Infections of the Fetus and

Newborn
( Congenital and Perinatal infections )

By

A. Badr- El - Din, M.D.

Professor of Pediatrics & Neonatology
Alexandria University
 Introduction
Vertically transmitted ( mother to child ) infections
of the fetus and newborn can generally be
divided
Into two major categories :
 Congenital infections : which are transmitted
to the fetus in utero.
 Perinatal infections : which are acquired
intrapartum or in the postpartum period.
 Congenital Infections
Important points to remember:

5. The time to provide information to mothers

about these infections is before pregnancy
begins, because this is the best time for
preventive measures.
6. The first trimester is usually the most
dangerous time to acquire these
infections.
3. Infection in the mother can often be
accompanied by trivial or even no
symptoms, and the condition may not be
remembered or diagnosed.

4.Infection in the mother does not always

mean that the baby will be affected.
5.Some infections can be avoided by the
mother through simple measures, e.g.
immunization (Rubella, VZV ) during
childhood and before pregnancy.
Etiologic Agents:

Viruses: CMV,HSV,VZV,Rubella, Hepatitis B

virus, Parvovirus B19,HIV.
Bacteria: Treponema pallidum, Listeria
monocytogenes, Campylobacter fetus.
Fungi: Candida albicans.
Parasites: Toxoplasma gondii,Plasmodium spp.,
Trypanosoma cruzi.
The most common organisms causing
Congenital Infections Include:

CMV, HSV, Parvovirus B19,

Rubella, Hepatitis B virus,
VZV, Toxoplasma gondii,
HIV, Treponema pallidum
The acronym TORCH is not used any more.

When suspected, the diagnosis of each of the

possible infectious agents should be considered

separately.
 Pathogenesis

 Pregnant women are exposed to infections in

the community.
 They are also more likely to be exposed to

infections associated with young children.

 These infants are often sick and represent a

significant risk factor in exposure to infectious

diseases.
 The vast majority of these infections will
usually resolve spontaneously or with
appropriate antimicrobial agents and will not
affect the developing fetus.

 However, if the infecting organism invades

the blood stream, infection of the fetus may
occur.
 The most common means of infection of the
fetus is via the blood stream.

 Less common means of infections include:

* Extension from adjacent tissues and/organs.

*Invasive diagnostic or therapeutic interventions.
( e.g. monitors, fetal blood sampling, intrauterine
transfusions )
 Results of infection of the Embryo and
Fetus

 Death and resorption of the embryo.

 Abortion and stillbirth of the fetus.

 Live birth of a premature or term baby who

may or may not be normal.

 The newborn may be L.B.W.

 May have congenital anomalies.

 May have congenital disease.

 May have developmental abnormalities.

 The abnormalities may be apparent at birth

or may not be recognized for months or
years .
 Syndromes in neonates caused by congenital
infections
Microorganism Signs
Toxoplasma gondii Hydrocephalus, diffuse intracranial
calcification, chorioretinitis
Rubella virus Cardiac defects, sensorineural hearing
loss, cataracts
Cytomegalovirus Microcephalus, periventricular
calcification
Limb abnormalities, cicatricial lesions
Varicella - zoster virus
Erythrovirus B19 (Parvovirus B19) Diffuse edema (in utero hydrops
fetalis)
Vesicular lesions, keratoconjunctivitis
Herpes simplex virus
Bullous, macular, and eczematous
Treponema pallidum skin lesions involving the palms and
the soles; rhinorrhea, dactylitis
osteochondritis and periostitis.
Clinical signs of neonatal infections acquired in utero or at
delivery
Clinical Sign Rubella virus CMV HSV Toxoplasma

Hepatospleno
megaly
+ + + +

Jaundice + + + +

Adenopathy
+ - - +

Pneumonitis
+ + + +
 Rubella CMV HSV TOXOPLA
Clinical sign SMA

Microceph _ ++ + +
aly

Hydroceph + + + ++
alus

Intracranial _ ++ _ ++
calcifications

Hearing deficits + + _ _
 Toxoplasmosis
Clinical Rubella CMV HSV
sign
Skin lesions
+ + + +
purpura

Vesicles _ + ++ _

Maculopa _ _ + +
pular rash

CNS: + + + +
Meningo-
encephalitis
 Cytomegalovirus ( CMV )

 The most common cause of in-utero infection.

