Perinatal Infections: Update on Diagnosis & Management

Dr. Padmesh

• INTRODUCTION:

• Important cause of still births and morbidity

• Many diseases go undiagnosed

• Appropriate treatment can prevent morbidity/mortality

• 1971: Andres Nahmias proposed acronym ToRCH • 1975: Harold Fuerst added Syphilis to the acronym.

• ACRONYM: TORCHES CLAP

-TOxoplasmosis -Chickenpox-Rubella -Lyme disease-CMV -AIDS-Herpes simplex -Parvovirus B19-Enterovirus-Syphilis

• Latest addition: Zika virus

Toxoplasmosis

• Toxoplasma:

• Diagnosis :• IgG, IgM, IgA (Serum/CSF)• PCR • Ophthalmologic, auditory, and neurologic

examinations• CT Brain

Redbook American Academy of Pediatrics. 2012. p. 720–8.

• Toxoplasma:

Investigations

Normal

Negative

Abnormal

TREAT FOR 12 MONTHS

Positive

Repeat IgG after 6 months

• Toxoplasma:

• Treatment :

• Pyrimethamine, sulphadiazine and folinic acid for a duration of 1 year.

• Toxoplasma:

• Prevention- counselling :– Avoid raw/undercooked meat– wash hands after gardening– wash raw vegetables– minimise contact with young kittens and their litter etc

Rubella

• Rubella:

• In Maternal infection: - No treatment available

1st Trimester: Consider termination.2nd Trimester: Consider fetal testing.After 20 wks gestation: Rarely causes CRS

• Rubella:

• Diagnosis :• Isolation of virus by PCR or culture

• Rubella-specific IgM (False positivity +/-) • Increasing IgG over first 7 to 11 months of life.• Avidity testing of IgG

• Rubella virus RNA by reverse transcriptase PCR in nasopharyngeal swabs, urine, CSF, and blood at birth

• Rubella:

• Diagnosis : Avidity:• Strength with which IgG binds to antigenic epitropes

expressed by a specific protein.

• Gradually matures over months.

• IgG produced in first few months following primary infection Low avidity (Bind weakly to Ag)

• Therefore, LOW IgG avidity is a marker of RECENT PRIMARY infection.

• High avidity excludes primary infection in preceding 3 months.

• Rubella:

• Diagnosis : Avidity:

• Rubella:

• Diagnosis :

AT BIRTH:• Ophthalmology screening, • Cardiac screening• Hearing assessments

FOLLOW UP UPTO 12 MONTHS

• Rubella:

• Treatment :

• No specific treatment• Breast feeding not contraindicated

• Prevention:• Vaccination

CYTOMEGALOVIRUS

• CMV:

• Diagnosis :• Virus culture from urine/saliva

• CMV-DNA PCR in urine, blood, saliva and CSF

• CMV IgM antibodies in blood before 3 weeks of age.

• IgG Avidity testing

Rev Med Virol 2010;20(4): 202–13.

• CMV: Treatment :

Virologically proven CMV in Newborn

Underlying Immune disorder

Treat as Life threatening

infection

Immunocompetent

Life threatening symptoms

Non-Life threatening symptoms

No Symptoms

No treatment

Life Threatening infection

IV Ganciclovir for 4-6 weeks

Oral Valganciclovir for 6 months

Non-Life threatening infection

• CMV: Treatment :

Continue for 12 months/ Change in regimen

Viremia at 6 mths

• CMV:

• Treatment :• Foscarnet, Cidofovir for refractory CMV/ Ganciclovir

resistance

HERPES SIMPLEX VIRUS

• HSV:

• Diagnosis :• Surface cultures: HSV culture on swab specimens

from mouth, nasopharynx, conjunctivae, and anus 12-24 hours after birth

• HSV culture & PCR from any skin vesicle present

• HSV PCR on CSF and whole blood

• HSV:

START EMPIRICAL IV ACYCLOVIRDiagnostic evaluation of Newborn

Positive

SEM disease CNS/ Disseminated

Negative

IV Acyclovir for 14 days

IV Acyclovir for 21 days

IV Acyclovir for 10 days

• HSV:

• Treatment:

• After completion of parenteral therapy suppressive course of oral acyclovir for 6 months

• HSV:

• 85% neonatal HSV are acquired perinatally.

