood
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IgM
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Maternal: infection if IgM present or
> 4x increase in IgG

Management/Prevention
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no specic treatment
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offer vaccine before or after not during
pregnancy
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check titre in T1
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infected newborns shed virus for many
months so other baby/adults low/no
immunity are at risk
Outline
1 Overview of Fetal Infections
2. TORCH Infections
A. Toxoplasma gondii
B. Treponema pallidum
C. Rubella
D. Cytomegalovirus
E. Human Immunodeciency Virus
F. Herpes Simplex Virus
Cytomegalovirus
Transmission:
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To mom: blood transfusion, saliva, urine, organ transplant, sexual contact
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50-80% US women: serologic evidence
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To baby: transplacental, during delivery, breast milk

Greatest Transmission Risk To Fetus:
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T1-T3

E!ect on Fetus
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hearing loss, seizures, petechial rash, blueberry mufn rash
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5-10%: CNS involvement

E!ect on Mother
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Asymptomatic or mononucleosis -like symptoms:
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fever, pharyngitis, lymphadenopathy, polyarthritis
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primary inf (more severe) ! latent ! reactivation and shedding ! secondary inf (less severe)
Cytomegalovirus
Diagnosis
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serology screen: maternal IgM, IgG
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QT-PCR: fetal blood, amniotic uid
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ultrasound: microcephaly, ventriculomegaly, intracranial calcication
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! sensitivity

Management
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no treatment
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Gancyclovir (anecdotal evidence)
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for symptomatic with life/sight-threatening illness
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AE: testicular atrophy, BM suppression, etc
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Previously infected immunosuppressed mothers
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monitor IgG d/t risk for congenital CMV retinitis

Prevention
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maintain good hygiene especially at Day Care Centres
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avoid high risk situations
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previous CMV infection doesnt confer immunity (diff strains)
Outline
1 Overview of Fetal Infections
2. TORCH Infections
A. Toxoplasma gondii
B. Treponema pallidum
C. Rubella
D. Cytomegalovirus
E. Human Immunodeciency Virus
F. Herpes Simplex Virus
Human Immunodeciency Virus
Transmission:
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To mom: blood, semen, vaginal secretions
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To baby: in utero, during delivery, breast milk, ROM, invasive procedures

Greatest Transmission Risk To Fetus
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1/3 via utero, 1/3 via delivery, 1/3 via breastfeeding

E!ect on Fetus
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IUGR, PTL, PROM

Diagnosis
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screen: ELISA
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conrm: Western blot, PCR
Human Immunodeciency Virus
Management
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Maternal
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triple antiretroviral therapy
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Raltegravir, Lopinavir, Zidovudine
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Zidovudine: monitor blood count/liver function
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Neonate: 6 weeks of zidovudine syrup
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elective C/S
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efcacy: ! transmission rate by 66%
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monitor CD4+ count, viral loads regularly
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reduce duration of ruptured membrane


Prevention
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all pregnant woman offered screening: T1; T3 (some states)
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avoid breast feeding if infected
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antiretroviral + C/S reduces vertical transmission from 25%
! 2%
Outline
1 Overview of Fetal Infections
2. TORCH Infections
A. Toxoplasma gondii
B. Treponema pallidum
C. Rubella
D. Cytomegalovirus
E. Human Immunodeciency Virus
F. Herpes Simplex Virus
Herpes Simplex Virus
Transmission
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To mom: intimate mucocutaneous contact
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To baby: transplacental (5%), during delivery (85%), postnatal
(10%)

Greatest Transmission Risk To Fetus
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delivery (if genital lesions present); less common in-utero
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primary infection (50%) vs. secondary infection (<1-5%)

E!ect on Fetus (3 forms)
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1) skin (sometimes), eye, mouth with localized involvement
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2) CNS disease with encephalitis
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3) disseminated disease with multiple organ involvement

E!ect on Mother
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numbness, tingling, pain (prodromal symptoms), painful
vesicular lesions w/ erythematous base that heal w/o scarring
Herpes Simplex Virus
Diagnosis:
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Clinical
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Fetal viral culture of herpetic lesions, oropharynx, eye
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Maternal serology
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primary infection (severe): IgM
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secondary infection (less severe): IgG


Management
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when pt presents in labor
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ask about prodromal symptoms
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examine perineum, vagina, cervix for lesion
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IV acyclovir: ! symptom length, amount viral shedding;
prophylaxis if hx of infection
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C/S if prodromal or active genital lesions
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if primary maternal infection closer to delivery # fatal
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less time for maternal Ab to pass to fetus

Prevention:
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screen: maternal perineal exam
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if genital lesions then do C/S
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if hx of herpes but no current outbreak in pregnancy then some
doctors give acyclovir
High Yield Summary
Source: Baxter, S. (2012). Infections During Pregnancy. In The Toronto notes 2012: A comprehensive medical reference and review for the Medical Council of Canada Qualifying Exam - Part 1 and the United States Medical Licensing
Exam - Step 2 (28th ed., p. OB22). Toronto: Toronto Notes for Medical Students.
High Yield Summary
Source: Baxter, S. (2012). Infections During Pregnancy. In The Toronto notes 2012: A comprehensive medical reference and review for the Medical Council of Canada Qualifying Exam - Part 1 and the United States Medical Licensing
Exam - Step 2 (28th ed., p. OB22). Toronto: Toronto Notes for Medical Students.
References
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Baxter, S. (2012). Infections During Pregnancy. In The Toronto notes 2012: A comprehensive
medical reference and review for the Medical Council of Canada Qualifying Exam - Part 1 and the
United States Medical Licensing Exam - Step 2 (28th ed., p. OB22). Toronto: Toronto Notes for
Medical Students.
"
Gilbert, R., & Petersen, E. (2013, November 13). Toxoplasmosis and pregnancy. Retrieved
September 29, 2014, from http://www.uptodate.com/contents/toxoplasmosis-and-pregnancy?
source=preview&search=toxoplasma gondii pregnancy&selectedTitle=1~150&language=en-
US&anchor=H5#H5
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Johnson, K. (2014, January 15). Overview of TORCH infections. Retrieved September 29, 2014,
from http://www.uptodate.com/contents/overview-of-torch-infections?
source=search_result&search=torches infections&selectedTitle=1~150#H1
"
Kaufman, M., Holmes, J., Schachel, P., & Stead, L. (2011). Infections In Pregnancy. In First aid for
the obstetrics & gynaecology clerkship (3rd ed., pp. 156-166). New York: McGraw-Hill Medical.
"
Riley, L. (2014, March 6). Rubella in pregnancy. Retrieved September 29, 2014, from http://
www.uptodate.com/contents/rubella-in-pregnancy?source=preview&search=rubella in pregnancy
incidence&selectedTitle=1~150&language=en-US&anchor=H3#H3PUBMED
End of Presentation