Infections and Infestations in Pregnancy

Infections and Infections and Infestations in Infestations in

pregnancypregnancy

Seminar objectivesSeminar objectives

To know the various infections and To know the various infections and infestations that occur in infestations that occur in pregnancy.pregnancy.

To know their effects on pregnancy To know their effects on pregnancy and the effects of pregnancy on and the effects of pregnancy on them.them.

To know the management of these To know the management of these conditions.conditions.

OutlineOutline

MalariaMalaria UTIUTI Worm infestationsWorm infestations STORCH5STORCH5

MalariaMalaria Malaria is a major cause of morbidity and Malaria is a major cause of morbidity and

mortality in children and adults particularly mortality in children and adults particularly in the tropicsin the tropics

It is caused by Plasmodium parasites ;It is caused by Plasmodium parasites ; Plasmodium falciparumPlasmodium falciparum Plasmodium vivaxPlasmodium vivax Plasmodium malariaePlasmodium malariae Plasmodium ovalePlasmodium ovale

Plasmodium falciparum Plasmodium falciparum causes the severest causes the severest form of malaria and is transmitted through form of malaria and is transmitted through the bite of the female anopheles mosquitothe bite of the female anopheles mosquito

Incubation period is about two weeksIncubation period is about two weeks

Life cycle and Life cycle and pathogenesispathogenesis

Features of Features of uncomplicated malariauncomplicated malaria

FeverFever Rigors Rigors MalaiseMalaise HeadacheHeadache VomitingVomiting Abdominal discomfortAbdominal discomfort

Features of complicated Features of complicated malariamalaria

Dark-coloured urineDark-coloured urine JaundiceJaundice Drowsiness and coma Drowsiness and coma AnaemiaAnaemia Difficulty in breathingDifficulty in breathing Poor urine out putPoor urine out put Temp 39˚C or moreTemp 39˚C or more

Effects of pregnancy on Effects of pregnancy on malariamalaria

Pregnant women tend to have more Pregnant women tend to have more frequent and severe forms of malaria frequent and severe forms of malaria due to reduced immunity.due to reduced immunity.

Effects of malaria on Effects of malaria on pregnancy pregnancy

Placental parasitaemiaPlacental parasitaemia Maternal anaemiaMaternal anaemia AbortionsAbortions Preterm birthPreterm birth Low birth weightLow birth weight Severe malariaSevere malaria

Effect of Malaria on the Effect of Malaria on the foetusfoetus

Foetal anaemiaFoetal anaemia Low birth weightLow birth weight Pre-term deliveryPre-term delivery Still-birthStill-birth Congenital malariaCongenital malaria

Higher Risk GroupsHigher Risk Groups

First and second pregnanciesFirst and second pregnancies AdolescentsAdolescents HIV-infectedHIV-infected Sickle-cell diseaseSickle-cell disease Pregnant women from areas of low Pregnant women from areas of low

transmissiontransmission

InvestigationsInvestigations

Blood film for malaria parasitesBlood film for malaria parasites FBCFBC If the disease is severe and If the disease is severe and

diagnostic difficulties exist ,then diagnostic difficulties exist ,then culture of blood and urine is done to culture of blood and urine is done to exclude enteric fever and UTI exclude enteric fever and UTI respectively.respectively.

Management of malaria in Management of malaria in pregnancypregnancy

The Ministry of Health has adopted a The Ministry of Health has adopted a three-pronged approach:three-pronged approach: Insecticide-treated netsInsecticide-treated nets Intermittent preventive treatmentIntermittent preventive treatment Case-management of malariaCase-management of malaria

IPTIPT

Three doses of sulfadoxine Three doses of sulfadoxine pyrimethamine are given during pyrimethamine are given during ANC at monthly intervals after 16 ANC at monthly intervals after 16 weeks but before 36 weeks. But in weeks but before 36 weeks. But in Ghana, the first dose is given after Ghana, the first dose is given after 20 weeks.20 weeks.

Case managementCase management For uncomplicated malariaFor uncomplicated malaria

600mg of oral quinine tid for 7days600mg of oral quinine tid for 7days Artesunate 2.4mg/kg bwt given iv followed by Artesunate 2.4mg/kg bwt given iv followed by

1.2mg/kg bwt at 12hrs and 24hrs and 1.2mg/kg 1.2mg/kg bwt at 12hrs and 24hrs and 1.2mg/kg bwt daily for 6 days.The daily dose can be given bwt daily for 6 days.The daily dose can be given orally if the patient is able to swallow.orally if the patient is able to swallow.

Arthemether 3.2mg/kg bwt given im followed by Arthemether 3.2mg/kg bwt given im followed by 1.6mg/kg bwt daily for 6 days. Dose can be given 1.6mg/kg bwt daily for 6 days. Dose can be given orally if the patient can swallow.orally if the patient can swallow.

For complicated malariaFor complicated malaria IV quinine 10mg/kg body weight in 5% dextrose or IV quinine 10mg/kg body weight in 5% dextrose or

IM quinine 10mg/kg body weight 8-hourly for 48 IM quinine 10mg/kg body weight 8-hourly for 48 hours. Then continue with oral quinine for the next hours. Then continue with oral quinine for the next 5 days.5 days.

Urinary Tract Urinary Tract Infections in Infections in PregnancyPregnancy

IntroductionIntroduction UTIs are the most common bacterial infections UTIs are the most common bacterial infections

that complicate pregnancy.that complicate pregnancy. In normal pregnancy, profound changes occur In normal pregnancy, profound changes occur

in the renal system. These anatomical and in the renal system. These anatomical and physiological changes influence the physiological changes influence the occurrence, progress and outcome of UTIs.occurrence, progress and outcome of UTIs.

The calyces, renal pelvis and ureters dilate The calyces, renal pelvis and ureters dilate markedly and often give the erroneous markedly and often give the erroneous impression of obstructive uropathy.impression of obstructive uropathy.

Most pregnant women show evidence of Most pregnant women show evidence of urinary stasis by the third trimester.urinary stasis by the third trimester.

The urinary stasis predisposes pregnant The urinary stasis predisposes pregnant women to UTIs.women to UTIs.

Asymptomatic Asymptomatic BacteriuriaBacteriuria

It refers to the presence of actively multiplying It refers to the presence of actively multiplying bacteria in the urinary tract, excluding the distal bacteria in the urinary tract, excluding the distal urethra, in a patient without any obvious urethra, in a patient without any obvious symptoms.symptoms.

The incidence is the same in both pregnant and The incidence is the same in both pregnant and non-pregnant women(2-10%).non-pregnant women(2-10%).

It is twice as common in pregnant women who It is twice as common in pregnant women who have the sickle cell trait(AS) and 3 times as have the sickle cell trait(AS) and 3 times as common in pregnant women who are diabetic.common in pregnant women who are diabetic.

Organisms implicated include E. coli, Klebsiella, Organisms implicated include E. coli, Klebsiella, Staph. aureus, Group B Streptococcus and Staph. aureus, Group B Streptococcus and Proteus.Proteus.

If left untreated, 40% progress to symptomatic If left untreated, 40% progress to symptomatic UTI while 30% develop acute pyelonephritis.UTI while 30% develop acute pyelonephritis.

Effects on PregnancyEffects on Pregnancy

MaternalMaternal AnaemiaAnaemia PIHPIH Preterm labourPreterm labour

FetalFetal Low birth weightLow birth weight Preterm deliveryPreterm delivery

DiagnosisDiagnosis

Isolation of >10Isolation of >1055 organisms of the organisms of the same species per ml of urine. A same species per ml of urine. A suitable specimen for culture and suitable specimen for culture and sensitivity is a clean-catch sensitivity is a clean-catch midstream specimen of urine.midstream specimen of urine.

Other methods that may be used in Other methods that may be used in obtaining the specimen of urine obtaining the specimen of urine include suprapubic aspiration and include suprapubic aspiration and urethral catheterization.urethral catheterization.

TreatmentTreatment

The choice of drug is based on the The choice of drug is based on the sensitivity of the isolated organism.sensitivity of the isolated organism.

Ampicillin and cephalosporins can be Ampicillin and cephalosporins can be used safely in pregnancy.used safely in pregnancy.

Nitrofurantoin and short-acting Nitrofurantoin and short-acting sulfonamides may also be used.sulfonamides may also be used.

Repeat MSSU culture after treatment Repeat MSSU culture after treatment to ensure that the infection is cleared.to ensure that the infection is cleared.

Acute CystitisAcute Cystitis

It is a lower urinary tract infection It is a lower urinary tract infection involving the urinary bladder.involving the urinary bladder.

