Obstetrics Lecture: Infections in Pregnancy PDF

OBSTETRICS LECTURE LE 06 - Infections in Pregnancy Dr. Marth Louie Tarroza, M.D....

OBSTETRICS LECTURE LE 06 - Infections in Pregnancy Dr. Marth Louie Tarroza, M.D. 03 TABLE OF CONTENTS ◼ WHO recommendations: Exclusively breastfeed for the I. Maternal and Fetal Immunology IV. Protozoal Infections 1st 6 months of life, partial breastfeeding until 2 years of A. Maternal-Fetal Vascular A. Toxoplasmosis age Interface B. Malaria Newborns often fail to express classic clinical signs of infections B. Maternal Immunological C. Amebiasis → Depressed and acidotic at birth Changes V. Bioterrorism → Poor suck, vomiting or with abdominal distention C. Fetal and Newborn Immunology A. Anthrax → Respiratory insufficiency / Idiopathic respiratory distress D. Transmissions VI. Sexually Transmitted E. Specific Causes of Some Fetal Infections syndrome and Neonatal Infections A. Syphilis → Lethargic or jittery II. Viral Infections B. Gonorrhea → Hypothermic A. Cytomegalovirus (CMV) C. Chlamydial Infection → Depressed leukocyte and neutrophil count B. Varicella Zoster Virus D. Lymphogranuloma C. Influenza Virus VII. Venereum D.TRANSMISSIONS D. Mumps Virus A. Herpes Simplex Virus Horizontal Transmission E. SARS-CoV-2 B. Chancroid → The spread of an infectious agent from one individual to F. Measles Virus (Rubeola) C. Condyloma Acuminata (Genital another G. Rubella Virus (German Measles Warts) → Virus is transmitted directly from host to host; not associated H. Parvovirus B19 D. Vaginitis I. Zika Virus E. Human Immunodeficiency with infection of offspring during pregnancy III. Bacterial Infections VIII. Virus Vertical Transmission A. Group A Streptococcus (S. IX. VII. Review Questions → Passage of an infectious agent from mother to her fetus pyogenes) X. VIII. References through the placenta, during labor or delivery, or by B. Group B Streptococcus XI. IX. Appendix breastfeeding → Virus is transmitted from one generation to the next through LEGEND congenital infection ⭐ IMPORTANT 💬 LECTURE BOOK 📖 📋 PREVIOUS TRANS ABBREVIATIONS CMV Cytomegalovirus HSV Herpes Simplex Virus HPV Human Papillomavirus HIV Human Immunodeficiency Virus VZV Varicella-Zoster Virus MMR Measles-Mumps-Rubella LEARNING OBJECTIVES Understand the pathogenesis of the most common STI and Infectious diseases in pregnancy Diagnose these conditions Plan appropriate management I. MATERNAL AND FETAL IMMUNOLOGY A. MATERNAL-FETAL VASCULAR INTERFACE Provides protection of the fetus from infectious agents Conduit for transmission of infection B. MATERNAL IMMUNOLOGICAL CHANGES Th-1 type cytokine production of interferon gamma and interleukin 2 is suppressed → Affects ability to rapidly eliminate certain intracellular pathogens during pregnancy, clinical implications of this suppression are still unknown Increase in CD4+ T cells that secrete Th2-type cytokine, e.g. interleukins C. FETAL AND NEWBORN IMMUNOLOGY Active immunological capacity of the fetus and neonates are compromised compared to older children and adults Fetal innate and adaptive immunity begin to develop by 9 to 15 weeks AOG Figure 1. Specific Causes of Some Fetal and Neonatal Infections ⭐️ MUST KNOW Primary fetal response to infection is mediated by innate immunity [Lecture PPT] (macrophages and dendritic cells) → And to another extent by adaptive immunity Maternal and Fetal Immunology Passive immunity is provided by maternal immunoglobulin G → Provides protection of the fetus from infectious agents (IgG) transferred across the placenta → Conduit for transmission of infection → 16 weeks AOG → Transfer begins to rise rapidly Maternal Immunological Changes → 26 weeks AOG → Fetal = Maternal concentration → Th-1 type cytokine production of interferon gamma and → After birth → breastfeeding is protective against some interleukin 2 is suppressed infections → Increase in CD4+ T cells that secrete Th2-type cytokine, e.g. ◼ This protection begins to decline at 2 months of age interleukins Infections in Pregnancy | Alcantara, Alforque, Amante, Añes, Antonino AVPAA | Buenaventura OB | LE3 - NO. 06 PAGE 1 of 16 VPAA | Catcatan TE | Añes, I., Bautista  Fetal and Newborn Immunology CONGENITAL CMV INFECTION → Fetal innate and adaptive immunity begin to develop by 9 to 15 weeks AOG → Primary fetal response to infection is mediated by innate immunity (macrophages and dendritic cells) → Passive immunity is provided by maternal immunoglobulin G (IgG) transferred across the placenta ◼ 16 weeks AOG → Transfer begins to rise rapidly ◼ 26 weeks AOG → Fetal = Maternal concentration → Newborns often fail to express classic clinical signs of infections ◼ Depressed and acidotic at birth ◼ Poor suck, vomiting or with abdominal distention ◼ Respiratory insufficiency / Idiopathic respiratory distress syndrome Figure 2. CMV Infection [Lecture PPT] ◼ Lethargic or jittery ◼ Hypothermic Manifestations: ◼ Depressed leukocyte and neutrophil count → Growth restriction Transmissions → Microcephaly → Horizontal Transmission: The spread of an infectious agent → Intracranial calcifications from one individual to another → Chorioretinitis → Vertical Transmission: Passage of an infectious agent from → Mental and motor delays mother to her fetus through the placenta, during labor or → Sensorineural deficits delivery, or by breastfeeding → Hepatosplenomegaly → Jaundice CONCEPT CHECKPOINT → Hemolytic anemia 1. At what AOG is fetal concentration of IgG same as of maternal → Thrombocytopenic purpura concentration? a) 25 weeks AOG DIAGNOSIS b) 16 weeks AOG Routine prenatal CMV serological screening is NOT c) 20 weeks AOG recommended. d) 26 weeks AOG Only undergo serologic testing when: 2. True or False. Newborns are able to express classical clinical → Pregnant with a mononucleosis-like illness signs of infections like adults? → Congenital infection is suspected based on abnormal Answers: sonographic findings 