Infections in Pregnancy

Rubella

  • Congenital rubella syndrome is caused by maternal infection with rubella virus during the first 20 weeks of pregnancy
  • Women planning to become pregnant should ensure they have had the MMR vaccine
  • The features of congenital rubella syndrome are:
    • Congenital deafness
    • Congenital cataracts
    • Congenital heart disease (PDA and pulmonary stenosis)
    • Learning disability
notion image

Clinical presentation (mother)

  • Fever
  • Rash (maculopapular)
  • Lymphedenopathy
  • Polyarthritis

Investigations

  • Swab and serological and/or PCR
  • Rubella specific IgG antibody can be detected after natural infection or vaccination
  • Blood IgM should be done within 10 days of exposure

Management

  • If patient has no immunity - consider TOP (early gestation)
  • Supportive treatment - rest, fluids, paracetamol, avoid contact with other pregnant women

Chickenpox

  • Caused by the varicella zoster virus
  • It is dangerous in pregnancy because it can lead to:
    • More severe cases in the mother e.g. varicella pneumonitits, hepatitis, or encephalitis
    • Fetal varicella syndrome
    • Severe neonatal varicella infection
  • The typical features of congenital varicella syndrome include:
    • Fetal growth restriction
    • Microcephaly, hydrocephalus and learning disability
    • Scars and significant skin changes located in specific dermatomes
    • Limb hypoplasia (underdeveloped limbs)
    • Cataracts and inflammation in the eye (chorioretinitis)
notion image

Clinical presentation (mother)

  • Fever
  • Malaise
  • Vesicular rash

Investigations

  • Usually obvious on clinical grounds
  • Confirmation can be obtained by scraping a lesion and using immunohistochemical staining or PCR

Management

  • When the pregnant woman has previously had chickenpox, they are safe
  • When they are not sure about their immunity, test the VZV IgG levels
  • When they are not immune, they can be treated with IV varicella immunoglobulins as prophylaxis against developing chickenpox; this should be given within ten days of exposure
  • Supportive treatment
  • Acyclovir should be considered if 20+ weeks
  • Severe chicken pox:
    • Hospitalize, IV acyclovir
    • Aim to prevent complications - hepatitis, encephalitis, pneumonia

Measles

  • Non terotogenic however high fever can cause: IUGR, microcephaly, miscarriage, stillbirth and preterm birth
  • High mortality rate if mother develops pneumonia and encephalitis

Clinical presentation (mother)

  • Fever
  • White spots inside the mouth - Koplik spots
  • Cough
  • Red eyed
  • Rash

Investigations

  • Swab or serum sample for measles-specific IgM or RNA detection

Management

  • Supportive care

Listeria

  • Listeria monocytogenes is a gram-positive bacteria that causes listeriosis
  • Listeriosis in pregnant women has a high rate of miscarriage or fetal death; it can also cause severe neonatal infection
  • Listeria is typically transmitted by unpasteurised dairy products, processed meats and contaminated foods
  • Pregnant women are advised to avoid high-risk foods (e.g. unpasteurised milk, soft cheese, refrigerated smoked seafood) and practice good food hygiene

Clinical presentation

  • 'Flu-like', 'food poisoning'

Investigations

  • Cultures of amniotic fluid, blood, urine and cerebrospinal fluid (CSF)
  • Other imaging may be indicated

Management

  • Ampicillin and gentamicin (trimethoprim and sulfamethoxazole if penicillin allergic)

Congenital cytomegalovirus

  • Congenital cytomegalovirus infection occurs due to a cytomegalovirus (CMV) infection in the mother during pregnancy
  • The virus is mostly spread via the infected saliva or urine of asymptomatic children
  • Most cases of CMV in pregnancy do not cause congenital CMV
  • The features of congenital CMV are:
    • Fetal growth restriction
    • Microcephaly
    • Hearing loss
    • Vision loss
    • Learning disability
    • Seizures

Congenital toxoplasmosis

  • Toxoplasmosis gondii - associated with raw or uncooked meat and infected cat faces
  • Infection is usually asymptomatic, when infection occurs during pregnancy it can cross the placenta and cause congenital toxoplasmosis
  • There is a classic triad of features in congenital toxoplasmosis:
    • Intracranial calcification
    • Hydrocephalus
    • Chorioretinitis (inflammation of the choroid and retina in the eye)
  • Acute toxoplasmosis during pregnancy is treated with spiramycin

Parovirus B19

  • Parvovirus B19 infection typically affects children
  • The illness is self-limiting, and the rash and symptoms usually fade over 1 – 2 weeks
  • Infections with parvovirus B19 in pregnancy can lead to several complications, particularly in the first and second trimesters:
    • Miscarriage or fetal death
    • Severe fetal anaemia
    • Hydrops fetalis (fetal heart failure)
    • Maternal pre-eclampsia-like syndrome

Clinical presentation (mother)

  • Parvovirus infection starts with non-specific viral symptoms
  • After 2-5 days, the rash appears quite rapidly as a diffuse bright red rash on both cheeks, as though they have ‘slapped cheeks’
  • A few days later a reticular mildly erythematous rash affecting the trunk and limbs appears, which can be raised and itchy

Investigations

Women suspected of parvovirus infection need tests for:
  • IgM to parvovirus, which tests for acute infection within the past four weeks
  • IgG to parvovirus, which tests for long term immunity to the virus after a previous infection
  • Rubella antibodies (as a differential diagnosis)

Management

  • Treatment is supportive
  • Women with parvovirus B19 infection need a referral to fetal medicine to monitor for complications and malformations

Zika virus

  • The zika virus is spread by host Aedes mosquitos in areas of the world where the virus is prevalent; it can also be spread by sex with someone infected with the virus
  • Infection in pregnancy can lead to congenital Zika syndrome, which involves:
    • Microcephaly
    • Fetal growth restriction
    • Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy

Clinical presentation (mother)

  • It can cause no symptoms, minimal symptoms, or a mild flu-like illness

Investigations

  • Pregnant women that may have contracted the Zika virus should be tested with viral PCR and antibodies to the Zika virus

Management

  • Women with a positive result should be referred to fetal medicine for close monitoring of the pregnancy
  • There is no treatment for the virus