STIs including Zika virus infection in pregnancy: Risk factors for adverse pregnancy and birth outcomes Angélica Espinosa Miranda Universidade Federal do Espirito Santo Departamento de Medicina Social 17th IUSTI World Congress Marrakesh, 9-12 May, 2016

STIs and pregnancy Many sexually transmitted infections (STIs) can be transmitted from mother to child during pregnancy and childbirth chlamydia, gonorrhea, hepatitis B, HIV, syphilis, herpes virus and now Zika virus among others. Adverse pregnancy and birth outcomes are multifactorial and these factors may interact with one another. Goldenberg et al, 1997; Mullick et al, 2005; Ramaiya et al, 2014

Risk factors for adverse pregnancy and birth outcomes  Socio-cultural issues  poverty, access to care, racism  Maternal characteristics  age, race/ethnicity, marital status, income, employment, education, SES, nativity, immigrant status, insurance coverage  Behavioral risks  STIs, tobacco, drug abuse, physical activity, nutrition Savitz et al, 2004; Goldenberg et al, 2008; Polakowski et al., 2009; Beck et al, 2010; Mathews et al, 2010

Risk factors for adverse pregnancy and birth outcomes  Pregnancy-related risks  obesity, maternal complications & infections, parity/gravity, pregnancy spacing, prior pregnancy outcomes, pre-pregnancy health status  Genetic (including paternal) and intergenerational risks  Beliefs and attitudes  including no planned pregnancy Savitz et al, 2004; Goldenberg et al, 2008; Polakowski et al., 2009; Beck et al, 2010; Mathews et al, 2010

Exploring Potential Determinants PreconceptionPregnancy Labor & Delivery Birth Outcomes Maternal Risk Indicators Environ ment & Health Care System Risk Indicators MorbidityMortality Examining the impact of STIs on pregnancy outcome is complex Conrey, 2015

STIs and pregnancy STIs, including HIV, are of particular importance in determining pregnancy outcome, mainly in developing countries because the prevalence of infection is high. outcomes of pregnancy in which STIs agents play important etiologic roles. Ectopic pregnancy, spontaneous abortion and stillbirth, prematurity, congenital and perinatal infections, and puerperal maternal infections, premature rupture of the membranes (PROM). Mati et al, 1982; Who, 2001; Goldenberg et al, 2008

STIs and pregnancy Infection during pregnancy can produce miscarriage, chorioamnionitis, prematurity, and congenital infection. Some complications caused by STIs: Syphilis: Stillbirth, LBW, preterm birth, intrauterine growth retardation (IUGR), neonatal deaths and also congenital infection in a proportion of surviving infants. Watts et al, 1984; Schulz et al,1987; Temmerman et al, 1992; Donders et al, 1993; McDermott et al, 1993; Mullick et al, 1995; Gomez et al, 2013

STI and pregnancy There is evidence that STIs cause potential complications for pregnancy outcome: gestational age at delivery and type of delivery health of the newborn Photo: HINSG

Photos: HINSG

STI and pregnancy Chlamydia trachomatis: Stillbirth, preterm delivery, PROM and LBW. Maternal infection can also affect the neonate, leading to infant pneumonia and ophthalmia neonatorum. Neisseria gonorrhoeae: Preterm delivery, PROM, LBW, postpartum endometritis, and gonococcal ophthalmia neonatorum. Beem et al, 1977; Lacey et al, 1984; Gencay et al, 2000; Gencay et al, 2001, Kishore et al, 2003; Donders et al, 2003; Mullick et al, 1995; Bald et al, 2008; Bald et al, 2011

STIs and pregnancy Bacterial vaginosis: It has been implicated as a cause of preterm birth, LBW, PROM, postpartum sepsis, and spontaneous miscarriage. Trichomonas vaginalis: It has been associated with preterm delivery and LBW. Goldenberg et al, 1997; Mayaud et al, 1998; Mullick et al, 2005

STIs and pregnancy Herpes simplex virus: Neonatal herpes is a severe illness presenting with pulmonary disease, seizures, fever, intracranial findings, and a high case fatality rate following contact with infected genital secretions during delivery. HIV: LBW and stillbirth, spontaneous abortion and an increased risk of preterm delivery. The most significant sequela of maternal HIV infection in pregnancy is mother to child transmission of HIV. Scott, 1999; Temmerman, et al, 1994; Embree et al, 2000; Mullick et al, 2005

STI and pregnancy Zika virus infection Natural transmission cycle involves mosquitoes especially Aedes species. Potential risk for transfusion and sexual transmission Some recent data show the possibility of perinatal transmission Zika virus was detected in amniotic fluids from two pregnant women in Brazil whose fetuses had been diagnosed with microcephaly Lanciotti et al, 2007; Calvet et al, 2016; Oliveira Melo et al, 2016;

Photos: HUCAM

STIs and pregnancy Zika virus can cross the placental barrier and, possibly, infect the fetus. Fragments of Zika virus genome were identified in saliva, breast milk, urine, and serum of two mothers and their newborn babies within 4 days of delivery. Zika congenital syndrome: microcephaly, auditory impairment, ocular manifestations, such as focal pigment mottling and chorioretinal atrophy. Besnard et al, 2007; Calvet et al, 2016; de Paula et al, 2016

Clinical features and neuroimaging (CT and MRI) findings in presumed Zika virus related congenital infection and microcephaly. BMJ 2016;353:i1901 (A)Profound craniofacial disproportion; (B) Dystrophic calcifications hyperintense on T1; (C) shows severe ventriculomegaly; (D) Thickness and enhancement of frontal pachymeningis.

Zika virus and microcephaly Recife, Brazil

STIs and pregnancy Adverse pregnancy and birth outcomes are multifactorial Examining the impact of STIs on pregnancy and birth outcome is complex Zika virus should be considered as a potential infectious agent for human fetuses