Home > Encyclopedia of Nursing & Allied Health > Perinatal Infection

Definition

Perinatal infections are those infections affecting the mother during a pregnancy, and may be transmitted to the fetus during pregnancy, during delivery through the birth canal, or after delivery through the breast milk.

Description

Perinatal infections may be bacterial, fungal, or viral in nature. The degree to which the mother is affected by the infection is not an indication of its impact on the fetus. The mother may have slight or no symptoms, and yet the fetus may be significantly affected by the infection. The woman's sexual partner(s) may also be affected by these infections and should seek medical treatment. The more common perinatal infections significantly affecting the fetus are discussed below.

Causes and symptoms

Chlamydia

According to the Centers for Disease Control (CDC), chlamydia trachomatis is the most frequently reported bacterial sexually transmitted disease in the United States, with about 650,000 cases reported in 1999. It is often referred to as a silent disease, because so many infected individuals are asymptomatic. While about 75% of women are unaware of their infection, symptoms include purulent endocervical discharge, inflammation, edema, and bleeding. Chlamydial infection can permanently damage the reproductive tract. While asymptomatic, women can experience inflammation of the fallopian tubes, chronic pelvic pain, pelvis inflammatory disease, an increased risk for ectopic pregnancy, and infertility. For pregnant woman, chlamydial infection increases the risk for premature rupture of membranes, preterm delivery, and neonatal conjunctival or pneumonic infection. About 65% of infected neonates acquired the disease during a vaginal delivery.

Cytomegalovirus (CMV)

CMV is a common congenital viral infection, belonging to the herpes virus group of infections. Maternal infection usually occurs through sexual intercourse, including kissing, with an infected individual. Maternal infection may be asymptomatic, or the mother may present with mononucleosis-like symptoms, fatigue, lymphadenopathy, or fever. Transmission to the fetus can occur if the mother becomes infected during pregnancy, or if she has a flaring of a pre-exisisting CMV infection. Some immunity is transferred to the fetus if the mother has had a prior CMV infection. Infants infected in utero with CMV may be asymptomatic, or may have a delayed reaction, manifesting as mental retardation or deafness. About 10% of newborns with congenital CMV have evidence of disease at birth. CMV can also be acquired by the newborn through cervical secretions, saliva, urine, or breast milk. It can also be acquired in the newborn nursery by contact with infected individuals. Individuals with a compromised immune system, organ recipients, and those with HIV/AIDS are more likely to suffer severe consequences.

Genital herpes

Genital herpes is a sexually transmitted disease (STD) caused by the herpes simplex virus (HSV), and is considered a life-long infection. It may be contracted in two types, HSV-1 and HSV-2. According to a June 2001 report by the CDC, about 45 million Americans aged 12 and older have contracted HSV-2. The infections may exist subclinically, and later erupt in lesions. The risk of contracting the disease increases with the number of sexual partners. If genital herpes occurs for the first time during pregnancy, first trimester miscarriage and third trimester preterm birth may be the result. The greatest risk for the fetus occurs when genital herpes is contracted near term. Intrauterine transmission does occur, although it is more rare, and can take place across the placenta. After birth, neonates can also contract the disease from an infected newborn in the nursery.

Hepatitis B virus (HBV)

HBV is contracted through direct contact with the blood or other body fluids of an infected individual. It is sexually transmitted, through infected blood or blood products, and to the infant during a vaginal birth. In infants with HBV, 90% contract it at birth. The disease may present in very mild form, with no symptoms and only detected through liver function tests, or may be severe, even fatal, if it has advanced to liver necrosis. Symptoms of HBV infection include:

• jaundice
• fatigue
• rash
• fever that is usually either not present, or very mild
• vague abdominal discomfort
• abdominal pain
• loss of appetite
• nausea
• vomiting
• joint pain

Human immunodeficiency virus (HIV)

HIV is transmitted through direct contact with an infected individual's blood and body fluids (such as semen, amniotic fluid, breast milk, and vaginal and cervical secretions), and leads to the development of acquired immunodeficiency syndrome (AIDS). The majority of pediatric AIDS cases are due to vertical transmission from the mother to the fetus, and is a leading cause of death in children aged one to four years old. Transmission from the mother to the fetus occurs during pregnancy through the placenta, during a vaginal delivery or with premature rupture of membranes, or through the breast milk. Symptoms of an impaired immune system suspicious of HIV infection include:

• fever
• weight loss
• malaise
• oral candidiasis
• central nervous system dysfunction

Human papillomavirus (HPV)

HPV is a STD than can cause genital warts. However, many infected individuals are asymptomatic. This variability is due to the fact that there are about 30 types of HPV. The CDC estimates about 5.5 million new cases of HPV a year, with about 20 million people infected to date. About 28–46% of women under the age of 25 have HPV. Individuals who are immunocompromised, such as those with HIV, are at higher risk of contracting the disease. This is also true of those who are pregnant. Genital warts appear to grow more quickly during pregnancy, and can be large enough to obstruct the cervix for a vaginal delivery. Disruption to the warts of the genital tract during pregnancy or delivery can lead to significant maternal blood loss.

Rubella

Rubella is a contagious disease, and is spread through the respiratory tract. Because of effective vaccination, it is rare in pregnancy. However, it can be passed to the fetus through the placenta if the mother becomes infected during pregnancy. Maternal symptoms include:

• low-grade fever
• swollen glands
• rash starting at the face and moving down toward the extremities
• joint pain
• conjunctivitis

Streptococcus

Group B streptococcus (GBS) is a contagious, bacterial infection that is particularly harmful to pregnant women, newborns, the elderly, and those who are immunocompromised by other illnesses. According to the CDC, it is the most common cause of life-threatening illness in neonates. In pregnant women it can cause bladder infections, amnionitis, endometritis, and stillbirth. Newborns may develop early-onset disease, from day one to day seven, or late-onset disease, from day seven to several months postpartum. In early-onset disease, infants may present with sepsis, respiratory distress, apnea, pneumonia, shock, or meningitis. Late-onset disease may present as sepsis or meningitis. Individuals may harbor GBS without symptoms, but be able to transmit it to another individual. Premature infants are particularly vulnerable.

Syphilis

Syphilis is a sexually-transmitted disease caused by the bacterium Treponema pallidum. It progresses in three stages. In the primary stage, shortly after infection, a small, round, firm chancre sore develops at the site of transmission. Multiple sores may also exist, usually in the vagina, anus, rectum, lips, or mouth. It heals on its own, and may go unnoticed. Untreated, the disease progresses to the secondary stage. In this stage multiple locations break out in a rash of red or brown spots that do not itch. It may be accompanied by fever, weight loss, fatigue, or muscle pain. If untreated, the disease can progress to late-stage syphilis. In this stage, damage to internal organs, the central nervous system, and body systems develops. This stage can lead to paralysis, numbness, blindness, dementia, and death. A mother can pass the disease on to her fetus, who may be stillborn or die shortly after birth.

Toxoplasmosis

A pregnant woman can become infected with toxoplasmosis either by handling infected cat feces, or by ingesting raw or undercooked infected meat. The risk of maternal to fetal transmission is greater when the mother is suffering from an acute, rather than a chronic, infection of toxoplasmosis.

Diagnosis

Chlamydia

In women, chlamydia is diagnosed by evaluating a sample taken of the cervical secretions. A urine test is also available. The Pap smear does not test for chlamydia. To properly diagnose the disease, the endocervical sample needs to be adequate in amount and contain columnar epithelial cells.

Cytomegalovirus

A blood sample can be evaluated for the presence of a CMV-specific antibody, but about 20% of women will show no antibody presence. Prevalence of CMV among the adult general population is high, in some regions occurring in 40–100% of the population. About 33–66% of pregnant women test positive to the CMV IgG antibody. Ultrasound can detect fetal infection, presenting as intrauterine growth retardation, polyhydramnios, and central nervous system abnormalities.

Genital herpes

When lesions are present, tissue sample scrapings or a biopsy can be taken and cultured to confirm the diagnosis. When the condition is latent, diagnosis is more difficult. Blood tests are available, but accuracy of results is not guaranteed. At the first prenatal visit, mothers should be questioned about a prior history of lesions.

Hepatitis B

Diagnosis for HBV is through evaluation of a blood sample for the presence of antigens or antibodies.

