1. Infections in Pregnancy Jonathan Schaffir, MD Associate Professor Dept of Obstetrics & Gynecology The Ohio State University College of Medicine

2. Objectives Describe the routes of infection in pregnancy and when infection is likely to occur the different types of infections that occur in pregnancy, including “TORCH” infections, and their clinical significance At the end of this module, you will learn how to

3. Pregnant uterus = sterile environment Fetus with immature immune system (begins development at 14 weeks) The Fetus

4. Routes of infection in pregnancy Transcervical Transplacental Iatrogenic

5. Transcervical infection  Cervical mucus provides barrier between vagina and uterine cavity  Thickened under influence of progesterone

6. Intraamniotic infection

7. Intraamniotic infection: pathogens Chlamydia Gonorrhea STDs Group B strep E. coli Bacteroides Mycoplasma/ ureaplasma Pathogenic vaginal flora

8. Review question In which of the following scenarios is an intrauterine infection the most likely? After having a Pap smear at 14 weeks After having sexual intercourse at 28 weeks After having a pelvic exam at 37 weeks After 12 hours of labor with membranes ruptured and cervical dilation of 6 cm

9. Transplacental infection  Viruses and bacteria that have infected the maternal circulation can in theory reach the fetus through the placenta

10. “TORCH” infections  Refers to a group of pathogens that can cause transplacental infection:  T oxoplasmosis  O ther (syphilis)  R ubella  C ytomegalovirus  H erpes /HIV/ Hepatitis (rarely)

11. Toxoplasmosis  Parasitic coccidium can be asymptomatic in immunocompetent adults  Fecal-oral transmission from cats, soil  May cause infection of brain or retina, leading to blindness, severe mental retardation

12. Syphilis  Sexually transmitted spirochetal disease  Phenotype depends on when in pregnancy infected  Can cause mental retardation, deafness Saddle nose Hutchinson’s teeth Saber shins

13. Rubella  Maternal infection now rarely seen due to vaccination program  Triad of microcephaly, heart defects, and cataracts; deafness also occurs

14. Cytomegalovirus  Very common (50-80% of adults have had it)  Often contracted by oral route by infected children (day care/ preschool)  Usually mild symptoms  Can be reactivated  Infant may have mental retardation, retinitis, hepatosplenomegaly and rash “Blueberry muffin rash”

15. Herpes  More commonly a concern at delivery, with vertical transmission due to direct contact  May be transmitted transplacentally when mother has primary infection (acute viremia)  Possible CNS manifestations, death

16. HIV  Transmission depends on viral load, degree of intra- partum exposure and unknown immunological factors  Not associated with birth defects  Rate of transmission drastically reduced with prenatal and intrapartum treatment

17. Review question A boy comes to your pediatric clinic for evaluation of mental retardation and learning delays. You notice that his front teeth are peg-like and his shins are bow-shaped. His mother was most likely infected with: Toxoplasmosis Syphilis Rubella Cytomegalovirus

18. Some other important infections to know about Parvovirus ListeriaMalaria

19. Parvovirus  Common infection among children (“5 th disease”)  If contracted in pregnancy can induce hemolysis and severe anemia in fetus  Causes hydrops (diffuse swelling) and heart failure

20. Listeria  Predilection for pregnant women  Mild illness in mother; devastating to fetus  Frequently causes death in utero  Usually contracted through contaminated food

21. Malaria  Does not cause fetal infection  Infects the placenta, where parasites proliferate  Causes miscarriage, restricted fetal growth, and low birthweight  Prophylaxis recommended in endemic areas

22. Review question On a routine prenatal visit at 24 weeks, you find that the fetus has no heartbeat. Which of the following associations would lead you to believe the mother contracted listeria? Fetal hydrops Recent safari in Africa Recent high fever and shaking chills Recent stay on a cousin’s farm

23. Conclusions  Fetus is well-protected from external pathogens  Infections that can breach these protections may have devastating consequences  Important to prevent infection with careful screening, vaccination, patient education and appropriate treatment

24. Thank you for completing this module Questions? Jonathan.Schaffir@osumc.edu