Viral Infections in Pregnancy
Content
Viruses in Pregnancy
Author: Unknown Medical Student
Viruses in Pregnancy
Maternal and neonatal morbidity and mortality Viruses covered:
Hepatitis virus HIV Rubella parvovirus B19 Measles Cytomegalovirus(CMV) Herpes Simplex virus(HSV) Varicella virus
adverse effects on both the mother and fetus.
Transmission
Indirect contact Direct contact
respiratory secretions body fluids
Vertical Transmission
Transplacental Intrapartum Postpartum Breast feeding ?
Clinical Manifestations
symptomatic or asymptomatic General symptoms: fever, flu-like symptoms Jaundice: Hepatitis virus infections Vesicular eruption: Herpes group of viruses(ie HSV and VZV) Fever, rash, arthropathy and the classical slapped-cheek appearance (rare): parvovirus B19 Rash: other viral infections, such as rubella need to consider other possible viruses in the evaluation of a rash in pregnancy
Screening
Rubella (German measles) Syphilis test (VDRL) Hepatitis B HCV (only if the mother is at risk) HIV
Principles of Diagnosis
History taking, physical examinations and investigations Serology for most Hepatitis viruses, RNA testing for hepatitis C virus Herpes infection diagnosed clinically and/or serologically, viral cultures give definitive diagnosis HIV diagnosed by ELISA or the Western Blot Rubella from the clinical symptoms and physical examination, confirmed by serology or virus culture Parvovirus B19 confirmed with serum assays (ELISA or RIA) for IgG and IgM parvovirus specific antibodies.
Effects of viruses on pregnancy
More commonly
Spontaneous abortion low birthweight Prematurity Stillbirth IUGR congenital abnormalities nonimmune hydrops
Postnatal complications
developmental delay Pneumonitis CNS involvement
Hepatitis A
incidence in pregnancy is < 1:1,000 fecal-oral route recovery within 1-2 months serious sequelae from HAV infection during pregnancy usually does not develop, unless the mother is gravely ill
Complications to Mother
symptoms usually precede the onset of jaundice by 1-2 weeks electrolyte imbalance, fulminant hepatitis, coagulopathy and encephalopathy maternal deaths are increased
Complications to Fetus
risk of transmission to the fetus negligible. not teratogenic preterm birth neonatal infection mild and leads to lifelong immunity perinatal deaths slightly increased
Management
detecting IgM anti-HAV in the patient’s serum exposure of the pregnant woman - administration of immune gammaglobulin (IgG). some advocate administration of HAIG (HAV specific) to the exposed neonate supportive measures such as limited activity, bed rest & a diet adequate in protein and calories
Hepatitis B
occurs in 1-2/1000 pregnancies Chronic infection in 5-15/1000 pregnancies STD transmitted by exposure to infected blood and body fluids vertical transmission during delivery potential for eradication through immunization
Diagnosis of acute/chronic HBV
Serology is the cornerstone of diagnosis Acute infection : HBsAg and anti-HBc IgM HBeAg: exceptionally high viral inoculum and active viral replication Carrier state : HBsAg and anti-HBc IgG Anti-HBs IgG: immunologic response to infection and cure.
Pregnancy and HBV
Pregnancy does not usually affect the course of HBV infection Preterm birth occur more frequently with HBV Perinatal transmission occurs as a result of the infant's exposure to infected blood and genital secretions during delivery Management of acute infection supportive Serologic evaluation necessary to determine risk to fetus
Epidemiology of Infections among Infants
Infants infected by perinatal transmission have a 90% risk of chronic infection Up to 25% will die of chronic liver disease as adults Antenatal HBsAg testing of all pregnant women is now recommended in countries with a high HBV prevalence like Singapore
Prevention of Perinatal Hepatitis B Virus Infection through
early antenatal routine testing
for HBsAg
3 clinical scenarios
Scenario 1
HBsAg positive
Neonates should receive the appropriate doses of HBV vaccine and HBIG (0.5 mL) within 12 hours of birth
Scenario 2
HBsAg negative
Neonates should receive the first dose of HBV vaccine as soon as possible, within 24 hours of birth.
Scenario 3
No prior HBsAg screening
Women admitted for delivery without HBsAg test should be tested Infant should receive HBV vaccine within 12 hours of birth while awaiting results If the mother is later found to be HBsAg +ve, infant should receive HBIG within 7 days of birth
Additional point
Household contacts and sex partners of HBsAg-positive women identified through prenatal screening should be vaccinated.
