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Systemic Infections in Pregnancy

Systemic Infections in Pregnancy. Dr. Jasmin Sapanghila-Tamon. Varicella Rubella Hepatitis B Syphilis HIV. Varicella Infection. Varicella Infection. DNA Herpesvirus Primary infection causes varicella (chickenpox) Recurrent infection causes herpes zoster (shingles).

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Systemic Infections in Pregnancy

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  1. Systemic Infections in Pregnancy Dr. JasminSapanghila-Tamon

  2. Varicella Rubella Hepatitis B Syphilis HIV

  3. Varicella Infection

  4. Varicella Infection DNA Herpesvirus Primary infection causes varicella (chickenpox) Recurrent infection causes herpes zoster (shingles)

  5. Pathogenesis and Clinical Features • Incubation period 14-16 days • Mild prodrome for 1-2 days • Maculopapular rash generally appears first on the head; most concentrated on trunk

  6. Mode of Transmission • Direct Contact – with patient who sheds the virus from vesicles • Indirect Contact – through articles fresh soiled by discharges of infected persons • Airborne – or spread by droplet infection

  7. Period of Communicability: The patient is contagious about a day before the eruption of rashes and continuous to be so up to the 5th or 6th day after the last scab formation or until all vesicles have become encrusted.

  8. Diagnostic Test: Determination of V-Z virus though Complement Fixation Test Determination of V-Z virus through Electron Microscopic examination of vesicular fluid

  9. Complications: Secondary infection of the lesions – furuncles, cellulites, skin abscess, erysipelas Meningoencephalitis Pneumonia Sepsis

  10. Groups at Increased Risk of Complications of Varicella Normal adults Immunocompromised persons Newborns with maternal rash onset within 5 days before to 48 hours after delivery

  11. Is risk of severe chickenpox increased in pregnancy? • No definite evidence that varicella is more likely to be fatal in pregnant women than in non pregnant adult Hermmann KL. Clin Obstet Gynecol 1982;25:605-609.

  12. Fetal Effects of Varicella • No infection • Infection • Congenital Varicella syndrome • Neonatal varicella infection • Infant herpes zoster

  13. Transmission to the Fetus <13 weeks AOG: 0.4% 13-20 weeks AOG: 2% >20 weeks AOG: 0 Within 5 days before or after delivery: 10-20% neonatal varicella infection

  14. Congenital Varicella syndrome • Damage to sensory nerves • Damage to optic nerve and lens vesicles • Damage to cervical and lumbosacral cord • Damage to brain

  15. Diagnosis of Congenital varicella syndrome • Cordocentesis to estimate fetal VZV-specific IgMab • Chorionic villus sampling to detect VZV DNA sequence using PCR • Serum AFP • UTZ

  16. Management of the mother – Post exposure • Check VZV immunity • Consider • Prevention of chickenpox – VZIG • Treatment of chickenpox with antiviral • Counseling of mother and close fetal monitoring

  17. Exposure Criteria for Use of VZIG: • Continuous household contact • Playmate/officemate contact >1hour indoors • Hospital contact – adjacent bed or infected staff member • Newborn of infected mother – from 5days before to 2days after delivery AND • Time lapse from exposure is less than 96 hours

  18. Varicella zoster Immunoglobulin (VZIG) • Prevent congenital varicella syndrome ? • No definite evidence • No congenital varicella syndrome among 97 pregnant women who received VZIG, but not sufficient power to reach significance • Documented cases of congenital varicella syndrome despite VZIG Enders et al Lancet 1994: 343; 1548-1551.

  19. If patient is not pregnant but has a significant exposure to varicella • give vaccine within 120 hours of exposure • 70-100% effective if given within 72 hours of exposure • Not effective if given beyond 5 days of exposure but will produce immunity

  20. Treatment Generally, there is no need to treat uncomplicated varicella since this is almost always a self-limiting disease. Only in an immunocompromised host or when complications such as pneumonitis or encephalitis occur should antiviral therapy be considered.

  21. Treatment • For women infected with varicella • Give acyclovir 800mg 5 times a day for 5-7 days • Not recommended for routine use among otherwise healthy infants and children with varicella

  22. Summary Chickenpox may be serious for pregnant women and fetus Increasing numbers of seronegative women could result in increase chickenpox in pregnancy Vaccine strategy should aim to protect all non immune adults especially women of reproductive age Congenital varicella syndrome may be a rare occurrence, but the risk to the fetus is so high that prevention, post exposure prophylaxis and treatment, once infected, should always be an option.