It is uncommon in pregnancy.It is uncommon in pregnancy. Incidence is about 1%.Incidence is about 1%. Organisms implicated include E. Organisms implicated include E.

coli, Klebsiella, Staph. aureus, Group coli, Klebsiella, Staph. aureus, Group B Streptococcus and Proteus.B Streptococcus and Proteus.

Signs and SymptomsSigns and Symptoms

FrequencyFrequency UrgencyUrgency DysuriaDysuria Suprapubic painSuprapubic pain Cloudy and offensive urineCloudy and offensive urine Lower back painLower back pain HaematuriaHaematuria


MSSU for culture and sensitivityMSSU for culture and sensitivity Urine dipstickUrine dipstick Urine microscopyUrine microscopy Imaging of urinary tract in recurrent Imaging of urinary tract in recurrent

cases to exclude anatomical cases to exclude anatomical abnormalities.abnormalities.

TreatmentTreatment Treatment can be on OPD basis with oral Treatment can be on OPD basis with oral

antibiotics best chosen based on culture and antibiotics best chosen based on culture and sensitivity results.sensitivity results.

Nitrofurantoin, ciprofloxacin, co-amoxiclav, Nitrofurantoin, ciprofloxacin, co-amoxiclav, ampicillin, trimethoprim and cephalosporins ampicillin, trimethoprim and cephalosporins are effective.are effective.

Analgesics like paracetamol may be given.Analgesics like paracetamol may be given. Encouraging patient to drink plenty of fluids to Encouraging patient to drink plenty of fluids to

promote good urinary output.promote good urinary output. Personal hygiene and proper cleaning after Personal hygiene and proper cleaning after

defaecation.defaecation. Encouraging patient to urinate often.Encouraging patient to urinate often.

Acute PyelonephritisAcute Pyelonephritis It is an upper urinary tract infection It is an upper urinary tract infection

involving the renal pelvis.involving the renal pelvis. Occurs in 1-2% of pregnant women.Occurs in 1-2% of pregnant women. The risk of developing acute The risk of developing acute

pyelonephritis is markedly increased in pyelonephritis is markedly increased in pregnancy because of obstructive pregnancy because of obstructive uropathy and stasis of urine. Untreated uropathy and stasis of urine. Untreated asymptomatic bacteriuria adds to the asymptomatic bacteriuria adds to the risk.risk.

Organisms implicated include E. coli, Organisms implicated include E. coli, Klebsiella, Staph. aureus, Group B Klebsiella, Staph. aureus, Group B Streptococcus and Proteus.Streptococcus and Proteus.

Signs and SymptomsSigns and Symptoms Fever (temp>38.5°C)Fever (temp>38.5°C) Chills Chills RigorsRigors NauseaNausea VomitingVomiting Flank pain, renal angle tendernessFlank pain, renal angle tenderness HeadacheHeadache FrequencyFrequency UrgencyUrgency DysuriaDysuria DehydrationDehydration

Effects on PregnancyEffects on Pregnancy FetalFetal

IUGRIUGR IUFDIUFD Preterm deliveryPreterm delivery

MaternalMaternal Renal failureRenal failure Endotoxic shockEndotoxic shock Preterm labourPreterm labour AnaemiaAnaemia Pulmonary injuryPulmonary injury Hypothalamic instabilityHypothalamic instability


MSSU for culture and sensitivityMSSU for culture and sensitivity Urine dipstickUrine dipstick Blood for culture and sensitivity in Blood for culture and sensitivity in

severely ill patientsseverely ill patients Blood film for malaria parasites to Blood film for malaria parasites to

rule out malariarule out malaria FBCFBC BUE, creatinineBUE, creatinine

TreatmentTreatment Admit the patient.Admit the patient. IVFs (such as D/S and R/L) given for IVFs (such as D/S and R/L) given for

rehydration.rehydration. Start IV antibiotics such as cephalosporins Start IV antibiotics such as cephalosporins

whilst awaiting the urine culture and sensitivity whilst awaiting the urine culture and sensitivity results.results.

Analgesics and antipyretics such as paracetamol Analgesics and antipyretics such as paracetamol are given.are given.

Monitor fetal condition and watch out for Monitor fetal condition and watch out for preterm labour.preterm labour.

Check urine daily for proteins and keep a BP Check urine daily for proteins and keep a BP chart.chart.

Repeat urine culture 7 days after treatment to Repeat urine culture 7 days after treatment to make sure the infection is cleared.make sure the infection is cleared.

Worm infestations Worm infestations

There are two main species There are two main species • Ancylostoma duodenaleAncylostoma duodenale• Necator americanus (most common )Necator americanus (most common )

Clinical featuresClinical features

Ground itch at the site of entryGround itch at the site of entry Loffler’s syndromeLoffler’s syndrome AnaemiaAnaemia MalabsorptionMalabsorption

Life cycleLife cycle


Stool R/E for ova and occult bloodStool R/E for ova and occult blood Routine investigationsRoutine investigations

FBC (Hb)FBC (Hb)

ManagementManagement

AnthelminticsAnthelmintics The Ministry of Health recommends The Ministry of Health recommends

that all pregnant women be given that all pregnant women be given mebendazole(100mg bd for 3days or mebendazole(100mg bd for 3days or 500mg in the 2500mg in the 2ndnd to 3 to 3rdrd trimester) trimester)

AscariasisAscariasis

Mode of infectionMode of infection Ingestion of infective eggs in Ingestion of infective eggs in

contaminated foodscontaminated foods

Clinical featuresClinical features

Lofflers syndromeLofflers syndrome Digestive disordersDigestive disorders UrticariaUrticaria EosinophiliaEosinophilia Intestinal obstructionIntestinal obstruction Bile duct obstruction from heavy Bile duct obstruction from heavy

infestationinfestation


Mebendazole (500mg stat 2Mebendazole (500mg stat 2ndnd to 3 to 3rdrd trimester)trimester)

STORCH-5STORCH-5

SyphilisSyphilis ToxoplasmosisToxoplasmosis Others:Others:

Bacterial vaginosisBacterial vaginosis TrichomoniasisTrichomoniasis Group B Strep.Group B Strep. ListeriaListeria E. coliE. coli VaricellaVaricella

RubellaRubella CytomegalovirusCytomegalovirus H5:H5:

HIVHIV HerpesHerpes Hepatitis BHepatitis B HPVHPV Human Parvovirus Human Parvovirus

SyphilisSyphilisINTRODUCTIONINTRODUCTION Syphilis is caused by Syphilis is caused by TreponemaTreponema pallidumpallidum It is a spirochete: Gram negative with a long It is a spirochete: Gram negative with a long

slender, helically coiled body.slender, helically coiled body. The spirals are so thin that only immunofluorescent The spirals are so thin that only immunofluorescent

staining and dark field microscopy identifies them.staining and dark field microscopy identifies them. T. pallidum has never been cultured continuously T. pallidum has never been cultured continuously

on artificial media, in fertile egg or tissue culture.on artificial media, in fertile egg or tissue culture. T. pallidum is microaerophilic (survives best at 1-T. pallidum is microaerophilic (survives best at 1-

4% O₂4% O₂ Drying kills spirochetes; Temp. 42°C kills them.Drying kills spirochetes; Temp. 42°C kills them. Penicillin is treponemicidal in minute Penicillin is treponemicidal in minute

concentrations but at a slower rate because T. concentrations but at a slower rate because T. pallidum divides slowly (30 hours)pallidum divides slowly (30 hours)

Pathogenesis, Pathology and Pathogenesis, Pathology and Clinical PresentationClinical Presentation

Transmission is usually by sexual intercourse.Transmission is usually by sexual intercourse. Primary infection is on the skin or mucous membrane of Primary infection is on the skin or mucous membrane of

the genitaliathe genitalia In 10-20% , rectal or oral mucosa or perianal skin may be In 10-20% , rectal or oral mucosa or perianal skin may be

the site of primary infectionthe site of primary infection The organism may penetrate through intact skin or enter The organism may penetrate through intact skin or enter

through a break in the epidermisthrough a break in the epidermis The disease may go through stages of The disease may go through stages of primary , primary ,

secondary ,latent secondary ,latent and and tertiarytertiary syphilis syphilis Both primary and secondary syphilitic lesions are rich in Both primary and secondary syphilitic lesions are rich in

spirochetes and highly infectious.spirochetes and highly infectious. Contagious lesions may recur within 3-5 years after Contagious lesions may recur within 3-5 years after

infection, but thereafter the individual is non-infectious.infection, but thereafter the individual is non-infectious. Note that the course of syphilis is not affected by Note that the course of syphilis is not affected by

pregnancy and the risk of fetal infection pregnancy and the risk of fetal infection (congenital (congenital syphilis) syphilis) is 60% in 1° and 2° syphilis.is 60% in 1° and 2° syphilis.