1. D. → If either ultrasound or serological results indicate infection, 2. F. Newborns fail to express classical clinical signs of infections. diagnostic amniocentesis is pursued II. VIRAL INFECTIONS A. CYTOMEGALOVIRUS (CMV) Double-stranded DNA herpes surrounded by lipid envelope virus Most common perinatal infection in the developed world Following primary infection, the virus becomes latent but undergoes periodic reactivation characterized by viral shedding → This occurs despite high serum levels of anti-CMV IgG antibodies ◼ Do NOT prevent maternal recurrence, reactivation, or Figure 3. Congenital CMV Infection. (A) Transverse view of the fetal reinfection nor do they totally mitigate fetal or neonatal head demonstrates ventriculomegaly (LV) and periventricular infection calcifications. (B). Transverse image of the fetal abdomen with ascites TRANSMISSION (*) and echogenic bowel [Lecture PPT] Transmission: → Person-to-person contact with viral-laden saliva, semen, urine, blood, and nasopharyngeal and cervical secretions → Transplacental → During delivery and breastfeeding MATERNAL INFECTION Pregnancy does not decrease the risk of severity of maternal CMV CLINICAL ENTITIES Primary Infection → Majority are asymptomatic, but 10-15% have mononucleosis-like syndrome (fever, pharyngitis, lymphadenopathy, and polyarthritis) → Vertical Transmission: ◼ First trimester – 30-36% Figure 4. Diagnostic Evaluation of CMV Infection in Pregnancy ◼ Second trimester – 34-40% (Check appendix Figure 4 for big image) [Lecture PPT] ◼ Third trimester – 4-72% Serum levels of CMV IgM alone do not accurately diagnose Reactivated Disease primary CMV infection antibodies. May persist for more than a → Usually asymptomatic, although viral shedding is common year after infection and may rise again following reactivation or → Vertical Transmission: reinfection. ◼ 0.15-2% of pregnancies → To help clarify a primary infection from a past one, → Up to 90% of congenitally infected neonates in serological CMV-specific IgG avidity assay measures the high-prevalence areas are born with recurrent infection avidity or “binding” strength between IgG antibodies and the virus. OB | LE3 - 06 Infections in Pregnancy PAGE 2 of 16  → Following the primary infection, IgG antibodies have low FETAL/NEONATAL INFECTION avidity, which in 2-4 months matures into high avidity. CONGENITAL VARICELLA SYNDROME ◼ Low IgG avidity indicates primary CMV infection is within Includes: the preceding 3-4 months → Chorioretinitis ◼ High IgG avidity excludes primary infection within the → Microphthalmia previous months → Cerebral cortical atrophy ⭐ CMV Polymerase Chain Reaction (PCR) of the amniotic fluid Gold standard for diagnosing fetal infection → Sensitivity – 77-99% → Growth restriction → Hydronephrosis → Limb hypoplasia ◼ Highest at least 6 weeks after maternal infection → Cicatricial skin lesion ◼ After 21 weeks AOG Viral Culture DIAGNOSIS PCR-based testing of amniotic fluid MANAGEMENT → However, a positive result does not correlate well with an Symptomatic treatment infection No proven treatments for CMV infection Anatomical sonographic evaluation Leruez-Ville and associates (2016): → Should be performed at least 5 weeks after maternal infection → Oral treatment with Valacyclovir, 8g mitigated adverse which may disclose abnormalities but with low sensitivity outcomes for 80% of asymptomatic fetuses compared with a historical cohort PERIPARTUM VARICELLA INFECTION Kimberlin and colleagues (2015) Exposure before or during delivery → IV Valganciclovir given for 6 weeks to neonates with → “5 days before and 2 days after delivery” symptomatic CNS disease prevented hearing deterioration at No maternal antibodies against Varicella Zoster 6 months and possibly later → Attack rate: 25-50% Hughes (2021) → Mortality rate: 30% → CMV-specific hyperimmune globulin given to pregnant In some instances, neonates develop Disseminated visceral and women with primary infection was ineffective in lowering CNS disease perinatal CMV infection rates PREVENTION PREVENTION Delivery is usually delayed to decrease the risk of having No vaccine peripartum varicella infection Prevention of congenital infection relies on avoiding maternal → If possible at least 7 days from appearance of rash primary infection, especially in early pregnancy → Good hygiene → Handwashing → Avoidance of sharing of food and utensils CMV may be sexually transmitted among infected partners B. VARICELLA ZOSTER VIRUS Double stranded DNA herpes virus Incubation: 10-21 days Primary Infection: Varicella or Chickenpox Reactivation: Herpes Zoster Shingles Figure 6. Limb Hypoplasia (R) and Neonatal Infection (L) [Lecture PPT] TRANSMISSION Respiratory droplets MANAGEMENT Direct contact For exposed individuals with negative clinical history of Vertical Transmission chickenpox or vaccination, VZV Serologic Testing is advised → VZV Serologic Testing MATERNAL INFECTION ◼ ~70% are seropositive 1- to 2-day flu-like prodrome, which is followed by pruritic ◼ If seronegative: vesicular lesions that crust after 3 to 7 days. – Give Varicella Immunoglobulin (VariZIG) via IM Contagious from 1 day before the rash onset until all lesions within 96 hrs from exposure become crusted – 125 units per 10 kg, max dose 625 units (5 vials) Mortality is higher than childhood disease → Secondary infection/ If symptomatic: VZV pneumonia → Isolation Vertical Transmission: → CXR → 20 weeks AOG - Rare → IV Acyclovir 500 mg/ m2 or 10-15 mg/ kg every 8 hours DIAGNOSIS → With an additional Oral Acyclovir 800 mg/ tab, 5x daily, to Clinical complete 7 days Laboratory If uncomplicated (without hospitalization) Primary Varicella → Tzanck Smear → Oral Acyclovir 800 mg/ tab, 5x daily for 7 days → Tissue culture PREVENTION → Antibody testing Varivax → Attenuated live-virus vaccine → 2 doses, 4-8 weeks apart results in 97% seroconversion → NOT given for pregnant patients → Can be given to breastfeeding patients ◼ Not secreted in breastmilk C. INFLUENZA VIRUS Orthomyxoviridae Influenza A & B RNA viruses Clinical Presentation Figure 5. Pruritic Vesicular Lesions → Fever OB | LE3 - 06 Infections in Pregnancy PAGE 3 of 16  → Dry cough Vaccination → Systemic symptoms → mRNA Pregnant women are more susceptible to more serious ◼ Ex. Pfizer and Moderna complications, particularly pulmonary involvement → Viral vector NO firm evidence links influenza virus A and congenital ◼ Ex. J&J, AstraZeneca and Gamaleya malformations → Protein subunit ◼ Ex. Novavax DIAGNOSIS → Inactivated Clinical diagnosis ◼ Ex. Sinovac-Corona Vac Rapid enzyme immunoassays Immuno-fluorescence E. MUMPS VIRUS RNA Paramyxovirus MANAGEMENT Primarily infects the salivary glands but may involve the gonads, Neuraminidase Inhibitors meninges, and pancreas → Oral Oseltamivir Mumps in pregnancy is no more severe than in non pregnant ◼ 75 mg twice daily for 5 days, within 48 hours symptoms adults onset Increased risk of spontaneous abortion in first trimester ◼ Post-exposure Prophylaxis: 75 mg once daily for 7 days Not associated with congenital malformations → Other Medications: Zanamivir (inhalation) and Peramivir (IV) Fetal infection is RARE PREVENTION Inactivated or Recombinant Influenza Vaccine → Formulated annually 📋 TRANSMISSION 📋 Occurs before and within parotitis onset Direct contact with respiratory secretions, saliva, or fomites → Non-teratogenic → Vaccination especially for those with DM, heart disease, HIV, MANAGEMENT asthma Isolation → Vaccination DURING pregnancy → Infants are protected for 3 Symptomatic Treatment months against LRTI PREVENTION D. SARS-CoV-2 MMR vaccine Causes Coronavirus Disease 2019 or the COVID-19 Respiratory illness in more than 151 million people and 3 million deaths worldwide ⭐ → Live-virus vaccine Contraindicated in pregnancy → Pregnancy should be avoided for 30 days after vaccination Mortality rate: 1-2% in adults and increases with age → Breastfeeding is NOT contraindicated TRANSMISSION F. MEASLES VIRUS (RUBEOLA) Predominantly via respiratory droplets Highly contagious RNA Paramyxovirus MATERNAL INFECTION TRANSMISSION Symptoms in gravidas do not differ from non-pregnant patients Respiratory droplets CLINICAL PRESENTATION CLINICAL PRESENTATION Asymptomatic Fever, Coryza, Conjunctivitis, Cough Fever, cough, myalgia, anosmia, ageusia Koplik spots Dyspnea, tachypnea, decreased O2 saturation and rarely acute → Whitish lesions with surrounding erythema on buccal mucosa respiratory distress syndrome Erythematous maculopapular rash At higher risk for ICU admission, invasive ventilation and death → Starts at the face and neck, then spreads to back, trunk, and Higher rate of preterm birth (13%) than that of general population extremities (10%) FETAL INFECTION Infection of the placenta by SARS-CoV-2 has been demonstrated, but transmission to the fetus is rare. Infected neonates may have asymptomatic, mild or severe illness. No evidence suggests transmission through breast milk. DIAGNOSIS RT-PCR testing Figure 7. Koplik spots [2025 trans] Rapid antigen testing Specimen: nasopharyngeal, nasal and saliva DIAGNOSIS Serology MANAGEMENT RT-PCR Mild to Moderate illness: → Supportive care → Delivery is reserved for obstetric indications ⭐ MATERNAL AND FETAL INFECTION Increased risk for pregnancy loss, pneumonia, and death Risk of neonatal infection → Molnupiravir ◼ Not recommended for use in pregnancy and MANAGEMENT breastfeeding Supportive treatment Severe to Critical Illness: Exposure prophylaxis → Goal of respiratory support is to maintain O2 saturation > 95% → 400 mg/ kg of Intravenous Immunoglobulin (IVIG) given and reduced dyspnea and tachypnea within 6 days of exposure → Remdesivir and Tocilizumab → Dexamethasone in patients requiring supplemental oxygen or PREVENTION mechanical ventilation MMR vaccine → Live-virus vaccine PREVENTION ◼ Contraindicated in Pregnancy Non-pharmaceutical interventions → Susceptible women should be routinely vaccinated → Universal masking postpartum → Maintaining physical distance → Hand hygiene G. RUBELLA VIRUS (GERMAN MEASLES) OB | LE3 - 06 Infections in Pregnancy PAGE 4 of 16  RNA Togavirus Respiratory secretions Incubation period: 12-23 days Blood transfusion Organ donation TRANSMISSION Nasopharyngeal secretions with 80% transmission rate to non MATERNAL INFECTION immune individuals 20-30% are asymptomatic Infectious during viremia and through 7 days after rash onset Presents with fever, headache and flu-like symptoms Bright red rash with erythroderma of the face (“slapped cheek CLINICAL PRESENTATION appearance”) is usually observed Mild febrile illness Rash spreads to the trunk and extremities Generalized Maculopapular Rash No evidence suggests that parvovirus infection is altered by → Face and spreads to trunk and extremities pregnancy Arthralgias or arthritis, head and neck lymphadenopathy, and conjunctivitis DIAGNOSIS Isolation from urine, blood, nasopharynx, and cerebrospinal fluid Serology → IgM – 4-5 days AFTER disease onset up to 6 weeks after → IgG – peaks 1-2 weeks AFTER rash onset FETAL INFECTION Figure 9. Slapped Cheek Appearance [2025 trans] FETAL INFECTION Can cause: → Abortion → Non-immune hydrops ◼ Can be seen in ~4% of pregnant patients with this type of infection → Still birth Fetal loss rate: → 20 weeks - rare → Presents with: ◼ Cardiac septal defects Figure 10. Fetal Hydrops [2025 trans] ◼ Pulmonary stenosis ◼ Microcephaly DIAGNOSIS ◼ Cataracts Serology ◼ Microphthalmia PCR OF maternal serum and amniotic fluid ◼ Hepatosplenomegaly ◼ Intellectual disability ◼ Neonatal purpura ◼ Radiolucent bone disease MANAGEMENT Supportive treatment Droplet precaution for 7 days after rash onset Postexposure passive immunization → Within 5 days of exposure Targeted sonographic examination is recommended Referral to and counseling by a Maternal-fetal medicine