Perinatal Infections Laura Plachta, M.D.

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Perinatal InfectionsLaura Plachta, M.D.

• Viral Perinatal Infections
• Hepatitis B
• HIV
• HSV
• Varicella (Chickenpox)

• Bacterial Perinatal Infections
• Group B b strep
• Gonorrhea
• Chlamydia
• Syphilis

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Hepatitis B

• Viral infection, causing hepatitis
• 85-90 of older children and adults resolve
  initial infection, but 6-10 develop chronic
  infection, and continue to manifest Hep B surface
  antigen (HBsAg)
• Transmission of HBV from mother to baby occurs
  primarily at delivery
• 70-90 of infected newborns become chronic
  carriers of HBV
• Detection routine screening of pregnant women at
  onset of pregnancy or at time of delivery if
  unknown

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Hepatitis B, contd

• Babies born to HBS antigen positive mothers
  should be vaccinated and given one dose of HBIG
  within 12 hours of birth
• PREVENTS PERINATAL HBV IN 95 OF INFANTS
• Can give HBIG and initial HBV vaccine
  simultaneously, (but give in different sites)
• Bathe stable infants promptly to remove blood
  from skin
• If HBsAg status of mother unknown, give vaccine
  immediately and obtain maternal blood for
  testing. If found to be positive, give HBIG
  immediately (out to 7 days)
• preterm infants

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HIV

• Blood and human milk are modes of transmission
• Perinatal HIV transmission is lowered 68 by
  prenatal and intrapartem administration of
  Zidovudine
• routine testing of all pregnant women is
  recommended
• Zidovudine protocol is offered to all HIV
  positive mothers
• Counsel mothers to not breastfeed
• Infants are asymptomatic at birth and for first
  few months
• Diagnosis cannot be made for certain until age
  4-6 months

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HIV - contd

• Care in nursery
• Prompt bathing of stable infants to remove blood
  from skin
• No special precautions or isolation rooming-in
  recommended
• Gloves not required for diaper changes

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Herpes Simplex Virus (HSV)

• Active primary genital HSV infection poses
  greatest risk to newborn
• 33-50 infection rate
• Recurrent disease associated with lower risk to
  newborn
• 2-5 infection rate
• Complete history-taking and examination of the
  perineum at time of delivery are essential

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HSV in the newborn

• Low incidence
• May be generalized or localized to CNS, skin,
  eyes or mouth
• Typically, clinical disease not present at birth
• Occurs in first month after birth
• Acyclovir should be initiated if HSV suspected

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VZV (Chickenpox)

• non-immune pregnant women
• Varicella in adults is a serious and potentially
  life-threatening disease due to varicella
  pneumonia this is especially severe during
  pregnancy
• VZV immune globulin may prevent or ameliorate the
  illness if administered within 96 hours of
  exposure.

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VZV (Chickenpox) - contd

• Varicella early in pregnancy (1st trimester) is
  associated with severe congenital malformations
  and fetal death
• If onset of clinical maternal infection occurs
  within 5 days before or 2 days after delivery,
  VZIG (125 units) should be administered to the
  newborn
• Premature infants born less than 28 weeks
  gestation and exposed to varicella VZIG

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Group B Beta Strep (GBBS)

• 10-30 of women colonized with GBBS (asymptomatic
  genital or rectal colonization)
• GBBS causes 8000 cases of neonatal sepsis
  annually in US with 300 deaths
• GBBS infection of newborn characterized by
  sepsis, meningitis, pneumonia

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Signs of sepsis in a newborn

• Respiratory distress
• grunting, nasal flaring, chest wall retraction,
  respiratory rate 60
• Hypotension
• Poor profusion
• Hypothermia/temperature instability
• Lethargy, poor feeding

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GBBS - contd

• GBBS is acquired vertically from mother to infant
  during LD
• Risk factors
• preterm birth
• prolonged rupture of membranes (18 hours)
• maternal fever
• GBBS bacteruria during pregnancy
• previous delivery of infant with GBBS

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GBBS - prevention

• Antibiotic chemoprophylaxis
• intrapartum penicillin given for positive GBBS
  culture or risk factors observed

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Management of newborns/GBBS

• If symptomatic treatment and close observation
  in the NICU
• If asymptomatic evaluation for infection,
  including CBC, blood culture, observation
  antibiotic
• preterm infants warrant treatment regardless of risk factors

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Gonorrhea

• Sexually-transmitted bacterial infection of the
  genital tract
• Highest rates in females aged 15-19
• Other risk factors
• lower SES
• single status
• multiple sexual partners
• substance abuse

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Clinical manifestations of Gonorrhea in the
newborn

• Eye disease, gonococcal ophthalmia
• Scalp abscess (electrode)
• Disseminated disease

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Management of Gonorrhea

• Asymptomatic infants born to mothers with
  gonorrhea at time of delivery single dose of
  ceftriaxone IM
• if any symptoms treatment with ceftriaxone for
  10-14 days

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Chlamydia

• Very commonly STD causing genital tract infection
• Risk factors similar to gonorrhea
• Tested for and treated simultaneously
• Infection transmitted from genital tract to
  newborn during delivery

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Chlamydia - contd

• Most common neonatal diseases are conjunctivitis
  and pneumonia
• Installation of topical erythromycin into
  conjuctival sac at birth has not been shown to
  prevent eye or other infection
• Infants should be treated with 2 week course of
  oral erythromycin

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Syphilis

• Sexually transmitted infection caused by
  corkscrew-shaped bacteria (spirochete)
• Can cause entire body involvement, including
  brain, if untreated
• All pregnant women tested with a VDRL or RPR
  early in pregnancy, and again at term if risk
  factors are present
• Congenital infections occur transplacentally
  during pregnancy or can occur as infant passes
  through birth canal by contact with sores

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Syphilis - contd

• Can cause stillbirth, prematurity may be
  asymptomatic at birth or have evidence of
  multi-organ involvement
• No infant should be discharged without
  determination of serologic status of mother
• If RPR/VDRL are positive, must determine if
  maternal treatment has occurred, was appropriate,
  complete, and timely