Primary SyphilisPrimary Syphilis

Local multiplication at site of entry and Local multiplication at site of entry and spread to nearby lymph nodes and in blood spread to nearby lymph nodes and in blood stream occur 2-10 weeks after infection.stream occur 2-10 weeks after infection.

The primary lesion is a papule which The primary lesion is a papule which develops at the site of entry and breaks down develops at the site of entry and breaks down to form an ulcer with a clean, hard base. to form an ulcer with a clean, hard base. ((Hard chancre).Hard chancre).

The chancre is painless with lymphocytes The chancre is painless with lymphocytes and plasma cells predominating in the and plasma cells predominating in the inflammation.inflammation.

The primary lesion always heals The primary lesion always heals spontaneously.spontaneously.

Secondary SyphilisSecondary Syphilis This occurs 6 weeks - 6 months after the primary lesion.This occurs 6 weeks - 6 months after the primary lesion. Red maculopapular rash may occur anywhere in the body Red maculopapular rash may occur anywhere in the body

(may include hands and feet).(may include hands and feet). Moist pale papules (Moist pale papules (Condylomata lata):Condylomata lata):Flat topped Flat topped

papules occurring in groups covered by necrotic layer of papules occurring in groups covered by necrotic layer of epithelium and which secrete seropurulent fluid. epithelium and which secrete seropurulent fluid.

Sites for the condylomata lata include Sites for the condylomata lata include anusanus,, axillae, axillae, mouth mouth and in general wherever contiguous folds of skin and in general wherever contiguous folds of skin produce heat and moisture.produce heat and moisture.

Other Conditions in Secondary SyphilisOther Conditions in Secondary Syphilis Syphilitic meningitisSyphilitic meningitis ChorioretinitisChorioretinitis HepatitisHepatitis Nephritis-immune complex typeNephritis-immune complex type PeriostitisPeriostitis

Secondary lesions also resolve spontaneouslySecondary lesions also resolve spontaneously..

Latent SyphilisLatent Syphilis

This occurs in 1/3 of untreated This occurs in 1/3 of untreated cases.cases.

Serologic tests remain positive but Serologic tests remain positive but patient is asymptomatic.patient is asymptomatic.

The latent phase may last 2-20 yearsThe latent phase may last 2-20 years

Tertiary SyphilisTertiary Syphilis

The infection may remain sub-clinical and The infection may remain sub-clinical and patient may pass through the primary patient may pass through the primary and secondary stages with no symptoms and secondary stages with no symptoms and yet develop tertiary syphilisand yet develop tertiary syphilis

30% of patients achieve complete cure 30% of patients achieve complete cure from early syphilitic lesions.from early syphilitic lesions.

30% of untreated cases remain latent and 30% of untreated cases remain latent and the remainder may progress to tertiary the remainder may progress to tertiary syphilis.syphilis.

Lesions of Tertiary Lesions of Tertiary SyphilisSyphilis

Granulomatous lesionsGranulomatous lesions: Gummas appear : Gummas appear on skin, bones and liveron skin, bones and liver

CCNS NS : Degenerative changes: Degenerative changes Meningovascular syphilisMeningovascular syphilis ParesisParesis TabesTabes

CardiovascularCardiovascular Aortitis, Aortic aneurysm, Aortic valve insufficiencyAortitis, Aortic aneurysm, Aortic valve insufficiency

Treponemes are very rare in tertiary Treponemes are very rare in tertiary syphilis. syphilis.

Congenital SyphilisCongenital Syphilis Transplacental transmission to foetus beginning 10-15 weeks of Transplacental transmission to foetus beginning 10-15 weeks of

gestation.gestation. If the disease is discovered and treated before 18 weeks, the foetus If the disease is discovered and treated before 18 weeks, the foetus

appears to suffer few sequelae. After 18 weeks, signs of congenital appears to suffer few sequelae. After 18 weeks, signs of congenital syphilis occur in the foetus.syphilis occur in the foetus.

ImplicationsImplications a. Intra-uterine foetal death a. Intra-uterine foetal death B. MiscarriageB. Miscarriage C. Still birthsC. Still births

Signs of Congenital syphilis in Live-born Babies:Signs of Congenital syphilis in Live-born Babies: Interstitial keratitisInterstitial keratitis Hutchinson’s teethHutchinson’s teeth(notched and narrower incisal edge) and (notched and narrower incisal edge) and

Mulberry molarMulberry molar( with alternating nonanatomical depressions and ( with alternating nonanatomical depressions and rounded enamel nodules on it’s crown surface)rounded enamel nodules on it’s crown surface)

Saddle nose:Saddle nose: Markedly depressed nasal bridge. Markedly depressed nasal bridge. Periostitis Periostitis CNS abnormalities : CNS abnormalities : May include 8May include 8thth cranial nerve hearing loss. cranial nerve hearing loss.

DiagnosisDiagnosis Darkfield microscopyDarkfield microscopy Immunoflourescence staining Immunoflourescence staining A) A) Non-treponemal antibodiesNon-treponemal antibodies VDRL:VDRL: RPRRPR TRUST: Toluidine red unhealed TRUST: Toluidine red unhealed

serum testserum test VDRL/RPR VDRL/RPR become positive 2-3 become positive 2-3

weeks after infectionweeks after infection

VDRL/RPR become negative 6 months following VDRL/RPR become negative 6 months following treatment.treatment.

False positive may occur in malaria, leprosy, measles, False positive may occur in malaria, leprosy, measles, infectious mononucleosis, SLE, polyathritis nodosa.infectious mononucleosis, SLE, polyathritis nodosa.

1° syphilis-serology is negative and dark field 1° syphilis-serology is negative and dark field microscopy is positive microscopy is positive

2° syphilis both serology and Darkfield microscopy are 2° syphilis both serology and Darkfield microscopy are positive.positive.

3° syphilis serology is positive but darkfield 3° syphilis serology is positive but darkfield microscopy is negative.microscopy is negative.

TREPONEMAL ANTIBODIESTREPONEMAL ANTIBODIES FTAFTA (Fluorescent Trepanoma Antibody) (Fluorescent Trepanoma Antibody) TPHATPHA (Treponema Pallidum Haemagglutination Assay) (Treponema Pallidum Haemagglutination Assay) Treponema pallidum particle agglutination test Treponema pallidum particle agglutination test

( TPPA)( TPPA) Microhaemagglutination for T. pallidum (MHTP)Microhaemagglutination for T. pallidum (MHTP)

TreatmentTreatment Penicillin is the drug of choicePenicillin is the drug of choice Benzathine Penicillin 2.4 MU, IM as a single dose for Benzathine Penicillin 2.4 MU, IM as a single dose for

primary and secondary and latent syphilisprimary and secondary and latent syphilis If infection over 1 year give three doses at weekly If infection over 1 year give three doses at weekly

intervalinterval Erythromycin 500mg qid for 14 days may be used in Erythromycin 500mg qid for 14 days may be used in

penicillin allergypenicillin allergy Procaine penicillin 1.2 MU daily by IM for 12 days and Procaine penicillin 1.2 MU daily by IM for 12 days and

for 21 days in tertiary syphilis may also be used.for 21 days in tertiary syphilis may also be used.

Typical Jarisch-Herxheimer reaction within 12-24 hours Typical Jarisch-Herxheimer reaction within 12-24 hours of treatment may occur due to the release of pro-of treatment may occur due to the release of pro-inflammatory cytokines in response to dying organisms.inflammatory cytokines in response to dying organisms.

This may occur as fever or a rise in symptomsThis may occur as fever or a rise in symptoms

DeliveryDelivery

If no indication for a caesarean section If no indication for a caesarean section then vaginal delivery is indicated.then vaginal delivery is indicated.

ControlControl Prompt treatment of casesPrompt treatment of cases Follow up on source of infection and Follow up on source of infection and

sexual contactssexual contacts ABC of STI controlABC of STI control Maternal screening(VDRL)Maternal screening(VDRL)

HUMANHUMANCYTOMEGALOVIRUSCYTOMEGALOVIRUS

Human Cytomegalovirus (CMV), is Human Cytomegalovirus (CMV), is DNA herpesvirus also known as Human DNA herpesvirus also known as Human Herpes Virus 5 Herpes Virus 5

HCMV is one of the TORCH infections HCMV is one of the TORCH infections that lead to congenital abnormalitiesthat lead to congenital abnormalities

It has the ability with other Herpes It has the ability with other Herpes viruses to establish latencyviruses to establish latency

The incidence of infection in The incidence of infection in Pregnancy is not known precisely Pregnancy is not known precisely but it is estimated to be 1 in 200 but it is estimated to be 1 in 200 pregnancies, of which 40% will pregnancies, of which 40% will result in fetal Infection result in fetal Infection

Incidence is higher in women who Incidence is higher in women who are of low socioeconomic status or are of low socioeconomic status or who have poor personal hygiene.who have poor personal hygiene.