specialist PREVENTION MMR vaccine → Live-virus vaccine ◼ Contraindicated in Pregnancy ◼ Can be given to non-immune individuals right after delivery → Susceptible women should be routinely vaccinated postpartum → Avoid pregnancy until 1 month after vaccination Figure 11. Flowchart for diagnosis of Parvovirus 19 [2025 trans] H. PARVOVIRUS B19 MANAGEMENT & PREVENTION Small, single-stranded DNA virus Symptomatic treatment Erythema infectiosum or fifth disease No vaccine available Causes fetal anemia No evidence that antiviral treatment prevents maternal and fetal infection TRANSMISSION I. ZIKA VIRUS OB | LE3 - 06 Infections in Pregnancy PAGE 5 of 16  RNA Flavivirus which targets the neural progenitor cells → Diagnosis First recognized major mosquito-borne teratogen ◼ Routine prenatal CMV serological screening is NOT TRANSMISSION recommended. ◼ CMV Polymerase Chain Reaction (PCR) of the amniotic Mosquito bite fluid Sexual transmission – Gold standard MATERNAL INFECTION ◼ Viral culture Asymptomatic to mild symptoms of rash, fever, arthralgia, and → Management conjunctivitis ◼ Symptomatic treatment ◼ No proven treatments for CMV infection FETAL INFECTION ◼ Oral Valacyclovir, 8g mitigated adverse outcomes for Congenital Zika Syndrome 80% of asymptomatic fetuses → Microcephaly ◼ IV Valganciclovir given for 6 weeks to neonates with → Lissencephaly symptomatic CNS disease prevented hearing → Ventriculomegaly deterioration at 6 months → Intracranial calcification ◼ CMV-specific hyperimmune globulin given to pregnant → Ocular abnormalities women with primary infection was ineffective → Congenital contractures Varicella Zoster Virus → Primary Infection: Varicella / Chickenpox ◼ Reactivation: Herpes Zoster Shingles → Transmission: respiratory droplets, direct contact, vertical transmission → Maternal infection: contagious from 1 day before the rash onset until all lesions become crusted → Congenital infection: diagnosis based on PCR-based testing (amniotic fluid) and anatomical sonographic evaluation (at least 5 weeks after maternal infection) → Peripartum infection: disseminated visceral and CNS disease ◼ Prevention: delayed delivery, at least 7 days from the appearance of rash → Management: ◼ VZV serologic testing (seronegative: VariZIG) ◼ Isolation, CXR, supportive care ◼ (+) pneumonia: hospitalization; Figure 12. Clinical Manifestations of Zika Virus [2025 trans] ◼ Oral acyclovir (uncomplicated primary varicella) → Prevention DIAGNOSIS ◼ Varivax Serologic Testing – CI in Pregnancy Detection of Zika Virus RNA in blood or urine (PCR) – Can be given to breastfeeding patients MANAGEMENT Influenza virus Supportive treatment → Orthomyxoviridae Influenza A&B → Clinical presentation: fever, dry cough, and systemic PREVENTION symptoms No vaccine available → Diagnosis: clinical, rapid EIA, immunofluorescence Protective netting and insect spray to control the vector mosquito → Management: oral oseltamivir (neuraminidase inhibitors) Sexually active men and women should be counseled and offered ◼ Also used as prophylaxis following exposure a full range of contraceptive methods → Prevention: Inactivated or recombinant influenza vaccine → Men: at least 3 months SARS-CoV-2 → Women: at least 2 months ⭐️ → Causes Coronavirus Disease 2019 or the COVID-19 MUST KNOW → Respiratory illness in more than 151 million people and 3 Cytomegalovirus million deaths worldwide → Most common perinatal infection in the developed world → Mortality rate: 1-2% in adults and increases with age → Following primary infection, the virus becomes latent but → Transmission: undergoes periodic reactivation characterized by viral ◼ Respiratory droplets shedding → Maternal Infection → Transmission ◼ Symptoms in gravidas do not differ from non-pregnant ◼ Person-to-person contact patients ◼ Transplacental → Clinical presentation ◼ During delivery and breastfeeding ◼ Asymptomatic → Maternal Infection ◼ Fever, cough, myalgia, anosmia, ageusia ◼ Pregnancy does not decrease the risk of severity of ◼ Dyspnea, tachypnea, decreased O2 saturation, and maternal CMV rarely acute respiratory distress syndrome ◼ Majority of patients are asymptomatic for primary ◼ At higher risk for ICU admission, invasive ventilation, and infection death → Congenital CMV Infection ◼ Higher rate of preterm birth (13%) than that of the ◼ Growth restriction general population (10%) ◼ Microcephaly → Fetal Infection ◼ Intracranial calcifications ◼ Infection of the placenta by SARS-CoV-2 has been ◼ Chorioretinitis demonstrated, but transmission to the fetus is rare. ◼ Mental and motor delays ◼ Infected neonates may have an asymptomatic, mild or ◼ Sensorineural deficits severe illness. ◼ Hepatosplenomegaly ◼ No evidence suggests transmission through breast milk. ◼ Jaundice → Diagnosis: ◼ Hemolytic anemia ◼ RT-PCR testing ◼ Thrombocytopenic purpura ◼ Rapid antigen testing OB | LE3 - 06 Infections in Pregnancy PAGE 6 of 16  ◼ Specimen: nasopharyngeal, nasal and saliva ◼ Serologic Testing → Management: ◼ PCR (urine and blood) ◼ Mild to Moderate illness → Management: Supportive treatment – Supportive care → Prevention: No vaccine available – Delivery is reserved for obstetric indications III. BACTERIAL INFECTIONS – Molnupiravir ○ Not recommended for use in pregnancy and A. GROUP A STREPTOCOCCUS (S. pyogenes) breastfeeding Most frequent bacterial cause of acute pharyngitis ◼ Severe to Critical Illness Also causes systemic and cutaneous infections – Goal of respiratory support is to maintain O2 saturation Most common cause of severe maternal postpartum infection and > 95% and reduced dyspnea and tachypnea death worldwide – Remdesivir and Tocilizumab TREATMENT – Dexamethasone in patients requiring supplemental Penicillin and Clindamycin oxygen or mechanical ventilation → Prevention: B. GROUP B STREPTOCOCCUS ◼ Non-pharmaceutical interventions Maternal and fetal GBS effects range from asymptomatic – Universal