Infection in pregnancy

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INFECTIONduring Pregnancy : 

INFECTIONduring Pregnancy Bambang Widjanarko Obstetrics & Gynecology Departement School Of Medicine and Health Muhammadiyah University Jakarta-Indonesia

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With the exception of poliomyelitis, pregnancy does not alter a woman’s resistance to infection The severity and time of onset infection in pregnancy , correlates positively with its effect to the fetus Infection have an indirect and a direct effect on the fetus Indirect effect : Reducing the oxygenation of the placental blood Altering nutrient exchange through the placenta Direct effect : Depends on the ability of the micro organism to penetrate the placenta and infect the fetus Most viral infections do not affect the fetus unless the motther’s infection is very severe Exception is : rubella, cytomegalovirus and herpes simplex infection → congenital defects

Urinary Tract Infection : 

Urinary Tract Infection Urinary tract infection is the most disturbing of the bacterial infection It occurs because the urinary tracts dilates owing to the relaxation of the muscles of the ureter and the bladder in pregnancy with conseqences urinary stasis

Asymptomatic Bacteriuria : 

Asymptomatic Bacteriuria Bacteriuria : > 100.000 bacteriuria per ml of urine Prevalence bacteriuria in non-pregnant 2% ; rises to 3 – 8% in pregnancy 30% pregnant woman with AB will developed symptomatic UTI Unless treating : slightly higher chance developing hypertension in pregnancy and twice the risk of delivering low birth weight baby Routine screening for asymptomatic bacteriuria during pregnancy ??

Asymptomatic Bacteriuria : 

Asymptomatic Bacteriuria A mid stream specimen of urine for culture 85% of cases , Escherecia coli are isolated Treatment of AB : Amoxycilline 3 g ; or cephalexine 2 g as single dose 7 days after treatment, a mid stream specimen of urine is reaximined

Pyelonephritis : 

Pyelonephritis 30% of untreated bacteriuria will developed pyelonephritis during pregnancy Pyelonephritis usually begin after the 20th wop Mild case complain: Tiredness Urinary frequency Dysuria Severe case complain: Chills and rigors Fever Pain over one or both renal Dehydrated

Pyelonephritis : 

Pyelonephritis Diagnosis : Confirmed by examining midstream urine specimen Excluded other causes of abdominal pain ( appendicitis, torsion of the ovarial cyst, abruptio placenta ) Treatment : Correcting the dehydration Appropriate antibiotics with bacterial sensitivity Initial antibiotics treatment : Cephalosporine or Amoxyxilline intravenously Follow-up of midstream urine specimen at 2 weeks interval

Vaginal Infection : 

Vaginal Infection Diagnosis and treatment of vaginal infection due to candida spp, trichomonas and bacterial vaginosis are the same as in non-pregnant women Group B Streptococcus : colonies of GBS are harboured in the upper vagina of 6 – 30% of pregnant woman If GBS present during labour the bacteria may colonize 50% of the neonate and 1 – 2% of them develop streptococcal infection Routine screening for GBS ?? Gonorrhoea : Depending on population, 1 – 6% of pregnant are found to have Gonorrhoea on culture studies Complain : dysuria and vaginal discharge

Syphilis : 

Syphilis Treponemes are able to penetrate the placenta after the 15 wop and infect the fetus By the time of the birth the fetus it is in the second stage of syphilis Every pregnant women should be tested for syphilis using a reagin test ( VDRL or Rapid Plasma Reagin test ) at the first antenatal visit and repeated at the 30th wop As sign of syphilis in neonate are often equivocal and the serology is inaccurate, the infant of a women who has been diagnosed as having syphilis whilst pregnant and who has not had a complete course of treatment and follow-up, should be given a full course of antibiotic treatment ( aqueous procain penicilline 50.000 U per kg BW daily for 10 days )

Viral Infection : 

Viral Infection Rubella Genital Herpes Hepatitis B Cytomegalovirus Chicken Pox ( varicella )

Rubella : 