CMV resides in theCMV resides in the respiratory tractsrespiratory tracts Genitourinary tractsGenitourinary tracts CMV may be shed in bodily fluids CMV may be shed in bodily fluids

(urine, saliva, blood, tears, semen, (urine, saliva, blood, tears, semen, and breast milk) and breast milk)

Mode of transmission is thus through;Mode of transmission is thus through; Blood TransfusionBlood Transfusion Transplantation of OrgansTransplantation of Organs Close contacts: Kissing and Sexual Close contacts: Kissing and Sexual

ContactContact Acquired In uteroAcquired In utero BreastfeedingBreastfeeding

What are the symptoms of What are the symptoms of CMV?CMV?

Most children and adults who are Most children and adults who are infected with CMV do not develop infected with CMV do not develop symptoms, whereas others may symptoms, whereas others may experience an infectious experience an infectious mononucleosis-like symptoms, three mononucleosis-like symptoms, three to twelve weeks after exposure: to twelve weeks after exposure:

Fever Fever Swollen glands Swollen glands

ClassificationClassification

Primary InfectionPrimary Infection Secondary InfectionSecondary Infection

Primary InfectionPrimary Infection Primary Infection is CMV infection in a Primary Infection is CMV infection in a

previously seronegative person.previously seronegative person.

The virus becomes dormant and exists in a The virus becomes dormant and exists in a latent state, from which it can be latent state, from which it can be reactivated. Its reactivation is designated as reactivated. Its reactivation is designated as SECONDARY INFECTION. (ie. in SECONDARY INFECTION. (ie. in immunosuppressed state)immunosuppressed state)

However, there are several strains of CMV However, there are several strains of CMV that infect humans, so reinfection can that infect humans, so reinfection can occur, even in immunocompetent occur, even in immunocompetent individuals. individuals.

Secondary InfectionSecondary Infection

Secondary Infection is defined as Secondary Infection is defined as intermittent excretion of the virus, intermittent excretion of the virus, due to either reactivation of an due to either reactivation of an endogenous virus or exposure to a endogenous virus or exposure to a new virus strain from an exogenous new virus strain from an exogenous source.source.

Effects of Infection in Effects of Infection in PregnancyPregnancy

Congenital Cytomegalovirus Congenital Cytomegalovirus InfectionInfection

Spontaneous AbortionSpontaneous Abortion

Congenital Cytomegalovirus Congenital Cytomegalovirus InfectionInfection

This is the in utero infection of the fetus This is the in utero infection of the fetus with the Human Cytomegaloviruswith the Human Cytomegalovirus

Congenital infections are the result of Congenital infections are the result of transplacental transmission of CMV.transplacental transmission of CMV.

Transmission to the fetus may occur Transmission to the fetus may occur because of primary or secondary because of primary or secondary maternal infection.maternal infection.

The probability of intrauterine transmission following The probability of intrauterine transmission following primaryprimary

infection during pregnancy is 30% to 40%, infection during pregnancy is 30% to 40%, compared with only 1% following secondary infection. compared with only 1% following secondary infection.

10-15% percent of congenitally infected infants will 10-15% percent of congenitally infected infants will have symptoms at birth including ;have symptoms at birth including ;

intrauterine growth restriction,intrauterine growth restriction, microcephaly, microcephaly, hepatosplenomegaly,hepatosplenomegaly, petechiae, petechiae, jaundice,jaundice, chorioretinitis, chorioretinitis, thrombocytopenia,thrombocytopenia, anemiaanemia

20% to 30% of them will die, mostly of20% to 30% of them will die, mostly of disseminated intravascular coagulation,disseminated intravascular coagulation, hepatic dysfunction, hepatic dysfunction, bacterial superinfectionbacterial superinfection

Most of the congenitally infected infants (85–90%) Most of the congenitally infected infants (85–90%) have nohave no

signs or symptoms at birth.signs or symptoms at birth. 5% to 15% of them will develop sequelae such as 5% to 15% of them will develop sequelae such as sensorineural hearing loss, sensorineural hearing loss, delay of psychomotor developmentdelay of psychomotor development visual impairment.visual impairment.

Prenatal DiagnosisPrenatal Diagnosis

The first step in the prenatal diagnosis The first step in the prenatal diagnosis of congenital CMV infection is;of congenital CMV infection is;

Determination of maternal primary Determination of maternal primary

and secondaryand secondary infection by serological testing.infection by serological testing. In women with proven CMV infection, In women with proven CMV infection,

the second step is ;the second step is ; To identify fetal infectionTo identify fetal infection

Fetal Infection is determined by;Fetal Infection is determined by; non-invasive investigationsnon-invasive investigations

(ultrasound examination)(ultrasound examination) Invasive procedure (amniocentesis)Invasive procedure (amniocentesis)

Determination of maternal primary Determination of maternal primary and secondaryand secondary

infection by serological testing infection by serological testing

The diagnosis of primary CMV The diagnosis of primary CMV infection is ascertained when infection is ascertained when seroconversion is documentedseroconversion is documented

Seroconversion is the de novo Seroconversion is the de novo

appearance of virus-specific IgG in appearance of virus-specific IgG in the serum of a pregnant woman who the serum of a pregnant woman who was previously seronegative. was previously seronegative.

Serologic diagnosis of primary Serologic diagnosis of primary CMV infection during pregnancy is CMV infection during pregnancy is documented by eitherdocumented by either

seroconversion (the appearance of seroconversion (the appearance of CMV-specific IgG antibody in a CMV-specific IgG antibody in a previously seronegative woman) orpreviously seronegative woman) or

detection of specific IgM antibody detection of specific IgM antibody associated with low IgG avidity. associated with low IgG avidity.

Since intrauterine transmission of Since intrauterine transmission of the virus occurs in only 30% to 40% the virus occurs in only 30% to 40% of pregnancies in women with of pregnancies in women with primary infection and at a primary infection and at a significantly lower rate in women significantly lower rate in women with secondary infection, it is with secondary infection, it is important in cases of proven important in cases of proven maternal infection to find out if the maternal infection to find out if the fetus is infected.fetus is infected.

DIAGNOSIS OF FETAL DIAGNOSIS OF FETAL INFECTIONINFECTION

CMV isolation from amniotic fluid has CMV isolation from amniotic fluid has been recognized as the gold standard for been recognized as the gold standard for prenatal diagnosis of fetal CMV infection.prenatal diagnosis of fetal CMV infection.

To achieve the highest sensitivity, the To achieve the highest sensitivity, the amniocentesis should be performed until amniocentesis should be performed until at least 7 weeks after the onset of at least 7 weeks after the onset of maternal infection and after 21 weeks of maternal infection and after 21 weeks of gestation because a detectable quantity of gestation because a detectable quantity of the virus is not secreted to the amniotic the virus is not secreted to the amniotic fluid until 5 to 7 weeks after fetal infection fluid until 5 to 7 weeks after fetal infection and replication of the virus in the kidneyand replication of the virus in the kidney

Ultrasonographic findings are Ultrasonographic findings are helpful but not diagnostic because helpful but not diagnostic because CMV has features in common with CMV has features in common with other intrauterine infections and other intrauterine infections and with other fetal diseases. Moreover, with other fetal diseases. Moreover, these abnormalities are observed in these abnormalities are observed in less than 25% of infected fetuses.less than 25% of infected fetuses.

The most frequently reported sonographic findings of The most frequently reported sonographic findings of fetal CMV infection include:fetal CMV infection include:

fetal growth restriction, fetal growth restriction, cerebral ventriculomegaly, cerebral ventriculomegaly, ascites,ascites, intracranial calcifications, intracranial calcifications, abnormality of amniotic fluid volumeabnormality of amniotic fluid volume(usually oligohydramnios), (usually oligohydramnios), microcephaly, microcephaly, Hyperechogenic bowel, Hyperechogenic bowel, hydrops fetalis,hydrops fetalis, pleural effusion, and pleural effusion, and Liver calcificationsLiver calcifications

TREATMENTTREATMENT

Despite advances in the diagnosis of Despite advances in the diagnosis of fetal CMV infection, there is no effective fetal CMV infection, there is no effective therapy.therapy.

There are no treatments for prenatal or There are no treatments for prenatal or postnatal therapy of the infection. postnatal therapy of the infection.

Vaccines for treatment are still in the Vaccines for treatment are still in the research and developmental stages.research and developmental stages.

How can CMV be prevented?How can CMV be prevented?

Transmission of cytomegalovirus is often Transmission of cytomegalovirus is often preventable because it is most often transmitted preventable because it is most often transmitted through infected bodily fluids that come in through infected bodily fluids that come in contact with hands and then are absorbed contact with hands and then are absorbed through the nose or mouth of a susceptible through the nose or mouth of a susceptible person.person.