Treatment of pregnant women
prednisone plus interferon alfa-2b interferon alone treatment of pregnant women delayed until after childbirth because the medications are teratogenic.
Precautions
Wash hands, wear gloves & change gloves between tasks Wear a mask and eye protection or a face shield during procedures likely to generate splashes or sprays of bodily fluid Wear a gown Handle, transport, and process used soiled linen with care Proper handling & disposal of sharps
Risk of transmission by breastfeeding
No evidence that breastfeeding increases risk of mother to child transmission However, concerns that breast pathology such as cracked or bleeding nipples or lesions with serous exudates could expose the infant to infectious doses of HBV.
Hepatitis D
requires the presence of HBsAg co-infects with HBV superinfects 20-25% of chronic HBV carriers HBV/HDV infections during pregnancy are more severe than HBV infections alone
Diagnosis of HDV
history of continued exposure to blood or blood products HDV super-infection suspected in a patient with chronic hepatitis B whose condition suddenly worsens particularly aggressive acute hepatitis B infection could suggest hepatitis D co-infection Co-infection or super-infection with hepatitis D virus in a patient with hepatitis B diagnosed by the presence of antibodies against the hepatitis D virus
Management of HDV
no effective treatments prevention of the HBV infection HBV vaccination the best treatment for HDV infection
Hepatitis C
prevalence varies from 0.1-6% transmitted via infected blood exposure, but less so through exposure to semen, saliva or urine vertical transmission, intravenous drug users blood transfusion, organ transplantation, tattoos and needle accidents.
Clinical course of HCV
no symptoms or only mild fatigue in 65-75% of cases 25% experience jaundice and 10% are unwell with fatigue, nausea and loss of appetite Chronic infection leads to liver cirrhosis
Screening
Indicated for high risk groups Based on their risk for infection
High risk groups
Persons who ever injected illegal drugs, including those who injected once or a few times many years ago and do not consider themselves as drug users. Persons with selected medical conditions, including
persons who received clotting factor concentrates produced before 1987; before persons who were ever on chronic (long-term) hemodialysis; and (longhemodialysis; persons with persistently abnormal alanine aminotransferase levels.
Prior recipients of transfusions or organ transplants, including
persons who were notified that they received blood from a donor who later tested positive for HCV infection; persons who received a transfusion of blood or blood components before July 1992; and persons who received an organ transplant before July 1992.
Persons who should be tested routinely for HCV-infection based on a recognized exposure Healthcare, emergency medical, and public safety workers after needle sticks, sharps, or mucosal exposures to HCV-positive blood. Children born to HCV-positive women.
Diagnosis of HCV
Detection of HCV RNA by PCR positive at 2 weeks post-exposure reflect disease activity thus used to predict response to treatment or the risk of vertical transmission negative tests should be repeated on at least 2 occasions for confirmation.
Vertical Transmission, Progression & Pregnancy Outcome
Vertical transmission of HCV Most studies report a rate of 5% vertical transmission. HCV disease progression & pregnancy outcome Pregnancy does not appear to induce deterioration of liver disease in women with HCV, nor does the presence of HCV increase the risk of obstetric complications.
Breast-feeding & Management
Breast-feeding & HCV transmission HCV found at much lower levels than in serum (1/100 to 1/100,000). All studies have failed to demonstrate transmission via this route. Management of Hepatitis C Prevention & screening Alpha-interferon-2b mainstay of therapy but contraindicated in pregnancy.
Hepatitis E
Faecal-oral route more severe disease than HAV mortality rates in pregnant women of 10-30% infection especially severe in pregnant women chronicity does not occur and there is no known chronic carrier state.
Diagnosis
Viral-like particles identified in the stool of infected patients by electron microscopy: which will agglutinate when combined with serum from the patient Fluorescent antibody blocking assay Western blot assay
Management
No specific treatment proven effective Symptomatic and supportive treatment
In conclusion
Utmost importance that the doctor should proceed with the appropriate history taking, physical examinations, laboratory testing to exclude other possible causes of the presenting illness signs and symptoms and attempt to identify the virus. Proper treatment, reassurance, counselling and monitoring of the well being of both the mother and fetus are carried out with preparations made for suitable treatment of the newborn, if appropriate.
Continue…..
reduce the incidence of mothers being infected with potentially dangerous virus and their transmission to the fetus and serious sequelae Proper treatment helps reduce the morbidity and mortality associated with the virus infected pregnancies.