Rubella By the age of 19 years more than 85% of people have been infected ; 9 out of 10 of those infected habe life-long immunity Rubella infection in a 40% non-immune women in the first 14 wop will be damaged the fetus ; Infection in 4 – 12 wop affect the lens (cataract) and ears (deafness) ; Infection in 5 – 12 wop : affect the chambers of the heart Rubella infection may cause widespread cellular damage leading to : Fetal growth restriction Thrombocytopenia Hepatyosplenomegali Vasculitis Renal artery stenosis

Rubella : 

Rubella A woman should tested for Rubella antibodies either when she decides to become pregnant or at the first antenatal visit used Single Radial Haemolysis (SRH) Test If this test is positive with titre > 15.000 IU/L the women is immune to Rubella A non immune woman who is not pregnant may be offered vaccination but should avoid pregnancy for 3 months A problem rises when a pregnant non-immune woman develops a rubelliform rash ( half of the rash is not due to Rubella ), or has been in contact with a case of Rubella. A serological test should be made as soon as possible within 15 days of appearance rash or the contact

Genital Herpes : 

Genital Herpes In pregnancy HSV may cross the placental barrier to infect the fetus ( 1 fetus per 1000 being infected ) The risk is greater during childbirth, particularly if the mother has developed a recurrence of the condition or is sheeding the virus from her cervix A women with a history of genital herpes need no anxiety that her baby will be infected and may expect to deliver vaginally, unless a recurrence of the infection or new infection occurs during pregnancy If a first infection or recurrence of genital herpesoccurs during pregnancy, but has healed by the time labour starts, the woman may give birth vaginally If herpetic lession are present when the membranes rupture or labour starts, a caesarean section should be performed to avoid the risk that the baby will acquire a herpetic infection during the passage through birth canal

Hepatitis B : 

Hepatitis B Hepatitis B virus is readily transmitted to the baby, probably during the birth Babies at particularly high risk are those whome mothers have HBcAg as well as HBsAg in their blood If not treated, many of the babies will develop hepatocellular carcinoma when adult If babies at high risk are given hepatitis B immune globulin together with hepatitis B vaccine 10ug at birth, and two further injections of the vaccine at the ages of 1 and 6 months

Cytomegalovirus Infection : 

Cytomegalovirus Infection Over half of all pregnant women show serological evidence of previous CMV infection One per cent of women may become infected with CMV during pregnancy and most of whom are asymptomatic The infection is associated with an increased perinatal mortality and 3 – 7% of the infants have congenital abnormalities Screening has proved to be of no value – there is no vaccine available

Varicella : 

Varicella Varicella infection is common, overe 80% of pregnant women testing positive for IgG antibodies to the varicella zoster virus ( VZV ) Primary infection can result in serious complications for both mother and baby because during pregnancy, the maternal immune system is less efficient Pneumonia occurs in 10% of women and can result in death Infection in the first trimester→ 2 – 10% of fetuses are infected and the viral vesicle can cause of wide spectrum of abnormalities including lung hypoplasia-microcephaly-cortical atrophy-cataracts-psychomotor retardation-convulsion-intra uterine growth restriction

Varicella : 

Varicella If the maternal infection becomes apparent 7 days before or 7 days after delivery, the baby is at risk of developing disseminated varicella infection, as maternal antibody production will not yet be adequate If there is doubt the diagnosis or previous history of infection, maternal blood should be taken for anti-VZV, IgG and IgM antibodies If there is high risk of maternal or fetal complications, the mother should be given 12.5 unit per kg of VZV immunoglobulin ( VZIG) intramuscularly For severe maternal infection, acyclovir 5 – 10 mg/kg should be given every 8 hours An infected infant may be given VZIG and acyclovir

Infections in the tropics : 

Infections in the tropics Helmint infestations – hookworm disease Two types of hookworm are found : Ancylosytoma duodenale and Necator americanus Blood loss due to hookwarm varied 2 – 90 ml / day and cause of iron deficiency anemia Treatment by administering bephenium hydroxynaphtoate ( Alcopar) in a dose 5 g daily for 3 days and treating anemia with iron Malaria Excacerbation and relaps during pregnancy may precipitate abortion or the onset of premature labour Occasionaly, in non-immune patients, congenital transmission of malaria occurs

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Thank you Bambang Widjanarko Obstetrics & Gynecology Departement School Of Medicine and Health Muhammadiyah University Jakarta-Indonesia

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