Infectious Disease During

Pregnancy
Natasha Kumar
Warren S. Alpert Medical School
August 28, 2015

Objectives
Recognize ID complications in pregnancy
HIV
HPV
HSV
Hepatitis
GBS

Rubella
Toxoplasmosis
Cytomegalovirus
Varicella
Parvovirus
Other STIs

Understand impact of these conditions on pregnant

patients and newborn fetus

TODAY IN THE OFFICE

Patient A
30 year old G1 presenting for 1st prenatal visit at 72
Married, sexually active with 1 male partner in the last
5 years
Patient B
24 year old G3P2 presenting for prenatal visit at 362
Last seen in office at 254
Hx of herpes and Hepatitis C, chlamydia @ 1st PNV
In relationship with FOB, sexually active with 2 male
partners in the last year

PATIENT A: 1st PNV Screening

WHAT LABS SHOULD YOU

ORDER AT 1st PRENATAL VISIT?

PATIENT A: 1st PNV Screening

Blood type & screen
HIV / RPR (Syphilis)
Hepatitis B surface Antigen
Rubella antibodies
Gonorrhea/Chlamydia swabs
Pap (+HPV >30 years old)
Wet Mount if symptomatic, prior infection
PPD

HIV in Pregnancy
Dx: +HIV at first PNV or in third trimester (>28)
rapid HIV test for women in labor (unknown status)
Sequelae: perinatal transmission of HIV, infections
and chronic diarrhea in neonate
Management
ARVs during pregnancy + labor
On HAART before pregnancy: continue regimen minus teratogenic
ARVs (e.g. efavirenz); zidovudine infusion in labor / 3 hours before CS

Not on HAART: start HAART (+zidovudine) after 1st trimester; zidovudine

infusion in labor / 3 hours before CS

Elective CS if HIV RNA >1000 or late presentation to care

No BF, Zidovudine for baby for 6 weeks PP

Hepatitis B in Pregnancy
+HbSAg at first PNV visit
HbSAg
+

Anti HBc +

IgM anti HBc + Anti HBs + Acute infection

HbSAg
+

Anti HBc +

IgM anti HBc -

Anti HBs -

Chronic infection
(HbSAg+ >20 wks)

Sequelae
Mom: chronic infection liver disease
Baby: perinatal transmission
85-95% risk of chronicity vs. 10-20% in adult-acquired HBV

Management
Mom: refer to specialist for chronic HBV (tenofovir if high risk)
Fetus: HBIG / HBV within 12 HOL + 2 more HBV by 6 months
CS is not indicated, breastfeeding is safe

Rubella in Pregnancy
Screen: Rubella antibodies at first PNV visit
Dx: maternal serology if suspected (+IgM, 4-fold
increase in IgG)
Mom: Rash,
lymphadenopathy, arthritis
Baby: PDA (or pulmonary
artery hypoplasia),
cataracts, and deafness,
blueberry muffin rash

Management
MMR vaccine preconception or postpartum (live vaccine)

Patient A: 1st PNV Screen

HIV RPR HbSAg + Rubella antibodies
Gonorrhea/Chlamydia
HPV +, no cervical dysplasia
Wet Mount: no clue cells, no trichomonads

HPV in Pregnancy
Dx: HPV+ on Pap smear (at 1st PNV or <5 years when >30
yo)
Sequelae
Minimal risk of perinatal transmission
Respiratory papillomatosis

Management
HPV 6 and 11 (warts)
If possible, delay treatment due to risk of PTL
If warts obstruct vagina, treat with surgery, cryotherapy or electrotherapy

HPV 16 and 18 (Pap smear/cervical dysplasia)

Colposcopy, LEEP, cone can be done antepartum
Recommend TOP + hysterectomy if invasive cervical cancer

REVIEW!
HIV
Hepatitis B
Rubella
HPV

Patient B: 36 Week Visit

CC: patch of painful blisters on my private area
PERTINENT HX:
+Chlamydia at 1st PNV
>1 partner in past year
History of HSV / HCV

WHAT HISTORY/PHYSICAL
EXAM/LABS DO YOU NEED?

Patient B: 36 Visit
PE: examine patient for possible herpetic outbreak
Third trimester PNV (>28)
Repeat HIV / RPR + TDAP vaccine
Repeat GC/chlamydia swabs
Risk factors: Hx of chlamydia in pregnancy, multiple
sexual partners

>35-37 PNV
GBS swab

HSV in Pregnancy
Dx: no routine screening
Ask about HSV symptoms early in pregnancy
PE for herpetic lesions if known history of HSV
Culture new lesions if no history of HSV

Neonatal Sequelae
Disseminated (25%), CNS (30%), skin/eyes/mouth (45%)
High mortality rates (30% disseminated, 4% CNS)
Neurologic impairment (20% of survivors)

Management: C section if prodromal sx / genital lesions

Suppressive viral therapy if recurrent active HSV >36 weeks:
400 mg acyclovir TID

GBS in Pregnancy
Dx: routine screen at 35-37 rectovaginal swab!
Treat if GBS in urine, prior infant with GBS sepsis

(no screen)

Sequelae: vertical transmission to neonate

Responsible for 75% of GBS colonization of neonates
1-2% will develop infection fatality 11-50%

Management
Mom: IV penicillin 5 million units when admitted in labor,
repeat 2.5 million units q4 hrs
If <37 weeks, empiric Rx
PCN allergy: clindamycin (if sensitive) or vancomycin
(unknown sensitivity / resistant)