Author: Unknown Medical Student
Viruses in Pregnancy
Maternal and neonatal morbidity and mortality Viruses covered:
Hepatitis virus HIV Rubella parvovirus B19 Measles Cytomegalovirus(CMV) Herpes Simplex virus(HSV) Varicella virus
adverse effects on both the mother and fetus.
Transmission
Indirect contact Direct contact
respiratory secretions body fluids
Vertical Transmission
Transplacental Intrapartum Postpartum Breast feeding ?
Clinical Manifestations
symptomatic or asymptomatic General symptoms: fever, flu-like symptoms Jaundice: Hepatitis virus infections Vesicular eruption: Herpes group of viruses(ie HSV and VZV) Fever, rash, arthropathy and the classical slapped-cheek appearance (rare): parvovirus B19 Rash: other viral infections, such as rubella need to consider other possible viruses in the evaluation of a rash in pregnancy
Screening
Rubella (German measles) Syphilis test (VDRL) Hepatitis B HCV (only if the mother is at risk) HIV
Principles of Diagnosis
History taking, physical examinations and investigations Serology for most Hepatitis viruses, RNA testing for hepatitis C virus Herpes infection diagnosed clinically and/or serologically, viral cultures give definitive diagnosis HIV diagnosed by ELISA or the Western Blot Rubella from the clinical symptoms and physical examination, confirmed by serology or virus culture Parvovirus B19 confirmed with serum assays (ELISA or RIA) for IgG and IgM parvovirus specific antibodies.
Effects of viruses on pregnancy
More commonly
Spontaneous abortion low birthweight Prematurity Stillbirth IUGR congenital abnormalities nonimmune hydrops
Postnatal complications
developmental delay Pneumonitis CNS involvement
Hepatitis A
incidence in pregnancy is < 1:1,000 fecal-oral route recovery within 1-2 months serious sequelae from HAV infection during pregnancy usually does not develop, unless the mother is gravely ill
Complications to Mother
symptoms usually precede the onset of jaundice by 1-2 weeks electrolyte imbalance, fulminant hepatitis, coagulopathy and encephalopathy maternal deaths are increased
Complications to Fetus
risk of transmission to the fetus negligible. not teratogenic preterm birth neonatal infection mild and leads to lifelong immunity perinatal deaths slightly increased
Management
detecting IgM anti-HAV in the patient’s serum exposure of the pregnant woman - administration of immune gammaglobulin (IgG). some advocate administration of HAIG (HAV specific) to the exposed neonate supportive measures such as limited activity, bed rest & a diet adequate in protein and calories
Hepatitis B
occurs in 1-2/1000 pregnancies Chronic infection in 5-15/1000 pregnancies STD transmitted by exposure to infected blood and body fluids vertical transmission during delivery potential for eradication through immunization
Diagnosis of acute/chronic HBV
Serology is the cornerstone of diagnosis Acute infection : HBsAg and anti-HBc IgM HBeAg: exceptionally high viral inoculum and active viral replication Carrier state : HBsAg and anti-HBc IgG Anti-HBs IgG: immunologic response to infection and cure.
Pregnancy and HBV
Pregnancy does not usually affect the course of HBV infection Preterm birth occur more frequently with HBV Perinatal transmission occurs as a result of the infant's exposure to infected blood and genital secretions during delivery Management of acute infection supportive Serologic evaluation necessary to determine risk to fetus
Epidemiology of Infections among Infants
Infants infected by perinatal transmission have a 90% risk of chronic infection Up to 25% will die of chronic liver disease as adults Antenatal HBsAg testing of all pregnant women is now recommended in countries with a high HBV prevalence like Singapore
Prevention of Perinatal Hepatitis B Virus Infection through
early antenatal routine testing
for HBsAg
3 clinical scenarios
Scenario 1
HBsAg positive
Neonates should receive the appropriate doses of HBV vaccine and HBIG (0.5 mL) within 12 hours of birth
Scenario 2
HBsAg negative
Neonates should receive the first dose of HBV vaccine as soon as possible, within 24 hours of birth.
Scenario 3
No prior HBsAg screening
Women admitted for delivery without HBsAg test should be tested Infant should receive HBV vaccine within 12 hours of birth while awaiting results If the mother is later found to be HBsAg +ve, infant should receive HBIG within 7 days of birth
Additional point
Household contacts and sex partners of HBsAg-positive women identified through prenatal screening should be vaccinated.