Human immunodeficiency virus (HIV)

The HIV infection affects the immune system, causing progressive deterioration during which the individual becomes susceptible to infections and neoplasms rarely seen in those with an intact immune system, such as wasting syndrome, Pneumocystis carini, and Karposi's sarcoma. The diagnosis of these conditions promotes further evaluation for the presence of HIV/AIDS. The average latency between HIV infection and the development of AIDS is about 11 years. A blood sample is used to detect the presence of HIV infection.

Human papillomavirus

Genital warts are diagnosed during a clinical exam.

Rubella

Because rashes can mimic several diseases, the best diagnostic evaluation for rubella is a blood test for the presence of a rubella-specific IgM antibody. The test can also be performed by evaluating samples of nasal or throat secretions, as well as cerebrospinal fluid.

Streptococcus

Diagnosis is done through cultures of rectal or vaginal secretions taken during the third trimester. In the neonate, blood samples can be taken.

Syphilis

Syphilis diagnoses are often missed because the signs can mimic other conditions or be so mild in appearance as to go unnoticed. Samples from chancre sores can be evaluated for the presence of syphilis, or a blood test can be run. While antibodies do develop, they diminish as time passes, and the individual may become reinfected.

Toxoplasmosis

Maternal infection with toxoplasmosis may be asymptomatic. About 10–20% of infected women may present with lymphadenopathy. Fatigue and mononucleosis-like symptoms may also be present. A blood sample can be evaluated for the maternal presence of a toxoplasmosis-specific IgM antibody. Amniotic sampling can detect fetal infection. Infected neonates may present with liver or spleen enlargement, jaundice, fever, hydrocephalus, or microcephalus.

Treatment

Chlamydia

The drugs azithromycin, doxycycline, and oflaxacin are the first-choice treatment for chlamydia, but are contraindicated in pregnancy. Erythromycin and amoxicillin are used during pregnancy. Repeat testing is recommended three weeks after the conclusion of treatment.

Cytomegalovirus

Since no fetal treatment exists for CMV, maternal testing is usually not recommended. In affected infants, acyclovir (Zovirax) and ganciclovir have been used to suppress the infection. However, the infection reappears once the medication is discontinued.

Genital herpes

Antiviral medical treatment does not cure herpes, but rather shortens the course of the disease. For severe maternal complications, intravenous acyclovir may be used. Acyclovir should be given to all neonates with the disease. Treatment can prevent disease progression to serious consequences. Even with antiviral treatment, if the HSV has spread throughout the infant, mortality may be as high as 50%.

Hepatitis B

Because HBV affects the liver, alcohol should be avoided. HBV-infected individuals should have their liver evaluated for signs of disease. The CDC reports that the use of alpha interferon and lamivudine are effective for about 40% of patients. The use of these medications in pregnancy is contraindicated.

Human immunodeficiency virus (HIV)

Careful monitoring of the mother's immune status is an essential component of HIV management. For pregnant HIV-positive women, the medical focus is to maximize benefit for the mother herself, while avoiding vertical transmission, if at all possible. The use of zidovudine (ZDV) reduces the incidence of maternal transmission to the fetus. The pregnant state also balances the side effects of treatment on the mother. The use of ritonavir and nelfinavir (Virocept) are first-line protease inhibitor choices for the pregnant woman. The treatment plan of the HIV-infected individual is determined by the amount of virus present in the body, referred to as viral load. The greater the viral load, the greater the degree to which the maternal immune system is compromised, and the higher the risk of transmission to the fetus. During the first trimester of pregnancy, the teratogenic effects of the antiviral agents given to the mother are the greatest for the fetus.

Human papillomavirus

Direct treatment of the warts is done to provide symptomatic relief. However, the nearby normal-looking tissue can also harbor the HPV. The drugs podophyllin, podofilox, and imiquimod are not used during pregnancy. Instead, laser therapy, surgical excision, cryosurgery, or trichloroacetic acid may be used. To avoid transmission of the disease during vaginal delivery, cesarean birth may be performed. Despite the treatment used, the likelihood of recurrence is high.

Rubella

There is no antiviral treatment for rubella. Prevention through vaccination is the best means of avoiding contracting the disease.

Streptococcus

Penicillin or ampicillin are the drugs of choice, but penicillin-resistant strains exist. Severe infection may warrant the use of an aminoglycoside in addition to the penicillin.