People who interact with children should use People who interact with children should use safe hygiene practices including good hand safe hygiene practices including good hand washing and wearing gloves when changing washing and wearing gloves when changing diapers. diapers.

Hand washing with soap and water is effective Hand washing with soap and water is effective in preventing the spread of CMVin preventing the spread of CMV

If you develop a mononucleosis-like If you develop a mononucleosis-like illness, you should be checked for illness, you should be checked for CMV infection CMV infection

Refrain from sharing food, eating Refrain from sharing food, eating utensils and drinking utensils with utensils and drinking utensils with anyone. anyone.

Your doctor can test the CMV Your doctor can test the CMV antibodies to determine if you have antibodies to determine if you have already had CMV infection. already had CMV infection.

Pregnant women who are infected Pregnant women who are infected with CMV rarely have symptoms, but with CMV rarely have symptoms, but rather their developing baby may be rather their developing baby may be at risk for at risk for

Congenital CMV Infection and its Congenital CMV Infection and its associted problems to the new bornassocited problems to the new born

Bacterial vaginosisBacterial vaginosis

Bacterial vaginosis is the commonest cause Bacterial vaginosis is the commonest cause of abnormal vaginal discharge in women of of abnormal vaginal discharge in women of reproductive age. It is characterised by an reproductive age. It is characterised by an increase in the concentration of anaerobic increase in the concentration of anaerobic organisms in the vagina accompanied by a organisms in the vagina accompanied by a rise in vaginal PH to b/n 4.5-7.0rise in vaginal PH to b/n 4.5-7.0

Organisms often associated with BV are Organisms often associated with BV are Gardnerella vaginalis, Bacteroides spp , Gardnerella vaginalis, Bacteroides spp , Mobiluncus spp and Mycoplasma hominisMobiluncus spp and Mycoplasma hominis

TOXOPLASMOSIS AND TOXOPLASMOSIS AND PREGNANCYPREGNANCY

Toxoplasmosis is the disease Toxoplasmosis is the disease syndrome caused by a protozoan syndrome caused by a protozoan organism called organism called Toxoplasma Toxoplasma gondiigondii. . It affects most animals most notably It affects most animals most notably sheep, cats, and humans. However sheep, cats, and humans. However the primary host is the the primary host is the felid (cat) familyfelid (cat) family

EpidemiologyEpidemiology

Evidence of prior infection with Evidence of prior infection with T. gondii T. gondii is commonis common

throughout the world. In the United States, the overallthroughout the world. In the United States, the overall

age-adjusted seroprevalence is 22.5%,2 and 15% amongage-adjusted seroprevalence is 22.5%,2 and 15% among

women of childbearing age (15 to 44 years). There arewomen of childbearing age (15 to 44 years). There are

approximately 225,000 cases of approximately 225,000 cases of T. gondii T. gondii infection per year,infection per year,

which result in 5000 hospitalizations and 750 deaths, which result in 5000 hospitalizations and 750 deaths, makingmaking

T. gondii T. gondii the third most common cause of fatal foodbornethe third most common cause of fatal foodborne

illness in the country.illness in the country.

Mode of transmissionMode of transmissionTransmission is Transmission is

a.a.by eating raw or undercooked infected meat, by eating raw or undercooked infected meat,

b.b.by by ingestion of ingestion of fecesfeces of a of a catcat that has itself that has itself recently been infected, orrecently been infected, or

c.c. by transmission from mother to fetus by transmission from mother to fetus transplacentally. transplacentally.

Although cats are often blamed for spreading Although cats are often blamed for spreading toxoplasmosis, contact with raw meat is a toxoplasmosis, contact with raw meat is a more significant source of human infections in more significant source of human infections in many countries, and fecal contamination of many countries, and fecal contamination of hands is a greater risk factor.hands is a greater risk factor.

What are the risk of getting What are the risk of getting Toxoplasmosis Toxoplasmosis

Toxoplasmosis rarely causes any symptoms in otherwise Toxoplasmosis rarely causes any symptoms in otherwise

healthy adults. However, those with a healthy adults. However, those with a

weakened immune systemweakened immune system, such as , such as pregnantpregnant women,and women,and

AIDS patients may become seriously ill, and it can AIDS patients may become seriously ill, and it can

occasionally be fatal.occasionally be fatal.

Primary infection in pregnant women can be transmitted Primary infection in pregnant women can be transmitted

transplacentally to the fetus.transplacentally to the fetus.

Transmission of Toxoplasma to a fetus is extraordinarily Transmission of Toxoplasma to a fetus is extraordinarily

rare in immunocompetent mothers who have had rare in immunocompetent mothers who have had

toxoplasmosis earlier in life. ie Past infection confers toxoplasmosis earlier in life. ie Past infection confers

resistance to reinfection..resistance to reinfection..

And most new infections in pregnancy are due to And most new infections in pregnancy are due to

reactivation of a prior infection.reactivation of a prior infection.

The fetus’ risk of becoming infected rises as your The fetus’ risk of becoming infected rises as your

pregnancy progresses. pregnancy progresses. If pregnant woman get infected with toxoplasmosis in If pregnant woman get infected with toxoplasmosis in

the first trimester, the risk that the fetus will also be the first trimester, the risk that the fetus will also be infected is about infected is about 15 percent15 percent. .

If pregnant woman get infected in the second If pregnant woman get infected in the second

trimester, the fetus risk is about trimester, the fetus risk is about 30 percent30 percent, and, and

in the third trimester ,it's in the third trimester ,it's 60 percent60 percent. .

NOTE: NOTE: Although the transmission rate is higher in late Although the transmission rate is higher in late

pregnancy, the severity of congenital toxoplasmosis is pregnancy, the severity of congenital toxoplasmosis is

highest if the fetus becomes infected in the first highest if the fetus becomes infected in the first

trimester.trimester.

Symptoms and signs in Symptoms and signs in a pregnant womana pregnant woman

Pregnant women infected with T. gondii Pregnant women infected with T. gondii generally do not have clinical manifestations, generally do not have clinical manifestations, although some may have although some may have a mild mononucleosis-like syndrome a mild mononucleosis-like syndrome o fever, fever, oMuscle stiffness, Muscle stiffness, ojoint pain, joint pain, oFatigueFatigueregional lymphadenopathy,regional lymphadenopathy,Hepatomegaly and slenomegaly ORHepatomegaly and slenomegaly ORoccasionally chorioretinitis. occasionally chorioretinitis.

These symptoms may be so mild as These symptoms may be so mild as

to go unnoticed. Illness lasts 1 to 12 to go unnoticed. Illness lasts 1 to 12

weeks and is often dismissed asweeks and is often dismissed as

a bad cold or mononucleosis.a bad cold or mononucleosis.

Symptoms and signs in the Symptoms and signs in the neonateneonate

( Congenital Toxoplasmosis )( Congenital Toxoplasmosis )Most neonates are asymptomatic at Most neonates are asymptomatic at birth on routine pediatric examination. birth on routine pediatric examination.

Clinical manifestations of Clinical manifestations of toxoplasmosis in fetuses and neonates toxoplasmosis in fetuses and neonates vary. vary.

The classic triad of findings consists of The classic triad of findings consists of chorioretinitis, chorioretinitis, hydrocephalus, and hydrocephalus, and intracranial calcificationsintracranial calcificationsHowever this typical triad of signs does However this typical triad of signs does not always occur. not always occur.

Other signs suggestive of Other signs suggestive of Toxoplasmosis in the neonateToxoplasmosis in the neonate

feverfever microcephaly, microcephaly, seizures seizures PrematurityPrematurity Intrauterine growth restriction (small-for-Intrauterine growth restriction (small-for-

gestational-age )gestational-age ) JaundiceJaundice Hepatosplenomegaly Hepatosplenomegaly MyocarditisMyocarditis PneumonitisPneumonitis ThrombocytopeniaThrombocytopenia Various rashesVarious rashes Neurologic involvement which includes Neurologic involvement which includes

chorioretinitis, hydrocephalus, intracranial chorioretinitis, hydrocephalus, intracranial calcifications, microcephaly and seizures often calcifications, microcephaly and seizures often prominent .prominent .

Nevertheless, Deafness, mental Nevertheless, Deafness, mental retardation, and learning retardation, and learning difficulties are often detected only difficulties are often detected only later in life.later in life.

