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
before 1987;

persons who were ever on chronic (long-
(long-term) hemodialysis;
hemodialysis; and

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.