 Fetal infection is greatest ( 40% ) during
primary maternal infection & rarely during
recurrent infection.
 Only 10% of infants born with congenital
infections are symptomatic at birth.
 Infection during 1st trimester usually causes
severe affection.
 Survivors of this stage and a minority of
asymptomatic infants will develop late complications.

 A less severe form in the form of IUGR, microcephaly

with or without I.C. calcification may be seen at birth.

 If the infection is acquired during labour the symptoms

may appear after an I.P. of 4-12 wk or pass unnoticed
only to be discovered with hearing abnormalities later.

 Transfusion acquired CMV can occur.

congenital CMV infection : microcephaly
Congenital cytomegalovirus infection and microcephaly in a
neonate. Semi lateral skull radiograph shows intracranial
calcifications that conform to the shape of the ventricles.
 Diagnosis :
 Culture.
 PCR.
 CMV IgM & IgG.
 CT scan, abnormal CT predicts high

probability of CNS sequalae.

Treatment:
Gancyclovir – valgancyclovir
 Prevention :
 Attenuated virus vaccine.
 Hyper immune CMV immunoglobulin.

Breast milk :
 Herpes – simplex virus ( HSV )

Two types of HSV:

1. HSV-1 ( Recurrent oro-labial disease ).
2. HSV-2 ( Recurrent genital disease ).

Most mothers of infants with neonatal HSV

DO NOT have a history of HSV.
 IN-UTERO INFECTION of the fetus with
HSV is RARE. The most severe IUI has a
triad of:

1. Skin vesicles or scarring.

2. Eye disease : chorioretinitis,

keratoconjunctivitis.

3. Microcephaly or hydrancephaly.

INTRA-PARTUM INFECTION :


Responsible for 95% of cases : Always
symptomatic and frequently fatal particularly with
primary maternal infection.

 The risk of intra-partum transmission increases

with ruptured membranes more than 4 hours.
Intra-partum and post-natal infection
may present with:

1. Disease localized to skin, eye, or mouth.

2. Encephalitis with or without skin ,eye or

mouth involvement.

3. Disseminated infection of multiple organs.

Congenital HSV infection
Congenital HSV infection
DIAGNOSIS: Specific IgM, DFA, CSF

MANAGEMENT:
1. Pregnant mothers: C/S in 1ry infection and
when membranes are ruptured more than 4h.

2. Newborns at risk: Acyclovir for

symptomatic NB, may be to asymptomatic as
well pending laboratory evidence.
 VARICELLA –ZOSTER VIRUS

A. CONGENITAL VARICELL SYNDROME:

Occurs if infection is acquired between 7-20
weeks gestation and characterized by:
1. Ocular defects.
2. CNS abnormalities.
3. IUGR.
4. Early death.
These babies are unlikely to have an active viral
disease and antiviral therapy is NOT indicated.
Congenital varicella infection
B. SEVERE DISEASE:
When varicella occurs in the mother in the 5 days before or in the 2
days after delivery.

 Symptoms in the newborn begin 5-10 days after delivery.

 Mortality 30%.

 These babies may be given VZIG prophylactically within 72 hours of

exposure.

 Acyclovir safety and dose is not established in newborns

When in-utero transmission occurs before the peripartum

period there is no clinical impact in most cases.
Congenital varicella infection
C. POST- NATAL VARICELLA:
 Usually a mild disease.
 Rarely severe disseminated disease occurs in
newborns exposed shortly after birth.
 Treatment with acyclovir may be beneficial, the dose
and safety of acyclovir in treating neonatal vzv,
however, is not established.
 Breast feeding is deferred during the period of time in
which the mother is likely to be viremic and/or
infectious.
 Isolate the infant from the mother during this period.
 HEPATITIS
HEPATITIS A: No horizontal transmission.