masking colonization to septicemia – Maintaining physical distance Can cause maternal bacteriuria, pyelonephritis, osteomyelitis, – Hand hygiene postpartum mastitis and puerperal infections → Vaccination Leads to preterm labor, PROM, chorioamnionitis, fetal infections Mumps Virus Universal screening for GBS is done at 36-38 weeks AOG → Increased risk of spontaneous abortion in 1st trimester followed by antibiotic prophylaxis for women identified to be → Transmission: direct contact (respiratory secretions, saliva, carriers fomites) PROPHYLAXIS → Management: isolation; symptomatic treatment → Prevention: MMR vaccine ◼ CI in pregnancy Rubella virus (German Measles) → Transmission: nasopharyngeal secretions → Clinical presentation: mild febrile illness, generalized maculopapular rash, arthralgia / arthritis, head and neck lymphadenopathy, conjunctivitis → Diagnosis: isolation (urine, blood, nasopharynx, CSF), and serology (IgM & IgG) → Management: supportive treatment, droplet precaution, post-exposure passive immunization, targeted sonographic examination, referral to maternal-fetal medicine specialist Figure 13. Indications for Intrapartum Group B Streptococcal → Prevention: MMR vaccine Infection Prophylaxis [2025 trans] ◼ CI in pregnancy Measles virus (Rubeola) → Transmission: respiratory droplets → Clinical presentation: fever, coryza, conjunctivitis, cough, Koplik spots, erythematous maculopapular rash → Diagnosis: serology, RT-PCR → Prevention: MMR vaccine → Management: ◼ Supportive treatment ◼ Exposure prophylaxis – 400 mg/ kg of Intravenous Immunoglobulin (IVIG) given within 6 days of exposure Figure 14. Regimens for Intrapartum Antimicrobial Prophylaxis for Perinatal GBS Disease [Lecture PPT] Parvovirus B19 → Erythema infectiosum or fifth disease and fetal anemia → Causes non immune hydrops secondary to fetal anemia ⭐️ MUST KNOW Group A Streptococcus (S. pyogenes) → Transmission → Most frequent bacterial cause of acute pharyngitis ◼ Respiratory secretions → Most common cause of severe maternal postpartum infection ◼ Blood transfusion and death worldwide ◼ Organ donation Group B Streptococcus → Management and Prevention → Maternal and fetal GBS effects range from asymptomatic ◼ Symptomatic treatment colonization to septicemia ◼ No vaccines available → Can cause maternal bacteriuria, pyelonephritis, ◼ No evidence that antiviral treatment prevents maternal osteomyelitis, postpartum mastitis and puerperal infections and fetal infection Zika Virus CONCEPT CHECKPOINT → First recognized major mosquito-borne teratogen 2. Which of the following is the most common cause of severe → Transmission maternal postpartum infection and death worldwide? ◼ Mosquito bite a) Borrelia burgdorferi ◼ Sexual transmission b) Listeria monocytogenes → Fetal Infection: Congenital Zika Syndrome c) Staphylococcus aureus ◼ Microcephaly d) Streptococcus pyogenes Answers: ◼ Lissencephaly 3. D. Group A Streptococcus (S. pyogenes) is the most frequent bacterial ◼ Ventriculomegaly cause of acute pharyngitis. It is also the most common cause of severe ◼ Intracranial calcification maternal postpartum infection and death worldwide. ◼ Ocular abnormalities IV. PROTOZOAL INFECTIONS ◼ Congenital contractures → Diagnosis A. TOXOPLASMOSIS OB | LE3 - 06 Infections in Pregnancy PAGE 7 of 16  Toxoplasma gondii Strategies: Endemic worldwide in humans and in domestic and wild animals → Cooking meat to safe temperatures → Seropositive rates ranging from 10 to over 90% (WHO) → Peeling or thoroughly washing fruits and vegetables The full natural cycle is maintained predominately by cats and → Cleaning all food preparation surfaces and utensils that have mice contacted raw meat or unwashed fruits and vegetables → Wearing gloves when changing cat litter or delegating this TRANSMISSION duty Food borne → Avoiding feeding cats raw or undercooked meat and keeping → Eating undercooked meat of animals harboring tissue cysts cats indoors Airborne → Consuming food or water contaminated with cat feces or by B. MALARIA contaminated environmental samples Life-threatening protozoal disease caused by infection with the Congenital (Transplacentally) parasites of genus Plasmodium Blood transfusion or organ transplantation → Plasmodium falciparum ◼ Associated with a great maternal and fetal morbidity and DIAGNOSIS mortality Maternal Serologic testing → Plasmodium vivax IgG avidity → Plasmodium ovale → High avidity (AI ≥ 60%): more than 3 months ago → Plasmodium malariae → Borderline avidity (50% 90 percent) are asymptomatic Third leading parasitic cause of mortality, after malaria and → Congenital Toxoplasmosis schistosomiasis ◼ Classic Triad: Hydrocephalus, Chorioretinitis, Intracranial calcifications Malaria → Life-threatening protozoal disease caused by infection with the parasites of genus Plasmodium → Transmission ◼ Bite from anopheline mosquito → Diagnosis ◼ Thick smear: Presence of malarial parasites Figure 16. Entamoeba histolytica [Lecture PPT] ◼ Thin smear: Identify the species and quantify parasite density TRANSMISSION → Presentation Feco-oral route ◼ Fever, chills, headache, myalgia, cough, neurologic signs Sexual transmission (confusion, disorientation, coma, dizziness) and DIAGNOSIS gastrointestinal pain Microscopic identification of cysts and trophozoites in stool → Management Immunodiagnosis ◼ Chloroquine or Hydroxychloroquine → Enzyme immunoassay (EIA) kits – Uncomplicated malaria (P. ovale, P. malariae, and → Indirect hemagglutination (IHA) chloroquine-sensitive falciparum) Molecular diagnosis ◼ Artemether lumefantrine or Artesunate plus mefloquine → PCR – For multidrug resistant P. falciparum (Non pregnant) ◼ Chloroquine-resistant P. vivax infection PRESENTATION – Quinine plus Clindamycin, or Mefloquine should be Colicky abdominal pain, with or without diarrhea given instead The stools are large, foul smelling and brownish-black in color – For women in their