InvestigationsInvestigations Serial IgG measurement (for maternal infection)Serial IgG measurement (for maternal infection) Amniotic fluid PCR (for fetal infection)Amniotic fluid PCR (for fetal infection) Serologic testing, brain imaging, CSF analysis, Serologic testing, brain imaging, CSF analysis,

and ophthalmologic evaluation (for neonatal and ophthalmologic evaluation (for neonatal infection)infection)

The most reliable Serologic testing are The most reliable Serologic testing are the Sabin-Feldman dye test, the Sabin-Feldman dye test, the indirect immunofluorescent antibody (IFA) the indirect immunofluorescent antibody (IFA)

test, and test, and the direct agglutination assaythe direct agglutination assay


Sometimes spiramycin for pregnant Sometimes spiramycin for pregnant womenwomen

Pyrimethamine , sulfadiazine , and Pyrimethamine , sulfadiazine , and leucovorin for neonatesleucovorin for neonates

PreventionPrevention1.1. Probably the most important thing is to be careful Probably the most important thing is to be careful

when cooking raw meat, especially lamb and pork. when cooking raw meat, especially lamb and pork. A PREGNANT WOMAN NOT EAT MEAT OR TASTE A PREGNANT WOMAN NOT EAT MEAT OR TASTE MEAT BEFORE IT IS FINISHED COOKING.MEAT BEFORE IT IS FINISHED COOKING.

2.2. Avoid handling cat or changing cat litter if Avoid handling cat or changing cat litter if possible. If she must do it, she must wear gloves possible. If she must do it, she must wear gloves and wash her hands thoroughly afterward. and wash her hands thoroughly afterward.

3.3. Wearing gloves during any contact with soil or Wearing gloves during any contact with soil or sand because it might contain cat feces. Wash sand because it might contain cat feces. Wash hands thoroughly after coming in contact with soil hands thoroughly after coming in contact with soil or sand.or sand.

4.4. Cook foods at safe temperatures and use a food Cook foods at safe temperatures and use a food thermometer to ensure that meat is cooked thermometer to ensure that meat is cooked thoroughly. The meat should not look pink and the thoroughly. The meat should not look pink and the juices should be clear.juices should be clear.

Prevention…continuePrevention…continue

5. A pregnant woman should not drink raw 5. A pregnant woman should not drink raw milk, especially goat’s milkmilk, especially goat’s milk

6. Peel or thoroughly wash fruits and 6. Peel or thoroughly wash fruits and vegetables before eating. vegetables before eating.

7. Wash cutting boards, dishes, counters, 7. Wash cutting boards, dishes, counters, utensils and hands with hot, soapy water utensils and hands with hot, soapy water after they have come in contact with raw after they have come in contact with raw foods.foods.

Risk factorsRisk factors

Women with IUCDWomen with IUCDWomen of afro-caribbean descentWomen of afro-caribbean descentPregnancyPregnancyFrequent douchingFrequent douchingMultiple sexual partners Multiple sexual partners Frequent use of antibiotics Frequent use of antibiotics Women who undergo termination of Women who undergo termination of pregnancypregnancySexually active women b/n 15 and 44 yearsSexually active women b/n 15 and 44 years

pathophysiologypathophysiology

BV arises from chemical and BV arises from chemical and biological imbalances that disrupts biological imbalances that disrupts the normal vaginal flora, allowing the normal vaginal flora, allowing anaerobes which are in lower anaerobes which are in lower concentrations to over-grow whiles concentrations to over-grow whiles reducing the amounts of reducing the amounts of lactobacillus in the vaginalactobacillus in the vagina

SymptomsSymptoms

The principal symptom of bacterial The principal symptom of bacterial vaginosis is fishy smelling discharge. vaginosis is fishy smelling discharge. It is characteristically thin, It is characteristically thin, homogeneous and adherent to the homogeneous and adherent to the walls of the vagina and may be white walls of the vagina and may be white or yellow in colour. The smell is or yellow in colour. The smell is particularly noticeable around the particularly noticeable around the time of menstruation or following time of menstruation or following intercourseintercourse

Effect of BV on pregnancyEffect of BV on pregnancy

MATERNAL EFFECTSMATERNAL EFFECTSSecond trimester abortionsSecond trimester abortionsInfection of foetal membranesInfection of foetal membranesPreterm premature rupture of membranesPreterm premature rupture of membranesPreterm deliveryPreterm deliveryPuerperal sepsisPuerperal sepsis

FETAL COMPLICATIONSFETAL COMPLICATIONSStill birthStill birthIUGRIUGRLow birth weightLow birth weightNeonatal sepsisNeonatal sepsis

Effects of pregnancy on Effects of pregnancy on BVBV

Not much is known about the effects Not much is known about the effects of pregnancy on BV but it is believed of pregnancy on BV but it is believed that increase in levels of stress that increase in levels of stress hormone (cortisol) during pregnancy hormone (cortisol) during pregnancy with resultant fall in immunity may with resultant fall in immunity may account for the increase in cases of account for the increase in cases of BV in pregnancyBV in pregnancy

DiagnosisDiagnosis

Diagnosis is made in the clinical setting Diagnosis is made in the clinical setting using the composite(Amsel) criteria.using the composite(Amsel) criteria.1)Vaginal PH>4.51)Vaginal PH>4.52)Release of a fishy smell on addition of 2)Release of a fishy smell on addition of alkali(10% KOH). Positive amine(whiff) testalkali(10% KOH). Positive amine(whiff) test3)A characteristic discharge on 3)A characteristic discharge on examinationexamination4)Presence of clue cells on microscopy4)Presence of clue cells on microscopy

NB. At least 3 of the four conditions must NB. At least 3 of the four conditions must be present to make a diagnosis of BVbe present to make a diagnosis of BV


a)PREVENTIONa)PREVENTIONPrevention is aimed at avoiding any Prevention is aimed at avoiding any activity that has the tendency to disrupt activity that has the tendency to disrupt the normal vaginal flora and these the normal vaginal flora and these includeinclude1)Avoiding douching1)Avoiding douching2)Avoiding prolonged and repetitive use 2)Avoiding prolonged and repetitive use of antibioticsof antibiotics3)Good sexual practices3)Good sexual practices4) Good hygienic practices especially in 4) Good hygienic practices especially in the area around the genitalsthe area around the genitals

Management 2Management 2

B) TREATMENTB) TREATMENT

This involves the use of antibiotics and This involves the use of antibiotics and the one commonly used is the one commonly used is metronidazole. metronidazole.

Regimen: 500mg bd for 7 days Regimen: 500mg bd for 7 days

NB clindamycin can also be usedNB clindamycin can also be used

Complications of BVComplications of BV

May predispose to other forms of May predispose to other forms of vaginal infections and STI’s eg herpes vaginal infections and STI’s eg herpes and gonorrhea.and gonorrhea.

May cause second trimester abortionsMay cause second trimester abortions

May lead to preterm labourMay lead to preterm labour

May lead to infected surgical scarsMay lead to infected surgical scars

TRICHOMONIASIS IN TRICHOMONIASIS IN PREGNANCYPREGNANCY

Trichomoniasis, commonly known as Trichomoniasis, commonly known as ‘trich’ is a sexually transmitted ‘trich’ is a sexually transmitted disease that is caused by a disease that is caused by a microscopic parasite, microscopic parasite, Trichomonas Trichomonas vaginalisvaginalis

How does it present?How does it present?

AsymptomaticAsymptomatic Yellowish or greenish vaginal Yellowish or greenish vaginal

discharge with a frothy appearance discharge with a frothy appearance and an unpleasant odour.and an unpleasant odour.

Vulva irritations and itchVulva irritations and itch Discomfort on urination or intercourseDiscomfort on urination or intercourse Less commonly lower abdominal Less commonly lower abdominal

discomfort.discomfort.

Symptoms may appear soon after the Symptoms may appear soon after the infection is contracted or later so the infection is contracted or later so the appearance of symptoms does not appearance of symptoms does not necessarily mean that the infection necessarily mean that the infection was acquired recently.was acquired recently.

Effects of trichomoniasis on Effects of trichomoniasis on pregnancypregnancy

Preterm birthPreterm birth Preterm premature rapture of Preterm premature rapture of

membranes(PPROM)membranes(PPROM) Low birth weightLow birth weight It also increases susceptibility to HIV It also increases susceptibility to HIV

infection if the woman is exposed to it.infection if the woman is exposed to it. There could also be a possible There could also be a possible

infection of the baby during delivery.infection of the baby during delivery.


The specimen taken is a high vaginal The specimen taken is a high vaginal swab for microscopy and culture.swab for microscopy and culture.

MicroscopyMicroscopy; the vaginal secretion is ; the vaginal secretion is mixed with saline and viewed under the mixed with saline and viewed under the microscope. It shows numerous microscope. It shows numerous polymorphonuclear cells and motile polymorphonuclear cells and motile organisms with 4 moving flagellae—the organisms with 4 moving flagellae—the trichomonads.(has 50-60% sensitivity)trichomonads.(has 50-60% sensitivity)

CultureCulture; the vaginal secretion can be ; the vaginal secretion can be cultured using the Fineberg-Whittington cultured using the Fineberg-Whittington medium.medium.

treatmenttreatment

It is treated with a course of oral It is treated with a course of oral metronidazole,metronidazole,

The partner should be treated as The partner should be treated as well whether he is showing well whether he is showing symptoms or not.symptoms or not.