HEPATITIS B: Can be acquired in-utero and

perinatally.
 Most infections are asymptomatic .
 Symptomatic infants have jaundice and HSM.
 Management of newborns depends on
mother’s serology:
 Infants born to HBsAg - positive mothers:
Give HBIG ( 0.5ml ) and 1st dose of hepatitis B
vaccine immediately after birth.
 Infants born to HBsAg - negative mothers:

Give hepatitis B vaccine within 2 months after

birth.
 Infants born to mothers whose HBsAg is

unknown:
Give 1st dose of vaccine within 12-hours of
birth, determine Mother’s serology ….etc.
 HEPATITIS C:
 Vertical transmission is rare ( 5% ).
 Mode of transmission unknown.
 Horizontal transmission:
Contaminated syringes, transfusions,...etc
 Infants born to HCV infected mothers have
antibodies.
 To diagnose infection in NB do PCR.
 CONGENITAL RUBELLA SYNDROME

 The risk of infection is greatest in 1st

trimester,
cardiac and hearing abnormalities invariably
occur
 The classic CRS is characterized by:

* Eye anomalies: cataracts, retinopathy,

microphthalmia.
* Congenital heart: PDA, P.S.
Cataracts in Congenital Rubella Syndrome
 * Neurological: meningoencephalitis, EEG
abnormalities, psychomotor retardation.
* Sensorineural hearing loss.
* Hematological: HSM, purpura.
* Radiological: bone lucencies.

 Some of these anomalies may not show until

months or years later.
 Management of recognized or suspected
maternal exposure to rubella

The best is to determine rubella specific IgG at

the 1st obstetric visit.
 If the mother is known to be seropositive:

 If the mother is a known seronegative:

 If the maternal immune status is unknown.

 Toxoplasma gondii

 An obligate intracellular parasite.

 The cat is the only definitive host.
 Infection in the mother does not always cause congenital
disease in the baby.

CONGENITAL INFECTION:
 Infection usually occurs after 1ry maternal infection, recurrence
is extremely rare.
 Neonatal symptomatic disease is usually severe, and is
characterized by a triad of HYDROCEPHALUS,
CHORIORETINITIS and I.C. CALCIFICATIONS.

 The sequelae of asymptomatic disease are unpredictable.

1. Ingestion of tissue cysts from contaminated raw or
undercooked beef, lamb, or pork.

2. Ingestion of oocysts from soil, milk, water, or

vegetables

3 Inhalation of oocysts.

4. Contaminated blood transfusions

organ transplants, and accidental
inoculation acquired in the laboratory
Laboratory diagnosis:
 Serology: * Toxoplasma specific IgG.

* PCR.
 CBC : leucocytosis or leucopenia,
lymphopenia, monocytosis, eosinophilia (30%),
thrombocytopenia.
 Others: ABR.

Treatment:
Mother:
Newborn:
 Erythrovirus ( Parvovirus 19 )

 A common viral infection causing the slapped

cheek syndrome; fifth disease.
 Has been implicated in 10% of cases of fetal
non-immune hydrops fetalis.
 A small percentage of susceptible women
exposed to the virus are infected.
fifth disease
 Perinatal and intrapartum infections are very
rare.

 Inutero infections can result in fetal death,

nonimmune fetal hydrops, birth defects ( eyes,
CNS ) and prematurity,
Diagnosis:
Serum IgM & IgG:
 Absent IgG antibodies in mother rules out

infection.

 IgM appears by day 3 after infection and

persists for 3 months at least.
Enteroviruses:

HIV:

Listeria:

Group B streptococci:
 PREVENTION

Pregnant women SHOULD AVOID :

1- Contact with ill people.

2- Eating raw or undercooked meat.

3- Contact with cat feces.

4- Sexual contact with partner infected with genital

herpes or HIV.
 Human immune serum globulin can be
given to seronegative mothers exposed to:
rubella, varicella, measles or hepatitis A virus.
However, their role is not definite.

 Treatment of women with positive culture

for GBS during labor and delivery.

 Treat eyes of newborns with erythromycin

to prevent ophthalmia neonatorum.
 Immunization for Rubella, Hepatitis and
VZV before pregnancy if they are
seronegative.

 Live viral vaccines should be given 3-6

months before conception.

 No Live Viral Vaccine should be given to

pregnant women for fear of causing
congenital infection.