Syphilis

If the infection is within a year, a single dose of penicillin can cure the disease, according to the CDC. A greater dose will be needed if the infection has been present for more than a year. The antibiotic will cure the disease, but not any damage that has already occurred. Mothers with syphilis can be treated while pregnant. The infant may require antibiotic treatment as well after birth.

Toxoplasmosis

Pregnant women infected with toxoplasmosis may be treated with pyrimethamine, folinic acid, spiramycin, and sulfonamide. Maternal treatment may prevent transmission to the fetus. Pyrimethamine can be teratogenic if given in the first trimester.

Prognosis

Chlamydia

Chlamydia infection can have serious consequences for the fetus and neonate. These include:

• spontaneous abortion
• premature rupture of membranes
• preterm delivery
• stillbirth
• neonatal death
• pneumonia

The prognosis for the mother depends on the degree of damage to the reproductive tract prior to treatment. Chlamydia responds well to antibiotic treatment.

Cytomegalovirus

Prognosis overall is good, as many infected individuals are asymptomatic. However, fetal death may occur, and infected infants born with mental retardation, chronic liver disease, motor disabilities, or deafness have lifelong consequences.

Genital herpes

About 30–50% of infants exposed to genital herpes near term will contract the disease. This is in comparison to the 3–5% rate of infection for infants exposed to recurrent genital herpes during pregnancy. Infants exposed to the virus during a vaginal birth have higher rates of the disease than those born via cesarean delivery. Infants with HSV localized to the eyes, skin, or mouth have the best outcome. HSV in infants can lead to death through disseminated intravascular coagulation, pneumonitis, or encephalitis.

Hepatitis B

According to the CDC, the number of new infections has declined from 450,000 in the 1980s to 80,000 in 1999. The area of highest growth is in those aged 20 to 49. Because of vaccinations of younger children, those numbers are declining.

Human immunodeficiency virus (HIV)

While long-term prognosis remains poor, short-term prognosis has been improving. Most studies have been done on men, with research focused on women trailing behind. Pregnancy does not appear to alter the course of the disease.

Human papillomavirus

HPV puts women at increased risk for cervical and anal cancer. Infants born via vaginal delivery may also develop papillomas in the larynx or conjunctiva.

Rubella

Rubella is most commonly seen in non-vaccinated children. In children, the disease course is milder than in adults. Fetal contraction of the disease can lead to fetal death, preterm delivery, and congenital defects such as heart anomalies, mental retardation, blindness, and deafness. The stage of gestation is a critical factor in the degree of impairment to the fetus. All fetal body organs and systems can be affected.

Streptococcus

GBS responds well to antibiotic treatment. Unrecognized or untreated, the effect on the neonate can be severe, including sepsis, pneumonia, or meningitis.

Syphilis

Prognosis depends on the stage to which the disease has progressed. Untreated infants may be asymptomatic, and if untreated may have seizures and die soon after birth.

Toxoplasmosis

The later in the pregnancy the infection is contracted, the better the chance of recovery. A chronic infection in which the mother is infected prior to pregnancy is less likely to be transmitted to the fetus. Fetal death may occur in about 10% of cases occurring in the first trimester of pregnancy. Fetal death is rare when the infection occurs in the third trimester. An acute infection is associated with premature birth and stillbirth. Spontaneous abortion is rare.

Health care team roles

Laboratory technicians and phlebotomists need to observe standard universal precautions in drawing and handling blood and other body fluids, as the complete infection status of a patient will not be known. This includes the use of gloves, eye protection such as a face-mask or goggles, and personal protective clothing. Radiology technicians will be involved in ultrasound scanning to detect fetal compromise as a result of infection. Ultrasound-guided sampling of amniotic fluid or fetal tissue may be used to diagnose fetal infection. Through individual discussion, waiting room videos, and pamphlets, nurses can educate pregnant mothers during routine visits about ways to prevent infection by these agents. Nurses can play a significant role in emphasizing the need for retesting after treatment (when required) and discussing the importance of having the woman's sexual partner tested and treated to avoid reinfection.

Prevention

Chlamydia

When a woman has multiple partners, the use of condoms every time a woman has sexual intercourse can decrease the risk of becoming infected. Limiting the number of sexual partners also decreases the risk of chlamydial infection.

