3. INTRODUCTION
CONGENITAL INFECTIONS
“Infections acquired in utero or during the birth process”
The infected newborn may show abnormal growth,
developmental anomalies, or multiple clinical and laboratory
abnormalities
Severity depends on the gestational age of fetus at the time
of infection & virulence of the organism
Timely diagnosis of perinatally acquired infections is crucial
the initiation of appropriate therapy.
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4. PERINATAL INFECTIONS
T = Toxoplasmosis
O = Others
R = Rubella
C = Cytomegalovirus
H = Herpes Simplex virus
The TORCH acronym has now become Obsolete, due to a
large basket of infections in “Others”
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5. TOXOPLASMOSIS
Causative Organism: Toxoplasma gondii
Oocyst excreted in cats feces is the source of infection to
humans Contaminates in soil, water & raw meat
Transmission: Vertical transmission can occur in utero or
during vaginal delivery & risk of fetal transmission is
25% in 1st Trimester
75% in 3rd Trimester
90% during last few weeks prior delivery.
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6. CLINICAL FEATURES
Most infected newborns are asymptomatic at birth
Few develop
IUGR
Fever
Maculopapular rash
Anemia
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• Jaundice
• Seizure
• Hepatospleenomegaly
• Thrombocytopenic purpura
8. DIAGNOSIS
Maternal history & Serology
Clinical Examination
Laboratory Evaluation - Serology/ CBC / LFT
Fundus Examination - Chorioretinitis
Neuroimaging – Intracranial Calcifications/ Hydrocephalus
Lumbar Puncture – Elevated CSF Protein/ Mononuclear Pleocytosis
Prenatal Diagnosis- PCR by Amniocentesis is the best method for
prenatal diagnosis of fetal infection.
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9. CONFIRMED CONGENITAL TOXOPLASMA
INFECTION
Any of the following:
1. Detection of toxoplasma specific IgM (after 5 days of life) or
IgA titres (after 10 days of life) is considered diagnostic of
congenital toxoplasmosis in infants with a positive
Toxoplasma IgG titre
2. Positive for Toxoplasma IgG beyond 12months of age
3. Positive CSF PCR
4. Increase in anti-Toxoplasma IgG titer during the first year of
life or increasing IgG titer compared with the mother's
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10. MANAGEMENT
WHO & CDC Recommends Combination Therapy for standard
treatment of congenital toxoplasmosis
Pyrimethamine (1mg/kg/day daily for first 6months &
1mg/kg/day thrice a week for second 6 months)
Sulfadiazine (100mg/kg/day in 2 divided doses for 1 year)
Leucovorin (Folinic Acid; 5-10mg thrice a week)
Prevention
Avoidance of Exposure- Food hygiene
Maternal Screening
Prenatal Treatment - Spiramycin
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11. RUBELLA
Also known as German Measles
Organism: RNA virus, a member of the Togavirus family
Transmission:
Direct droplet contact from nasopharyngeal secretions
virus replicates in the lymph tissue of the upper respiratory
tract spreads hematogenously across the placenta CRI
Maternal infection rate is high, especially at the time of 1st
trimester & last 1 month
Malformation occurs in 90% of infection during 2-10 weeks of
gestation.
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14. DIAGNOSIS
HISTORY OF MATERNAL INFECTION
Symptoms - Low-grade fever/Headache/mild coryza and
conjunctivitis occurring 1 to 5 days before the onset of rash.
Maculopapular exanthem that begins on the face and
the ears and spreads downward over 1 to 2 days.
The rash disappears in 5 to 7 days from onset,
Posterior cervical lymphadenopathy is common.
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15. DIAGNOSIS
ANTENATAL DETECTION
Specific IgM in Fetal blood obtained by percutaneous
umbilical cord blood sampling.
Rubella antigen and RNA in a Chorionic villous biopsy
specimen.
POSTNATAL DETECTION OF CONFIRMED CRI
Serology: Detection of Rubella Specific
IgM below 3months (or)
IgG between 6months to 12 months.
Virus Isolation: pharyngeal secretions/urine sample upto 1 yr
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16. MANAGEMENT
Supportive care
Multi disciplinary approach
Hearing loss - hearing aids and referral to an early
intervention program
Structural cardiac defects – Surgical correction
Ocular abnormalities – Referral to Ophthalmology expert
CNS abnormalities - special education services, speech,
language, occupational, and/or physical therapy.
Endocrine abnormalities – Expert Followup for Diabetes/
Hypothyroidism
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17. PREVENTION
Girls should be vaccinated against rubella before entering the
childbearing years.
Rubella vaccine is a live attenuated vaccine which is available
separately or as triple vaccine (MMR) that contain measles,
mumps and rubella.
Principal goal of Rubella vaccination is Prevention of CRS.
As per IAP recommendation – two doses of MMR vaccines -
1st at 15 months and the 2nd at 4–6 years
Special care should be taken in reproductive females to avoid
pregnancy for 3 months after MMR vaccination.
Avoidance of Exposure
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18. CMV
Causative Organism:
Cytomegalovirus - member of herpes virus family
It is the most common cause for Non-Hereditary cause of
SNHL worldwide.
Transmission:
Close contact – young children attending daycare center
Saliva/ Urine/ Blood & Breastmilk*
Route – Transplacental/ Intrapartam/ Postnatal
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19. CLINICAL FEATURES
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At birth, most infants with
congenital CMV are asymptomatic.
