Perinatal Infections Fetal Infection

1. Perinatal Infections Fetal Infection Nabeel BondagjiConsultant perinatologist KFSH&RC Jeddah

2. Infections • Toxoplasmosis • Rubella • Varicella • Parvovirus • CMV • HIV • Syphilis

3. Introduction • 3% of the perinatal mortalities are related to (fetal infection) • Fetus can be affected at any gestational age • Most severe affection occurs in the first trimester • Most of the fetal infections are preventable

4. Red indicates the most vulnerable period of development. (Moore 143).

5. First Trimester • Organogenesis • Growth restriction • Second and Third Trimester • Neuological Impairment • Growth restriction

6. Think of fetal infection • I.U.G.R • Hepatic Calcification • Intracrainal Calcification • Hydrocephally, Microcephally • Ascits • Pericardial,Pleural Effusion • Non Immune Hydrops Fetalis

13. Toxoplasmosis - Toxoplasmon gondii (intracellular parasite) • Trans-placental affect the placenta fetus • Transmission Rate - 10 –15% 1st trimester - 25% 2nd trimester - 60% 3rd trimester

15. Toxoplasmosis • Toxoplasmosis - Incidence of congenital toxoplasmosis - 0.07 – 0.5 : 1000 London - 2 : 1000 Brussels - 3.22 : 1000 Paris

16. Risks to the Fetus • 1st Trimester - 55 – 85% will show sequilie - Chrioretinitis severe impairment of vision - Hearing loss - Mental Retardation - Ascits - Periventirecular Calcification - Hydrocephally

17. Toxoplasmonsis Ultra Sound - Intracranial, hepatic, calcification - Ascitis - Hepatosplenomegally - Microcephally - I.U.G.R • Diagnosis Fetal Blood Sampling - IgM - PCR - Culture

18. Toxoplasmosis • Treatment - Reduce risk of transmission Spiramycin - If fetal infection documented - Pyrimethamine - Sulfadiazine….. Folic acid

19. Pyron F, Wallonlion C, Goner P, Cochrane Database Review January 2005 • Objective To assess whether treatment of toxoplasmosis reduces the risk of congenital toxoplasmosis • Selection Criteria RCT - Antibiotics - No treatment Proven Infection

20. Look, outcome of the children • 3332 Papers identified

21. NO Trial fulfill the criteria

22. Conclusion We do not know whether antibiotics Treatment reduces the congenital transmission or not. • Screening is Expensive Screening is not recommended in countries where screening and treatment is not routine.

23. Toxoplasmosis • Prevention to Toxoplasmosis: Advice to Pregnant Women whose Serological Tests are Negative. • Cook meat at 60oC + (Industrial deep-freezing also seems to destroy parasites efficiently). • When handling raw meat, do not touch eyes or mouth.

24. Cont.. Prevention of Toxoplasmosis • Carefully wash hands after handling raw meat, dirt, or vegetables soiled by dirt. • Wash fruit and vegetables before eating • Wear gloves when gardening • Avoid all contacts with things that may have been contaminated by cat feces • If the cat’s litter has to be changed, put on gloves and disinfect often with boiling water.

32. Rubella German Measles • Rubella - 3rd Disease • RNA Virus - Respiratory secretions - 2 – 3 weeks I.P.

33. Rubella • - 0.5 – 2% Non Immune - 0.2 – 0.5 Congenital Rubella Syndrome • Risk of Transmission - 8 – 12 weeks 90% -12 – 16 weeks 50% - 16 – 20 weeks 17%

34. Rubella Ultra Sound - I.U.G.R. - Hepto-splenomegally • Congenital Rubella syndrome - Eye Cataract, Retinopathy Microphthalmia, glaucoma - Ear Deafness -Heart PDA

35. Rubella • Diagnosis • IgM

36. RUBELLA • Prevention • Active immunization by vaccination is the only efficient way of preventing congenital rubella.

39. Varicella Zoster Virus DNA Herpes - Chickenpox - Herpes Zoster - Incidence in pregnancy 0.4 – 0.7 : 1000 • Maternal - Pneumonia increase mortality • Fetal Congenital Varicella Syndrome in 1st tri mester - Skin Scar, Limb Hyproplasia - Chrioretinitis, Microcephally

40. Varicella • Neonatal Infection • Increase in Mortality - 5 days before delivery – 48 hours post partum - Avoid delivery if possible in this period

41. Diagnosis • Viral Culture - PCR Presence of infection does not predicate the severity of the disease

42. VARICELLA • Prevention • Passive immunization is currently available and should be administered within 24-72 hours to sero-negative pregnant patients who have been exposed to varicella.

43. Varicella • Treatment - Oral cyclovir to improve sysmatic I.V. to treat pneumonia - Safe in Pregnancy - Does not prevent or decrease the fetal effect - VZIG to be given to the neonate 5 days before delivery – 2 days postpartum

44. Varicella • Screening - Not Recommended

47. Parvovirus B.19 the fifth disease • Infectious period 5 – 10 days after exposure • Mode of transmission - Transplacental 33% transmission risk - Fetal effect – abortion <20 weeks - Hydrops fetalis 18% of all non immune

48. Intrauterine fetal infection • Fetal effect of B19 : - A symptomatic - IUGR - Congenital anomalies - Hydrops fetalis - IUFD • Parvovirus B 19 pathogenesis: a) Anemia b) Fetal myocardium and hepatic affection c) Vasculitis

49. Diagnosis • Parpovirus - ELISA -Western blot test • IGM Diagnosis of Primary Infection • Elect Microscopy - Direct Visualization of the virus or viral particles

50. Parvovirus • Fetal Diagnosis • PCR in A.F., Placenta & Blood Ultra Sound • Hydropy Fetalis