second or third trimesters, Fulminant colitis due to ulceration and necrosis of the colon Artemether lumefantrine → The patient may become febrile and septic Amebiasis MATERNAL INFECTION → Entamoeba histolytica Usually associated with acute exacerbations and prominent → Transmission symptoms (bloody dysenteric stools, abdominal pain & ◼ Feco-oral route tenderness) ◼ Sexual transmission Electrolyte imbalance and dehydration → Presentation → Due to episodes of LBM ◼ Colicky abdominal pain, with or without diarrhea → May adversely affect the pregnancy ◼ Large, foul smelling and brownish black stools Hepatic involvement: most common extraintestinal complication ◼ Fulminant colitis: patient may become febrile and septic though it is not a frequent complication in pregnancy → Diagnosis → Tenderness & pain in the right hypochondriac region, and ◼ Microscopic identification of cysts and trophozoites referred pain on the right shoulder ◼ Immunodiagnosis: EIA kits and IHA → Fever with chills can occur ◼ Molecular diagnosis: PCR → Jaundice: common complication when the hepatic abscess → Maternal Infection compress on the gallbladder ◼ Associated with acute exacerbations and prominent symptoms FETAL INFECTION ◼ Electrolyte imbalance and dehydration No clear evidence of placental transmission of the parasite to the ◼ Hepatic involvement: most common extraintestinal fetuses complication; not a frequent complication in pregnancy Commonly occurring complications: Prematurity, oligohydramnios, → Fetal infection and growth restrictions ◼ No clear evidence of placental transmission MANAGEMENT ◼ Prematurity, oligohydramnios, and growth restrictions Table 2. Management of Amebiasis → Management: See Table 2 Non-Pregnant Patients Pregnant Patients V. BIOTERRORISM Mild to Moderate Intestinal Disease A. ANTHRAX Metronidazole 500-700 mg TID x Metronidazole 500-700 mg TID x Caused by Bacillus anthracis 7-10 days 7-10 days Caused by 3 types of clinical anthrax: or → Inhalational Tinidazole 2g OD x 5 days → Cutaneous Severe Intestinal and Extra Intestinal Disease (Hepatic → GIT Abscess) Manifestation: Metronidazole 750 mg TID x 7-10 Metronidazole 750 mg TID x 7-10 → Severe respiratory distress and high fever, mediastinitis, and days days hemorrhagic thoracic lymphadenitis or MANAGEMENT Tinidazole 2g OD x 5 days Toxoplasmosis ⭐️ MUST KNOW Ciprofloxacin 500 mg 2x a day x 60 days or Amoxicillin 500 mg 3x daily if the strain is proven sensitive Doxycycline 100 mg 2x a day x 60 days if with allergy to → Etiologic agent is Toxoplasma gondii ciprofloxacin or penicillin → The full natural cycle is maintained predominately by cats PREVENTION and mice Vaccination is avoided in pregnancy however, postexposure → Transmission antimicrobial prophylaxis is an essential adjunct even in ◼ Foodborne pregnancy ◼ Airborne ◼ Congenital (Transplacentally) ◼ Blood transfusion or organ transplantation Anthrax ⭐️ MUST KNOW → Maternal Infection OB | LE3 - 06 Infections in Pregnancy PAGE 9 of 16  → Caused by Bacillus anthracis → Caused by 3 types of clinical anthrax: ◼ Inhalational ◼ Cutaneous ◼ GIT → Management: ◼ Ciprofloxacin 500 mg ◼ Amoxicillin 500 mg ◼ Doxycycline 100 mg → Prevention: ◼ Vaccination is AVOIDED in pregnancy ◼ Postexposure antimicrobial prophylaxis is an essential Figure 19. Secondary Syphilis: Maculopapular rash and Condyloma adjunct in pregnancy lata [Lecture PPT] VI. SEXUALLY TRANSMITTED INFECTIONS LATE SYPHILIS A. SYPHILIS Clinical events appear 1 to 30 years after primary infection Caused by Treponema pallidum Tertiary Syphilis Incubation period: 10-90 days → Patients with late syphilis who have symptomatic manifestations (versus late latent syphilis) → Most common manifestations: ◼ Cardiovascular syphilis ◼ Gummatous syphilis ◼ CNS Involvement: neurosyphilis Figure 17. Treponema pallidum [Lecture PPT] Figure 20. Late Syphilis Lecture PPT] TRANSMISSION Sexual Contact LATENT SYPHILIS Transplacental Treponema pallidum infection with NO symptoms Blood Transfusion Diagnosis is based only upon the result of serologic testing Divided into: STAGES OF DISEASE → Early: initial infection occurred 12 months ago or the timing Early Syphilis Late Syphilis of infection is not known Primary Syphilis Tertiary Syphilis MATERNAL AND CONGENITAL INFECTION Secondary Syphilis Late Latent Syphilis Table 4. Maternal and Congenital Infection Early Latent Syphilis Adverse Pregnancy PRIMARY SYPHILIS Neonatal Effects Outcomes Chancre Fetal hepatic Jaundice → 1-2 cm ulcer with raised and indurated margin Preterm Labor abnormalities → With non-exudative base Petechiae or purpuric → Usually solitary and painless Fetal Death Anemia skin → Lymphadenopathy, often bilateral Fetal-growth Lymphadenopathy → Heals spontaneously: 2-3 weeks even without treatment Thrombocytopenia restriction Fetal infection Ascites and hydrops Rhinitis Pneumonia Myocarditis Nephrosis Long-bone involvement DIAGNOSIS Direct Methods: lesion exudate, tissue or body fluid → Darkfield Microscopy → Direct Fluorescent Antibody Testing (DFA-TP) → Polymerase Chain Reaction testing Serologic Testing → Non-treponemal Tests Figure 18. Primary Syphilis [Lecture PPT] ◼ Venereal Disease Research Laboratory (VDRL) ◼ Rapid Plasma Reagin (RPR) SECONDARY SYPHILIS → Treponemal-specific Tests Develops weeks to a few months after the chancre ◼ Fluorescent treponemal-antibody absorption tests Presentation (FTA-ABS) → Systemic symptoms (fever, malaise, anorexia, sore throat, ◼ T pallidum passive particle agglutination (TP-PA) test myalgia and weight loss) – Generally remain positive throughout life → Adenopathy → Diffuse, symmetric macular or papular eruption involving trunk APPROACH and extremities including the palms and soles Traditional Strategy → Mucous patches Reverse Sequence Strategy → Condyloma lata OB | LE3 - 06 Infections in Pregnancy PAGE 10 of 16  📋 No proven alternative drug during pregnancy Table 