• True intrauterine infection 5%

• Careful speculum examination for active genital HSV

• Caesarean section reduces risk of HSV transmission

SYPHILIS

• Syphilis:

• Diagnosis :• Adequacy of maternal treatment

• Examination of placenta/umbilical cord for pathology

• Dark field microscopy of suspicious lesions/body fluid

• Clinical findings suggestive of syphilis: Non immune hydrops/ jaundice/ hepatosplenomegaly/ rhinitis/ skin rash

• Quantitative VDRL / RPR (FTA-ABS or TPHA not required)

BMC Public Health 2011;11(Suppl 3):S9.

• Syphilis: Treatment :

PHYSICAL EXAMSUGGESTIVE OF CONGENITAL SYPHILIS

BABY’S VDRL/RPR4 TIMES HIGHER TITRE THAN MOTHER

MOTHER NOT TREATED OR INADEQUATELY TREATED

INJ. PENICILLIN G OR PROCAINE PENICIILIN FOR 10 DAYS

ADDL TESTS: CSF VDRL, LONG BONE XRAY, OPHTHAL EVALUATION, BERA

• Syphilis: Treatment :

PHYSICAL EXAMNORMAL

BABY’S VDRL/RPRLESS THAN 4 TIMES MOTHER’S TITRE

MOTHER NOT TREATED OR INADEQUATELY TREATED

INJ. PENICILLIN G OR PROCAINE PENICIILIN FOR 10 DAYS

ADDL TESTS: CSF VDRL, LONG BONE XRAY, OPHTHAL EVALUATION, BERA

+

• Syphilis: Treatment :

PHYSICAL EXAMNORMAL

BABY’S VDRL/RPRLESS THAN 4 TIMES MOTHER’S TITRE

MOTHER NOT TREATED OR INADEQUATELY TREATED

INJ. BENZATHINE PENICILLIN 50000 U/Kg/dose IM SINGLE DOSE

ADDL TESTS: CSF VDRL, LONG BONE XRAY, OPHTHAL EVALUATION, BERA

I

• Syphilis: Treatment :

PHYSICAL EXAMNORMAL

BABY’S VDRL/RPRLESS THAN 4 TIMES MOTHER’S TITRE

MOTHER ADEQUATELY TREATED DURING PREGNANCY

NO TREATMENT REQUIRED IF FOLLOW-UP IS CERTAIN

ELSE, INJ. BENZATHINE PENICILLIN 50000 U/Kg/dose IM SINGLE DOSE

NO FURTHER EVALUATION

VARICELLA

• Varicella:

-7 -5-6 -2-4 -3 +1-1 +3+2 +4

ONSET OF RASH IN MOTHER

• Varicella:

-7 -5-6 -2-4 -3 +1-1 +3+2 +4

Newborn will have protective antibodiesLikelihood of severe disease is low

- Do not separate baby from mother- Continue breast feeding- No VZIG-Acyclovir if baby develops rash

• Varicella:

-7 -5-6 -2-4 -3 +1-1 +3+2 +4

Newborn will not have protective antibodiesLikelihood of severe disease is high

-Separate baby from mother-If baby devps rash stay with mother-VZIG within 72 hours-Acyclovir

• Varicella:

-7 -5-6 -2-4 -3 +1-1 +3+2 +4

Newborn will not have protective antibodiesBut, likelihood of severe disease is low

-Separate baby from mother-If baby devps rash stay with mother-No VZIG -Acyclovir if baby develops rash

TUBERCULOSIS

• TB: MOTHER WITH TB

ON TREATMENT/ NO TREATMENT

TREATMENT COMPLETED

LOOK FOR CLINICAL EVIDENCE OF CONGENITAL TB

ABSENT PRESENT ABSENT

CXR, 3 GASTRIC ASPIRATES

CXR, LP3 GASTRIC ASPIRATES

Treat : HRZE

INH PROPHYLAXIS MANTOUX AT 3 MONTHS

FOLLOW UP AND EVALUATE FOR CLINICAL EVIDENCE TILL 6 MONTHS++

-

• TB:

• Reassure the mother to breast feed the baby

• Separation of mother & baby required only if mother – is sick– non adherent to treatment– has MDR TB

• CONCLUSION:

• Universal vaccination.

• Prompt recognition and management.

• Public health measures: antenatal screening for syphilis, HIV and hepatitis B .

• Good hygiene

THANK YOU !