Cytomegalovirus

CMV can be shed in body fluids, so care must be taken when handling these substances. This includes the handling of diapers, especially in day care environments. Those working in a hospital environment should always observe universal precautions when handling any body fluid or secretion. Careful hand washing can decrease the risk of transmission. Since CMV is shed in cervical secretions, cesarean birth may decrease the risk of transmission, although infection during the first two trimesters of pregnancy carries the greatest fetal risk. Research is investigating the usefulness of a preconception vaccine.

Genital herpes

Cesarean delivery can substantially reduce disease transmission to the neonate. For mothers with genital herpes, delivery following premature rupture of membranes (PROM) should be considered, as the risk of disease transmission increases by six hours after PROM. If maternal HSV is suspected, a fetal scalp monitor should be avoided, as this creates a direct portal of entry for the infection.

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KEY TERMS

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Lymphadenopathy—A disorder affecting the lymph nodes or lymphatic vessels.

Perinatal—The time during pregnancy, delivery, and until about one month postpartum.

Sexually transmitted diseases (STDs)—Those diseases transmitted from one individual to another during sexual interaction. They may also be referred to as venereal diseases.

Teratogenic—Tending to produce irregularities of formation.

Vertical transmission—The transmission of a disease or condition from one generation to the next, either through genetics, through the uterine environment, or through the breast milk.

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Hepatitis B

The HBV vaccine is considered the best prevention. It is a series of three injections over seven months. It is not contraindicated in pregnancy. Use of latex condoms will help reduce the risk of transmission. Avoiding high-risk contact, such as contact with blood and other body fluids, will also lessen the risk of HBV. The CDC recommends that newborns born to HBV-infected mothers receive hepatitis B immune globulin after birth as well as the first dose of the vaccine within 12 hours postpartum.

Human immunodeficiency virus (HIV)

In the early 1990s, studies of ZDV used during pregnancy and given to the neonate for six weeks postpartum resulted in a 70% decrease in maternal HIV transmission to the infant. Cesarean birth also reduces transmission, as compared with vaginal birth. Knowledge of the mother's HIV status during pregnancy is therefore important in reducing the transmission risk. Testing for HIV status should be offered to all pregnant women. Avoidance of breast-feeding can also decrease the risk of transmission. If untreated, about 20% to 30% of infants born to HIV-positive women will be infected. Treatment with ZDV and avoidance of breast-feeding has been reported to lower transmission to about 2% to 3%. In 1999, a Ugandan study reported that a single dose of nevirapine given to infected mothers during labor in addition to a single dose given to the neonate within three days of birth cut the transmission rate in half, as compared with those treated with AZT throughout pregnancy and during the first six weeks of life.

Human papillomavirus

Use of a condom and limiting the number of sexual partners decreases the risk of contracting the disease.

Rubella

Women in childbearing age should have a titer draw to test for immune status. If they have not been exposed to rubella, they can be vaccinated against the disease, but should not become pregnant for three months following the vaccination, due to potential devastating effects on the fetus.

Streptococcus

Prevention of transmission of GBS from the mother to the infant can be enhanced by careful monitoring of the mother during labor for potential signs of infection such as fever, urinary tract infection, or PROM before 37 weeks or 18 hours or more before delivery. Treating the mother with IV antibiotics during labor limits the risk of transmission.

Syphilis

Use of a latex condom can reduce the risk of contracting the disease. However, the condom may not cover the area of infection. A blood test is the best way of finding out if one has syphilis, as the sores may be in hidden areas.

Toxoplasmosis

Prevention of infection through cat feces is best done by having someone other than the mother clean the cat litter, and to avoid inhalation of airborne oocytes. If this is not possible, cat litter should be changed daily, as spores develop in one to five days in the litter. Cats become infected by eating contaminated wildlife, so keeping the cat completely indoors significantly reduces the risk of contagion. Infection through meat can be avoided by avoiding raw meat and by cooking meat to at least 159°F (71°C). Garden soil can be contaminated, so the use of gloves when gardening with thorough hand washing afterwards can decrease infection. Outdoor sandboxes should be covered to avoid contamination by stray cats.

Esther Csapo Rastegari, R.N., B.S.N., Ed.M.