Other STIs in Pregnancy

Syphilis (RPR)
Dx: +RPR at 1st PNV / 30-34 PNV, f/u FTA-Abs
Sequelae: PTB, stillbirth, disseminated neonatal disease
Mgmt: IV pencillin (desensitization if allergic)

Chlamydia
Dx: swab at 1st PNV (routine) / 36 PNV for (high risk)
Sequelae: PROM, PTB, LBW, neonate conjunctivitis/pneumonia
Mgmt: azithromycin+ceftriaxone, TOC; neonate eye ointment
Gonorrhea
Dx: swab at 1st PNV (high risk) / 36 PNV (high risk)
Sequelae: SAB, PROM, PTB, LBW, neonatal conjunctivitis
Mgmt: chlamydia Rx + neonate eye ointment

Hepatitis C in Pregnancy
Dx: no routine screening, Ab screen for high risk
patients
History of IV drug use
Transfusion recipient before 1987, organ transplant before
1992
Seeking evaluation or treatment for STDs e.g. HIV

Management
Mom: Refer to specialist for follow-up, no Rx in pregnancy
No preventive measures for vertical transmission to
neonate

CS is not indicated, breastfeeding is safe

REVIEW!
HSV
GBS
Hepatitis C
Syphilis
Gonorrhea/Chlamydia

OFFICE: PATIENT A 20 VISIT

CC:
I babysit for my nephew, who has been home sick from
school His cheeks are really red and he has a sore
throat and fever
Also, I work at a preschool where there has been an
outbreak of the chicken pox
Last but not least, we got a new kitten a few weeks
ago...

COULD THIS HURT MY BABY?

Parvo B19 in Pregnancy

Dx: post-exposure serology
IgM positive: monitor fetus for anemia
IgM negative, IgG negative: susceptible, repeat serology in 4 weeks
IgM negative, IgG positive: immune

Sequelae:
Mom: reticular rash on trunk, peripheral arthropathy,
transient aplastic crisis, asymptomatic (20%)
Baby: spontaneous resolution, spontaneous abortion,
hydrops fetalis (2/2 to aplastic anemia), stillbirth
Hydrops unlikely if >8 weeks after maternal infection

Management: serial fetal US / peak velocity of

MCA, blood sampling + intrauterine transfusion

Varicella in Pregnancy
Dx: US abnormalities after maternal infection
Hydrops, hyperechogenic foci in liver and bowel, cardiac malformations, limb
deformities, microcephaly, IUGR

Sequelae:
Mom: pneumonia (10-20%)
Baby: congenital varicella syndrome (1st trimester 0.4%, 2nd
trimester 2%, 3rd trimester 0%)
skin scarring, limb hypoplasia, chorioretinitis, microcephaly

Management
Mom: VZIG <10 days (ideally 96 hours), oral acyclovir <24
hours after rash
Infants: VZIG if mom develops varicella around delivery, IV
acyclovir if infected
VZV vaccine preconception or postpartum if nonimmune

Toxoplasmosis in Pregnancy
Dx: maternal serology, fetal US abnormalities,
amniocentesis (PCR) after 18
US; ventriculomegaly, intracranial calcifications, microcephaly,
ascites, HSM, IUGR

Sequelae:
Mom: asymptomatic cervical LAD (80%), fever,
malaise, night sweats, myalgias, HSM
Baby: chorioretinitis, hydrocephalus, periventricular
calcifications, seizures

Management
Maternal infection: Spiramycin
Does not prevent fetal infection but may reduce severity

Fetus: pyrimethamine, sulfadiazine, folinic acid antepartum

Baby: pyrimethamine, sulfadiazine, folinic acid for 1 year

Cytomegalovirus in Pregnancy
Most common congenital infection

(0.2-2.2% neonates)

Dx: ultrasound findings suggestive of infection, f/u

amniocentesis (PCR>culture) after 21
Abdominal/liver calcifications, HSM, echogenic bowel or kidneys,
ascites, ventriculomegaly, hydrops, IUGR

Sequelae:
Mom: usually asymptomatic, may have mono-like syndrome (fever,
chills, abnormal liver function, LAD)
Baby: death, neurologic morbidities, congenital hearing loss

Management: no Rx available, serial US for growth

and anatomy (e.g. cerebral ventricles)
Ongoing WIH RCT: IVIG Rx of maternal CMV infection to
prevent transmission

REVIEW!
Parvo
Varicella
Toxoplasmosis
CMV

References
ACOG Practice Bulletin No 82. Management of herpes in
pregnancy. 2007.
ACOG Practice Bulletin No 86. Viral hepatitis in pregnancy. 2007.
ACOG Practice Bullent No 151. Cytomegalovirus, Parvovirus B19,
Varicella Zoster, and Toxoplasmosis in Pregnancy. 2015.
Hollier LM, Wendel GD. Third trimester antiviral prophylaxis for
preventing maternal genital HSV recurrences and neonatal
infection. Cochrane Database Syst Rev 2008; (1): CD004946.
Jamieson DJ et al. Cesarean delivery for HIV infected women:
recommendations and controversies. Am J Obstet Gynecol 2007;
197 (3 Suppl): S96-100.
Jamieson DJ et al. Recommendations for HIV screening,
prophylaxis and treatment for pregnant women in the US. Am J
Obstet Gynecol 2007: 197 (3 Suppl): S26-32.
Winn HN. GBS infection in Pregnancy. Clin Perinatol 2007; 34:
387-92.