6. Recommended Treatment for Syphilis based on Stage Category Treatment Benzathine Penicillin G 2.4 M units Early syphilis as single injection – some (Primary, secondary, recommend a second dose one early latent) week Figure 21. Traditional Strategy (Serologic Testing) later 📋 Initially, requested a qualitative non-treponemal test (qualitative) is More than 1-year duration Benzathine Penicillin G 2.4 M units → If reactive: treponemal tests are requested for confirmation IM weekly for 3 doses → If again reactive: a quantitative nontreponemal titer is REACTIONS 📋 requested Treatment based on symptoms and stage Allergy/Anaphylaxis → Oral stepwise penicillin-dose challenge or skin testing should Table 5. Reverse Sequence Strategy be done to confirm the risk of IgE-mediated anaphylaxis Treponemal VDRL or Possible → If confirmed: penicillin desensitization is recommended TP-PA followed by benzathine penicillin G treatment Test RPR Interpretations 1. Absence of syphilis Jarisch-Herxheimer Reaction Nonreactive 2. Very early syphilis → Uterine contractions, mild maternal temperature elevation, before seroconversion decreased fetal movement, fetal heart rate decelerations Reactive 1. Prior treated → Treatment: supportive (antipyretics, hydration, O2 support) Syphilis B. GONORRHEA Reactive Nonreactive Reactive 2.Untreated Syphilis Causative agent: Neisseria gonorrhoeae Nonreactive 3. False-positive 2nd most common STD treponemal test Prevalence: 0.6 percent 1. Active syphilis Limited to lower genital tract in pregnant women 2. Recently treated Associated with septic abortion, preterm delivery, premature syphilis with rupture of membranes, chorioamnionitis, postpartum infection nontreponemal titers Vertical transmission: Gonococcal ophthalmia neonatorum Reactive Reactive that have not yet SCREENING become nonreactive First Trimester Screening: for those who live in high prevalence 3. Treated syphilis with area or with risk factors such as: persistent titers → ≤ 25 y/o, prior gonococcal infection 1. False-positive → other STDs Nonreactive Reactive nontreponemal test → prostitution, new or multiple sexual partners 📋 Most current strategy → Treponemal test is requested first, followed by a → drug abuse → black, Hispanic or American Indian ethnicity nontreponemal test → inconsistent condom use) Screening: 📋 Most current strategy Interpretation → TT nonreactive = absent syphilis or very early syphilis before → Culture or Nucleic Acid Amplification Test (NAAT) of samples from cervix and vagina (preferred) or urine. seroconversion MANAGEMENT → TT reactive → VDRL or RPR, if nonreactive → TP-PA, if Uncomplicated gonococcal infection during pregnancy: reactive = prior treated syphilis OR untreated syphilis → TT → 300lbs): Ceftriaxone, two simultaneous 500mg IM nonreactive = false positive treponemal test injection → TT reactive → VDRL or RPR, if reactive = active syphilis OR → Note: If Chlamydial co-infection is not excluded, Azithromycin recently treated syphilis with nontreponemal test that have 1gm oral is added not yet become reactive OR treated syphilis with persistent → Alternative Drug: titers (serofast) ◼ Cefixime 800 mg , oral, single dose → TT nonreactive → VDRL or RPR, if reactive = false positive ◼ Gentamicin 240 mg IM + 2-g oral Azithromycin (if with nontreponemal test allergy to cephalosporin but risks of neonatal effects, SEROLOGIC TEST RESULTS: nephrotoxicity, and ototoxicity should be discussed) → IF tests are positive: Disseminated gonococcal infection ◼ Check for signs of congenital syphilis: hepatomegaly, → Septic arthritis: Ceftriaxone 1 g IM or IV every 24 hours placental thickening, hydramnios, ascites, hydrops fetalis, (given 24-48 hrs after clinical improvement) then shift to oral elevated middle cerebral artery indices agent to complete 1 week of therapy → Sonographic evaluation for fetuses >20 weeks AOG If with → Endocarditis: Ceftriaxone 1-2 g IV every 12 hours at least 4 sonographic findings and fetus of viable age weeks ◼ Antepartum FHT monitoring prior to treatment is → Meningitis: Ceftriaxone 1-2 g IV every 12 hours 10-14 days recommended → Note: If Chlamydial co-infection is not excluded, Azithromycin MANAGEMENT 1gm oral is added Counsel and test all women with syphilis for HIV and other STDs C. CHLAMYDIAL INFECTION Do serological testing 6, 12 months after treatment to check for Causative agent: Chlamydia trachomatis treatment failure Most common STD in the US During pregnancy, serologic testing can be checked monthly in Infection rate: 646 cases/100,000 females in 2015 📋 📋 women at high risk for reinfection Penicillin G: preferred treatment for all stages during pregnancy A second dose of Benzathine Penicillin G given 1 week after initial Most pregnant women are asymptomatic Symptoms: urethral syndrome, urethritis, Bartholin gland infection dose is recommended during pregnancy and those with concomitant HIV infection OB | LE3 - 06 Infections in Pregnancy PAGE 11 of 16  Associated with delayed postpartum uterine infection (vaginal → Disseminated disease occurs in 32%, mortality rate is nearly bleeding or discharge, low-grade fever and uterine tenderness 2-3 30% weeks postpartum) Postpartum: uncommon route Neonatal transmission: conjunctivitis and pneumonia → By contact with an infected mother or family member or healthcare worker MANAGEMENT → Presentation similar with peripartum transmission Screening is recommended at first prenatal visit for women with In utero: rare and is part of TORCH collection of infection risk factors same as gonorrhea → involves the skin (blisters/scarring), CNS (hydrancephaly, Diagnosis: Culture or NAAT from vaginal or cervical smears microcephaly, intracranial calcification) or eyes (chorioretinitis, (preferred) or urine microphthalmia) Treatment: → Azithromycin 1g single dose is the first line of treatment in MANAGEMENT pregnancy Table 8. Antiviral Recommendations for Herpes