Treatment of pregnant women
prednisone plus interferon alfa-2b interferon alone treatment of pregnant women delayed until after childbirth because the medications are teratogenic.
Precautions
Wash hands, wear gloves & change gloves between tasks Wear a mask and eye protection or a face shield during procedures likely to generate splashes or sprays of bodily fluid Wear a gown Handle, transport, and process used soiled linen with care Proper handling & disposal of sharps
Risk of transmission by breastfeeding
No evidence that breastfeeding increases risk of mother to child transmission However, concerns that breast pathology such as cracked or bleeding nipples or lesions with serous exudates could expose the infant to infectious doses of HBV.
Hepatitis D
requires the presence of HBsAg co-infects with HBV superinfects 20-25% of chronic HBV carriers HBV/HDV infections during pregnancy are more severe than HBV infections alone
Diagnosis of HDV
history of continued exposure to blood or blood products HDV super-infection suspected in a patient with chronic hepatitis B whose condition suddenly worsens particularly aggressive acute hepatitis B infection could suggest hepatitis D co-infection Co-infection or super-infection with hepatitis D virus in a patient with hepatitis B diagnosed by the presence of antibodies against the hepatitis D virus
Management of HDV
no effective treatments prevention of the HBV infection HBV vaccination the best treatment for HDV infection
Hepatitis C
prevalence varies from 0.1-6% transmitted via infected blood exposure, but less so through exposure to semen, saliva or urine vertical transmission, intravenous drug users blood transfusion, organ transplantation, tattoos and needle accidents.
Clinical course of HCV
no symptoms or only mild fatigue in 65-75% of cases 25% experience jaundice and 10% are unwell with fatigue, nausea and loss of appetite Chronic infection leads to liver cirrhosis
Screening
Indicated for high risk groups Based on their risk for infection
High risk groups
Persons who ever injected illegal drugs, including those who injected once or a few times many years ago and do not consider themselves as drug users. Persons with selected medical conditions, including
persons who received clotting factor concentrates produced before 1987; before persons who were ever on chronic (long-term) hemodialysis; and (longhemodialysis; persons with persistently abnormal alanine aminotransferase levels.
Prior recipients of transfusions or organ transplants, including
persons who were notified that they received blood from a donor who later tested positive for HCV infection; persons who received a transfusion of blood or blood components before July 1992; and persons who received an organ transplant before July 1992.
Persons who should be tested routinely for HCV-infection based on a recognized exposure Healthcare, emergency medical, and public safety workers after needle sticks, sharps, or mucosal exposures to HCV-positive blood. Children born to HCV-positive women.
Diagnosis of HCV
Detection of HCV RNA by PCR positive at 2 weeks post-exposure reflect disease activity thus used to predict response to treatment or the risk of vertical transmission negative tests should be repeated on at least 2 occasions for confirmation.
Vertical Transmission, Progression & Pregnancy Outcome
Vertical transmission of HCV Most studies report a rate of 5% vertical transmission. HCV disease progression & pregnancy outcome Pregnancy does not appear to induce deterioration of liver disease in women with HCV, nor does the presence of HCV increase the risk of obstetric complications.
Breast-feeding & Management
Breast-feeding & HCV transmission HCV found at much lower levels than in serum (1/100 to 1/100,000). All studies have failed to demonstrate transmission via this route. Management of Hepatitis C Prevention & screening Alpha-interferon-2b mainstay of therapy but contraindicated in pregnancy.
Hepatitis E
Faecal-oral route more severe disease than HAV mortality rates in pregnant women of 10-30% infection especially severe in pregnant women chronicity does not occur and there is no known chronic carrier state.
Diagnosis
Viral-like particles identified in the stool of infected patients by electron microscopy: which will agglutinate when combined with serum from the patient Fluorescent antibody blocking assay Western blot assay
Management
No specific treatment proven effective Symptomatic and supportive treatment
In conclusion
Utmost importance that the doctor should proceed with the appropriate history taking, physical examinations, laboratory testing to exclude other possible causes of the presenting illness signs and symptoms and attempt to identify the virus. Proper treatment, reassurance, counselling and monitoring of the well being of both the mother and fetus are carried out with preparations made for suitable treatment of the newborn, if appropriate.
Continue…..
reduce the incidence of mothers being infected with potentially dangerous virus and their transmission to the fetus and serious sequelae Proper treatment helps reduce the morbidity and mortality associated with the virus infected pregnancies.