They are to abstain from sex until They are to abstain from sex until they have finished the treatment and they have finished the treatment and are symptom-free.are symptom-free.

PreventionPrevention

Having one faithful sexual partnerHaving one faithful sexual partner Protection using condoms during Protection using condoms during

sexual intercoursesexual intercourse

RUBELLARUBELLA

AETIOLOGYAETIOLOGY A disease caused by rubella virus.A disease caused by rubella virus. In the adult it is usually a mild febrile In the adult it is usually a mild febrile

illness with a faint rash.illness with a faint rash. Rubella is important because of the damage Rubella is important because of the damage

it can cause to the foetus when a mother it can cause to the foetus when a mother contracts the infection during pregnancy.contracts the infection during pregnancy.

Incubation period is from 14-23 daysIncubation period is from 14-23 days Period of infectivity is from a week to 5days Period of infectivity is from a week to 5days

after the appearance of the rash.after the appearance of the rash. Mode of transmission is through Mode of transmission is through

respiratory droplets and contacts.respiratory droplets and contacts. Infection of women in the first 12weeks of Infection of women in the first 12weeks of

pregnancy carries a very high risk(95%) of pregnancy carries a very high risk(95%) of fetal infection. In 20% of these serious fetal infection. In 20% of these serious damage to the fetus occurs.damage to the fetus occurs.

CLINICAL FEATURESCLINICAL FEATURESIn the adult;In the adult; Mild feverMild fever Sore throat Sore throat Enlarged tender lymph nodes (occipital ,retro Enlarged tender lymph nodes (occipital ,retro

auricular, posterior cervical.auricular, posterior cervical.

In the baby;In the baby; Immediately after birth; Immediately after birth;

Gregg’s triad-Gregg’s triad-CataractCataract, , Congenital heart Congenital heart diseasedisease and and deafnessdeafness..

First week of life; Hepatosplenomegaly, First week of life; Hepatosplenomegaly, Jaundice, Hypertonia, Lethargy, Convulsions, Jaundice, Hypertonia, Lethargy, Convulsions, Cloudiness of cornea, Microophthalmia, Cloudiness of cornea, Microophthalmia, Respiratory distress, LBW, PurpuraRespiratory distress, LBW, Purpura

DIAGNOSISDIAGNOSIS Rubella should be suspected in any SGA baby born with Rubella should be suspected in any SGA baby born with

congenital anomaliescongenital anomalies Congenital rubella can be diagnosed by detecting the Congenital rubella can be diagnosed by detecting the

virus in secretions from the throat, urine, stool, CSF, virus in secretions from the throat, urine, stool, CSF, blood, eyes, ears.blood, eyes, ears.

Maternal diagnosis is based on serologyMaternal diagnosis is based on serology A high IgG Ab titre is suggestive of recent infectionA high IgG Ab titre is suggestive of recent infection

PREVENTIONPREVENTIONThere is no specific treatment available so There is no specific treatment available so

prevention is the key.prevention is the key.*Vaccination with MMR between 9 and 12 months of *Vaccination with MMR between 9 and 12 months of

life.life.*Non immune women are advised to stay away from *Non immune women are advised to stay away from

known cases of rubella. known cases of rubella. *Encouragement of natural infection early in female *Encouragement of natural infection early in female

childrenchildren

PARVOVIRUS B19PARVOVIRUS B19 CHARACTERISTICSCHARACTERISTICS Non-enveloped virus with icosahedral symmetry Non-enveloped virus with icosahedral symmetry

and single stranded linear DNA genome. Virion and single stranded linear DNA genome. Virion contains no polymerase. There is one serotype.contains no polymerase. There is one serotype.

TRANSMISSIONTRANSMISSION Respiratory secretions, droplets and Respiratory secretions, droplets and

transplacental.transplacental.

DISEASESDISEASES Slapped cheek syndrome ( erythema Slapped cheek syndrome ( erythema

infectiosum), aplastic anemia, hydrops fetalis infectiosum), aplastic anemia, hydrops fetalis ( from maternal infection ) with risk of fetal loss ( from maternal infection ) with risk of fetal loss of 10% in infection before 20 weeks.of 10% in infection before 20 weeks.

PATHOGENESISPATHOGENESIS

1.1. The virus induces immune complex formation that deposit The virus induces immune complex formation that deposit in joints and the skin, causing ‘erythema infectiosum’.in joints and the skin, causing ‘erythema infectiosum’.

2.2. Virus preferentially infects erythroblasts, causing aplastic Virus preferentially infects erythroblasts, causing aplastic anemia in patients especially those with hereditary anemia in patients especially those with hereditary anemias. The virus can infect the fetus and cause severe anemias. The virus can infect the fetus and cause severe anemia, leading to congestive heart failure and edema anemia, leading to congestive heart failure and edema ( hydrops fetalis ).( hydrops fetalis ).

DIAGNOSISDIAGNOSIS Clinical, by characteristic rash and Serology.Clinical, by characteristic rash and Serology.

TREATMENTTREATMENT No specific antiviral therapy.No specific antiviral therapy. Supportive. IV gamma globulin may be given to women in Supportive. IV gamma globulin may be given to women in

aplastic crises with viraemia.aplastic crises with viraemia.

PREVENTIONPREVENTION There is no drug or vaccine.There is no drug or vaccine.

HEPATITIS BHEPATITIS B & &

PREGNANCYPREGNANCY

Hepatitis BHepatitis B

Hepatitis BHepatitis B is an infectious illness is an infectious illness caused by caused by hepatitis B virushepatitis B virus (HBV) (HBV) which infects the which infects the liverliver of of hominoideahominoidea, including humans, and causes an , including humans, and causes an inflammationinflammation called called hepatitishepatitis. .

Hepatitis BHepatitis B

About a third of the About a third of the world's populationworld's population, more than 2 , more than 2 billion people, have been infected billion people, have been infected with the hepatitis B virus. with the hepatitis B virus.

This includes 350 million This includes 350 million chronic carrierschronic carriers of the virus. of the virus.

Hepatitis B – modes of Hepatitis B – modes of transmissiontransmission

Infected body fluidsInfected body fluids Blood > semen or vaginal mucus > saliva, Blood > semen or vaginal mucus > saliva,

tears, breast milktears, breast milk No virus in urine, faeces, or sweatNo virus in urine, faeces, or sweat

Sexual Sexual (30% of sexual partners infected)(30% of sexual partners infected) Perinatal Perinatal (neonatal contact with mother’s (neonatal contact with mother’s

blood at delivery)blood at delivery) NeedlestickNeedlestick (= very high risk; much greater (= very high risk; much greater

than HIV)than HIV) Blood transfusionBlood transfusion (mostly historical)(mostly historical)

Signs and Signs and symptoms:symptoms:Acute InfectionAcute Infection

Acute infection with Acute infection with hepatitis B virus is hepatitis B virus is associated with acute viral associated with acute viral hepatitishepatitis an illness that an illness that begins with begins with

general ill-healthgeneral ill-health loss of appetiteloss of appetite nauseanausea vomitingvomiting body achesbody aches mild fevermild fever dark urine and then dark urine and then

progresses to development progresses to development of of jaundicejaundice

Signs and symptoms:Signs and symptoms:Acute InfectionAcute Infection

The illness lasts for a few weeks and The illness lasts for a few weeks and then gradually improves in most then gradually improves in most affected people. affected people.

A few patients may have more severe A few patients may have more severe liver disease (liver disease (fulminantfulminant hepatic failure hepatic failure), and may die as a result of it. ), and may die as a result of it.

The infection may be entirely The infection may be entirely asymptomatic and may go asymptomatic and may go unrecognized.unrecognized.

Signs and symptoms:Signs and symptoms:Chronic InfectionChronic Infection

Chronic infection with hepatitis B virus Chronic infection with hepatitis B virus may be either asymptomatic or may be may be either asymptomatic or may be associated with a chronic inflammation associated with a chronic inflammation of the liver (chronic hepatitis), leading of the liver (chronic hepatitis), leading to to cirrhosiscirrhosis over a period of several over a period of several years. years.