  23. Rubella

  24. Rubella • Highly communicable disease • Infected person may shed the virus in the upper respiratory tract from 1 week before to 5-7 days after the onset of rash • Incubation Period: 14 days (12-23 days)

  25. Rubella Low grade fever and mild upper respiratory tract infection Maculopapular rash on the face and neck, trunk and proximal extremities Development of adenopathy Rash fades within 1-3 days of onset

  26. Incubation Period: 12-23 days 20%-50% of infections may be asymptomatic Viremia precedes clinical signs by 1 week, and adults are infectious during viremia until 5-7 days of the rash

  27. Rubella • Risk of congenital defects: • </=12 weeks AOG: 80% • 13-14 weeks AOG: 54% • 15-28 weeks AOG: 25%

  28. Congenital Rubella Syndrome Eye defects Heart disease – PDA Sensorineural deafness CNS defects Pigmentary retinopathy Purpura Hepatosplenomegaly and jaundice Radiolucent bone disease

  29. Rubella in Pregnancy There is no treatment to ameliorate maternal disease or reduce the risk to the fetus when maternal infection is present Prevention of fetal infection requires prevention of maternal infection through widespread vaccination programs

  30. WHO Recommendation All countries to assess their rubella status and introduce immunization and surveillance, if appropriate

  31. Rubella Do serum rubella IgG on all pregnant patients If patient is seronegative to rubella, give rubella vaccine postpartum

  32. Counseling and Management • Pregnant women with confirmed rubella infection must have proper counseling about the risks and types of congenital anomalies

  33. Counseling and Management • Routine use of rubella Ig is not recommended for postexposure prophylaxis since this does not prevent infection nor viremia. Advisory Committee on CDC, Aug, 2006

  34. Rubella Vaccine • Long term protection (about 15 years) from vaccination is about 98 to 99%; thus about 2% of vaccinated women may be negative when tested. • Ideally all vaccinated women should have their serological status determined before becoming pregnant.

  35. Rubella Screening • MMR should not be given to adolescents who are known to be pregnant or to adolescents who are considering becoming pregnant within 3 months of vaccination.

  36. Recommendations Routine screening for rubella susceptibility by history of vaccination or by serology is recommended for all women of childbearing age at their first clinical encounter. Susceptible non pregnant women should be offered rubella vaccination; susceptible pregnant women should be vaccinated immediately after delivery. An equally acceptable alternative for non pregnant women of childbearing age is to offer vaccination against rubella without screening.

  37. Hepatitis B

  38. Caused by DNA hepadnavirus Incubation period: 6 weeks to 6 months Highest concentration in the blood, lower concentrations in other body fluids Transmitted by percutaneous or mucous membrane exposure to infectious blood or body fluids that contain blood

  39. Risk Factors 1. Persons of Asian, Alaskan, Sub-Saharan African descent 2. History of IV drug use 3. History of STD 4. Multiple sexual partners 5. Worker or patient in a hemodialysis unit 6. Health care or public safety worker

  40. Risk Factors 7. Household contact with Hepatitis B carrier 8. Sexual contact with Hepatitis B carrier 9. Worker or residence in an instiution for the developmentally disabled 10. History of blood transfusion 11. Delivery to a carrier mother

  41. Hepatitis B Risk for chronic infection is inversely related to age at infection In adults, approximately half of newly acquired HBV infections are symptomatic, 1% result in acute liver failure 90% of infants and 30% of children aged <5 years become chronically infected

  42. Diagnosis

  43. Pregnancy and HBV Infection Transmission of HBV from mother to infant (predominantly intrapartum) is one of the most efficient modes of HBV spread 4 Routes 1. Transplacental 2. Intrapartum 3. Post-partum 4. Breast milk

  44. Pregnancy and HBV Infection Perinatal Transmission Rates of Hepatitis B Virus

  45. Hepatitis B TREATMENT Acute Hepatitis B primarily supportive on an ambulatory basis with bed rest High protein diet Avoidance of hepatotoxic drugs

  46. Treatment of Hepatitis B Chronic Hepatitis B Goals of therapy 1. Suppression or complete resolution of chronic active hepatitis 2. Halting progression of liver disease 3. Converting patients to a non-infectious state

  47. Prevention • Hepatitis B immune globulin (HBIG) • 0.06mL/kg • Hepatitis B vaccine • Periodic testing to determine ab levels in immunocompetent persons is not necessary, and booster doses of vaccine are not recommended

  48. Hepatitis B CDC National strategy to eliminate transmision of HBV Prevention of perinatal infection Routine infant vaccination Vaccination of previously unvaccinated children and adolescents through age 18 Vaccination of previously unvaccinated adults at increased risk for infection

  49. Hepatitis B Post-Exposure Prophylaxis

  50. Hepatitis B Post-Exposure Prophylaxis

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