Simplex Virus → Alternative: Amoxicillin 500 mg 3x/day for 7 days Infection During Pregnancy Test of cure is recommended 4 weeks after completion of Indication Pregnancy Recommendation treatment and 3 months after treatment to exclude reinfection. Acyclovir 400 mg 3x/day x 7-10 days Primary or First Episode Infection For high-risk women, rescreening is recommended during the 3rd Valacyclovir 1gm 2x/day x 7-10 days trimester. Acyclovir 400 mg 3x/day x 5 days Treat partner to prevent reinfection Acyclovir 800 mg 2x/day x 5 days Symptomatic recurrent infection Acyclovir 800 mg 3x/day x 2 days D. LYMPHOGRANULOMA VENEREUM (episodic therapy) Valacyclovir 500 mg 2x/day x 3days Note: This section is entirely lifted from 2025 since it is not in the Valacyclovir 1gm daily x 5 days powerpoint presentation provided. Acyclovir 400 mg 3x/day from 36 weeks until Caused by L1, L2, L3 serovars of C. trachomatis delivery Primary genital infection is transient Daily suppression Valacyclovir 500 mg 2x/day from 36 weeks until CLINICAL MANIFESTATION delivery Matted inguinal adenitis that gives rise to the “groove sign” Amniocentesis, percutaneous cord blood sampling or Vulvar elephantiasis transabdominal chorionic villus sampling may be performed Severe rectal stricture, fistula formation even with active genital lesions MANAGEMENT Cesarean delivery is indicated for women with active genital Erythromycin base 500 mg orally 4x/day for 21 days lesions or prodromal symptoms Azithromycin 1gm oral weekly x 21 days Breastfeeding may be done if there are NO active breast lesions Antiviral treatment may be used for symptomatic maternal E. HERPES SIMPLEX VIRUS lesions during breastfeeding Herpes simplex virus type 1 and 2 Primary/First clinical episode F. CHANCROID Incubation: 2-12 days (4 days) Note: This section is entirely lifted from 2025 since it is not in the powerpoint presentation provided. CLINICAL MANIFESTATION Caused by Haemophilus ducreyi Painful genital ulcers; can be painless or pruritic Presents as painful, indurated genital ulcers ”soft chancre” May present with fever, malaise, and myalgias Accompanied by painful suppurative inguinal Reactive painful nodes common lymphadenopathy 2-4 mm multiple, small, grouped vesicles with erythematous base Presumptive diagnosis is based on clinical findings and a → vesicopustules → erosions → ulcerations negative test for syphilis and HS Recurrent Infection → Less severe MANAGEMENT → Atypical vaginal lesions (fissures or vulvar irritation) Azithromycin 1gm oral as single dose or → 25 % are asymptomatic Erythromycin base 500 mg 3x/day x 7 days or → 50 % have prodromal symptoms: Ceftriaxone 250 mg IM single dose ◼ local, mild tingling or shooting pain in the buttocks, legs, G. CONDYLOMA ACUMINATA (GENITAL WARTS) and hips Caused by human papillomavirus (HPV) – HPV 6 AND 11 DIAGNOSIS Common STD Viral culture Prevalence highest in younger women Polymerase chain reaction (PCR) – more sensitive method Most infections are asymptomatic and transient Direct fluorescent antibody Genital warts increase in number and size during pregnancy Type-specific serologic testing Not related to preterm labor/delivery Tzanck smear – Multinucleated giant cells MANAGEMENT Trichloroacetic acid or bichloroacetic acid 80-90% applied topically weekly Cryotherapy, laser ablation or surgical excision may be done Contraindicated: podophyllin resin, podofilox solution or gel, imiquimod cream, sinecatechins Treat only if symptomatic → Lesions frequently improve or regress rapidly following delivery HPV vaccination is not recommended during pregnancy Figure 23. Tzanck smear → Women who are breastfeeding may receive the vaccine VERTICAL TRANSMISSION CONGENITAL/NEONATAL INFECTION Peripartum: most frequent route Neonatal infection is minimal → Exposure from the cervix and lower genital tract (virus Juvenile onset recurrent respiratory papillomatosis invades the uterus after membrane rupture or by contact at → Rare benign neoplasm of the larynx delivery → Cause hoarseness and respiratory distress in children → Infection may be localized to skin, eye or mouth, → Caused by HPV 6 or 11 → Encephalitis occurs in 30% Risk factors for fetal infection are maternal genital HPV and longer labor OB | LE3 - 06 Infections in Pregnancy PAGE 12 of 16  Caesarean delivery is NOT recommended solely to prevent HPV Culture : Diamond’s modified medium transmission PCR NAAT G. VAGINITIS Genexpert Most common cause of abnormal discharge in reproductive age women CLINICAL MANIFESTATIONS Described as a “sexually associated” infection Copious, malodorous, frothy → Lack of single causative agent Yellow-greenish discharge → Lack of a disease counterpart in males Erythematous vulva and vagina → Presence of the disease in women who have never had Classic sign: strawberry appearance of upper vagina and cervix sexual contact of any type MANAGEMENT → Absence of inflammation Preferred Risk factors: new or multiple sexual partners, homosexual → Metronidazole 500mg orally twice daily for 7 days couples, douching, and social stressors, lack of hydrogen ◼ Resting is encouraged at 3 months to exclude reinfection peroxide–producing lactobacilli ◼ Tinidazole is not recommended in pregnancy Pathophysiology: reduction in lactobacilli (LB) and hydrogen peroxide production → a rise in the vaginal pH → overgrowth of I. CANDIDIASIS BV associated organisms (Prevotella sp., Prevotella and Symptomatic vaginitis affecting the vagina and/or the vulva Mobiluncus sp., Gardnella vaginalis, Ureaplasma, Mycoplasma) Characterized by inflammation in the setting of an overgrowth of Associated with: Candida organisms resulting in itching and erythema → Upper tract infections (endometritis, PID) Produced by a ubiquitous, airborne, gram-positive fungus: 90% → Postoperative vaginal cuff cellulitis Candida albicans → Multiple complications of infection during pregnancy Occurs at lower pH (