This type of infection dramatically This type of infection dramatically increases the incidence of increases the incidence of hepatocellularhepatocellular carcinoma carcinoma (liver cancer) (liver cancer)

Natural course of Natural course of Hepatitis BHepatitis B

Infectious contact

<1% fulminant hepatitis

Complete recovery(95% of adults;5-10% of neonates)

Chronic infection

(5% of adults;90-95% of neonates)

Asymptomatic carriers(80%)

Cirrhosis or cancer

(20%)

~1% of all infected people

Acute hepatitis

~12 weeks (35%)

Transient, asymptomatic infection (65%)

Effects During PregnancyEffects During Pregnancy

When a pregnant woman is infected When a pregnant woman is infected with hepatitis B virus, there is a chance with hepatitis B virus, there is a chance she will infect her fetus. Whether the she will infect her fetus. Whether the baby will get the virus depends on when baby will get the virus depends on when infection occurred.infection occurred.

If it was early in pregnancy(1If it was early in pregnancy(1STST trimester ), the chances are less than trimester ), the chances are less than 10% that the baby will get the virus. If it 10% that the baby will get the virus. If it was late in pregnancy (3was late in pregnancy (3RDRD trimester), there is up to a 90% chance trimester), there is up to a 90% chance that the baby will be infected. that the baby will be infected.


HBV infection does not appear to cause birth HBV infection does not appear to cause birth defects, but there appears to be a higher defects, but there appears to be a higher incidence of low birth weight among infants born incidence of low birth weight among infants born to mothers with acute infection during to mothers with acute infection during pregnancypregnancy

In one small study,acute maternal hepatitis (type In one small study,acute maternal hepatitis (type B or nontype B) had no effect on the incidence of B or nontype B) had no effect on the incidence of congenital malformations, stillbirths, abortions, congenital malformations, stillbirths, abortions, or intrauterine malnutrition. However, acute or intrauterine malnutrition. However, acute hepatitis did increase the incidence of hepatitis did increase the incidence of prematurityprematurity


Hepatitis can be severe in babies. It can Hepatitis can be severe in babies. It can threaten their lives. Even babies who threaten their lives. Even babies who appear well may be at risk for serious appear well may be at risk for serious health problems. health problems.

Infected newborns have a high risk (up to Infected newborns have a high risk (up to 90%) of becoming carriers. They, too, can 90%) of becoming carriers. They, too, can pass the virus to others when they pass the virus to others when they become adults.become adults.

Effect of Pregnancy on Effect of Pregnancy on Hepatitis BHepatitis B

In general, women with chronic hepatitis B do In general, women with chronic hepatitis B do well during pregnancy. However, pregnancy is well during pregnancy. However, pregnancy is associated with high levels of adrenal associated with high levels of adrenal corticosteroids, which is postulated to corticosteroids, which is postulated to increase levels of viraemia. increase levels of viraemia.

It has been known for some time that a It has been known for some time that a proportion of women have hepatitis flares with proportion of women have hepatitis flares with or without HBeAg seroconversion within the or without HBeAg seroconversion within the first months after delivery.first months after delivery. Seroconversion Seroconversion rates of 12.5%rates of 12.5% to 17% have been described.to 17% have been described.

Effect of Pregnancy on Effect of Pregnancy on Hepatitis BHepatitis B

Also, cases of exacerbation of Also, cases of exacerbation of hepatitishepatitis and even fulminant hepatic and even fulminant hepatic failure have been described in the failure have been described in the peripartum period. peripartum period.

It therefore appears prudent to It therefore appears prudent to monitor HBV-infected women closely monitor HBV-infected women closely for several months after delivery for for several months after delivery for hepatitis flares and seroconversion.hepatitis flares and seroconversion.

Hepatitis B- DiagnosisHepatitis B- Diagnosis The tests, called The tests, called assaysassays, for detection of hepatitis B , for detection of hepatitis B

virus infection involve virus infection involve serumserum or or blood testsblood tests that detect that detect either viral antigens (proteins produced by the virus) or either viral antigens (proteins produced by the virus) or antibodiesantibodies produced by the host. produced by the host.

The hepatitis B surface antigen The hepatitis B surface antigen ((HBsAgHBsAg) ) is most is most frequently used to screen for the presence of this frequently used to screen for the presence of this infectioninfection. .

It is the It is the first detectable viral antigen first detectable viral antigen to appear to appear during infection. However, early in an infection, during infection. However, early in an infection, this antigen may not be present and it may be this antigen may not be present and it may be undetectable later in the infection as it is being undetectable later in the infection as it is being cleared by the hostcleared by the host

PreventionPrevention

Hepatitis B is transmitted through body Hepatitis B is transmitted through body fluids; prevention is thus through the fluids; prevention is thus through the avoidance of such transmission:avoidance of such transmission:

unprotected sexual contactunprotected sexual contact blood transfusionsblood transfusions re-use of contaminated needles and re-use of contaminated needles and

syringessyringes vertical transmission during child birthvertical transmission during child birth

Hepatitis B – Drug Hepatitis B – Drug TreatmentTreatment

Available Drugs :Available Drugs :

Interferon Interferon (must be given by injection)(must be given by injection) HBV polymerase (RT) inhibitors (originally HBV polymerase (RT) inhibitors (originally

for HIV)for HIV) lamivudinelamivudine adefoviradefovir entecavirentecavir telbivudinetelbivudine tenofovirtenofovir

Drug resistance is commonDrug resistance is common Drug combinationsDrug combinations

Hepatitis B – Hepatitis B – ImmunizationImmunization

PassivePassive HB immune globulin (HBIG)HB immune globulin (HBIG) effective in emergencies (e.g., needlestick)effective in emergencies (e.g., needlestick) ExpensiveExpensive

ActiveActive recombinant HBV vaccine (HBsAg)recombinant HBV vaccine (HBsAg) 3 doses (0, 1 mo., 6 mos.) – revaccination not 3 doses (0, 1 mo., 6 mos.) – revaccination not

necessarynecessary

Candidates:Candidates: infants born to HBsAg+ mothers (+HBIG)infants born to HBsAg+ mothers (+HBIG) people with occupational riskpeople with occupational risk all sexually active peopleall sexually active people sexual partners of carrierssexual partners of carriers

TREATMENT DURING TREATMENT DURING PREGNANCYPREGNANCY

Pregnancy is not a contraindication to Pregnancy is not a contraindication to vaccination.vaccination.

The use of active and passive immunoprophylaxis The use of active and passive immunoprophylaxis to reduce the risk of perinatal transmission of to reduce the risk of perinatal transmission of HBV is well accepted in clinical practice.HBV is well accepted in clinical practice.

HBIg given at the time of birth in combination HBIg given at the time of birth in combination with three doses of the recombinant hepatitis B with three doses of the recombinant hepatitis B vaccine given over the first 6 months of life has vaccine given over the first 6 months of life has been up to 95% effective in preventing perinatal been up to 95% effective in preventing perinatal transmissiontransmission

TREATMENT DURING TREATMENT DURING PREGNANCYPREGNANCY

Viable treatment choices are Viable treatment choices are limited to lamivudine, tenofovir, limited to lamivudine, tenofovir, and telbivudine. Of these, and telbivudine. Of these, lamivudinelamivudine and and tenofovir tenofovir appear appear to be the therapeutic options to be the therapeutic options with reasonable human with reasonable human exposure and safety data in exposure and safety data in pregnancy. pregnancy.

Pregnant Hepatitis B carriers Pregnant Hepatitis B carriers should be advised toshould be advised to

• • Abstain form alcohol useAbstain form alcohol use

• • Avoid hepatotoxic drugs such as acetaminophen Avoid hepatotoxic drugs such as acetaminophen (Tylenol) that may worsen liver damage. (Tylenol) that may worsen liver damage.

• • Not donate blood and body organsNot donate blood and body organs

• • Not share any personal items that may have Not share any personal items that may have blood on them (e.g., toothbrushes and razors).blood on them (e.g., toothbrushes and razors).

• • Inform the infant’s pediatrician, OB/GYN, and Inform the infant’s pediatrician, OB/GYN, and labour staff that they are hepatitis B carriers. labour staff that they are hepatitis B carriers.

Pregnant Hepatitis B carriers Pregnant Hepatitis B carriers should be advised toshould be advised to

• • Make sure their baby receives hepatitis B Make sure their baby receives hepatitis B vaccine at birth, one month, and six months vaccine at birth, one month, and six months of age as well as H-BIG at birth.of age as well as H-BIG at birth.

• • Be seen at least annualy by their regular Be seen at least annualy by their regular Medical Doctor.Medical Doctor.

• • Discuss the risk for transmission with their Discuss the risk for transmission with their partner and discuss the need for counseling partner and discuss the need for counseling and testingand testing

Breast feedingBreast feeding

With appropriate hepatitis B With appropriate hepatitis B immunoprophylaxis, breast-feeding immunoprophylaxis, breast-feeding poses no additional risk for poses no additional risk for transmission from infected hepatitis transmission from infected hepatitis B virus carriers. B virus carriers.

Infections and Infestations in Pregnancy

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