Few Develop:
SGA/Prematurity
Hepatospleenomegaly
Microcephaly/Periventricular
Calcifications/SNHL/Seizures
Petechiae & Jaundice at Birth
Thrombocytopenia
Pneumonia
20. DIAGNOSIS
Diagnostic Testing of Urine/Saliva for CMV by
PCR
Viral Culture(Shell vial assay)
Detection of CMV IgG antibodies in blood
Post Natal Evaluation Include
Physical & Neurological Examination
Laboratory testing (CBC/Coagulation/LFT)
Hearing assessment (ABR)
Opthal assessment (Chorioretinitis)
Neuroimaging (USG Cranium/CT Brain)
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21. MANAGEMENT
For symptomatic congenital CMV
Ganciclovir* (12mg/kg/day iv infusion 2 div doses for 6
weeks)
Valganciclovir
Close monitoring & Followup of infected infants
Prevention
Personal protective measures/ Avoidance of unnecessary
blood transfusion & use of leukocyte depleted blood.
Prenatal diagnosis- By viral culture or CMV DNA detection in
amniotic fluid, or by CMV IgM antibody measurement in fetal
blood of the symptomatic fetus
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22. HSV
Organism:
Herpes Simplex Virus(HSV) - DNA virus with two virologically
distinct types: 1 and 2
The virus can cause localized disease of the infant's skin, eye,
or mouth (SEM) or may be Disseminated disease or CNS
disease.
Transmission:
Contact with genital lesions during delivery: Common
Transplacental : Rare.
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25. LESIONS OF NEONATE WITH
SEM DISEASE
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EYE VESICLES
HYPOPIGMENTED, SCALING, AND
CRUSTED EROSIONS OF THE
TRUNK AND EXTREMITIES
26. DIAGNOSIS
For SEM disease - Viral Culture by Isolation – Newer vesicular
fluid, Urine & conjunctival smears.
For Non SEM disease– PCR of CSF
EEG and Imaging studies of brain also aids in the diagnosis of
HSV encephalitis
Cytology of vesicular fluid – Presence of Tzanck cells
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27. MANAGEMENT
Acyclovir Therapy- 60 mg/kg/day 3 div doses
SEM disease : Duration for 14 days
CNS / Disseminated disease : Duration for at least 21 days, or
longer if the CSF PCR remains positive.
Infants with ocular involvement : Ophthalmologic evaluation/
Topical ophthalmic antiviral agents in addition to parenteral
therapy.
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28. Contd.,
Recent evidence : Suggests to start on suppressive therapy
following parenteral treatment with oral acyclovir 300 mg/m2
per dose three times per day for six months as it reduces
cutaneous recurrences and is associated with improved
neurologic outcomes in infants with CNS disease.
Prevention :
C-Section for mothers with genital lesions
Acyclovir for pregnant mothers with primary HSV
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29. PERINATAL HIV INFECTION
Organism:
Retrovirus
80% of HIV Infections in children occur during perinatal
period
Transmission:
35% Risk of Mother to child transmission(MTCT) of HIV
during perinatal period
30% Vertical
60% During labor & delivery
10% Breastmilk
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30. RISK FACTORS
Maternal:
High viral load/ Low CD4 count
Primary infection during pregnancy/Vaginal delivery
Pronlonged ROM
Fetoplacental:
Chorioamnionitis
Prematurity
Postnatal:
Breastfeeding (viral load)/Cracked nipples/Mastitis
EBF Infant having oral thrush at less than 6 months
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31. PREVENTION OF PERINATAL HIV
Risk of MTCT can be reduced by
ARV Prophylaxis to the mother during pregnancy/ labor & to
the infant after birth.
Elective C-Section(prior to onset of labor & ROM) &
Complete avoidance of breastfeeding
Membranes should not be artificially ruptured unless there is
fetal distress/delay in progress of labor
Repeated vaginal examinations/instrumental delivery/
invasive procedure on fetus/ routine episiotomy must be
avoided
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32. ARV REGIME – PREGNANT WOMEN
Recent WHO guidelines recommends an simplified, optimized
& fixed dose combination of ART
HIV detected Pregnant women during antenatal period must
be initiated on ART regimen as below throughout the
pregnancy (regardless of clinical stage/CD4 count)
Tenofovir(TDF) 300mg
Lamivudine(3TC) 300mg
Efavirez(EFV) 600mg
Initiation shouldn’t be delayed for C4 count
Lifelong ART is initiated as soon as possible
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Alternate Regimen
AZT+3TC+EFV
AZT+3TC+NVP
TDF+3TC+NVP
33. ARV REGIME – INFANTS BORN TO
HIV MOTHER
• If mother received ART adequately/regularly in antenatal
period: Daily NVP prophylaxis at birth till 6 weeks of life.
• If Infected Mother did not receive any ART earlier/ directly
presents in labor without adequate duration of ART(atleast 24
weeks): Daily NVP prophylaxis at birth till 12 weeks of life.
• First dose initiated within 6-12 hrs of delivery
• Dose can be increased to 20mg OD after 6-8 wks of age.
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B.WT NVP DAILY DOSE DAILY DOSE IN SUSP
<2kg 2mg/kg OD 0.2ml/kg
2-2.5kg 10mg OD 1ml OD
>2.5kg 15mg OD 1.5ml OD
35. HEPATITIS B VIRUS
Organism:
HBV- DNA Virus
Most common cause of acute & chronic Hepatitis
Transmission:
Exposure of Infected maternal blood via percutaneous or
permucosal routes during delivery.
Amniocentesis
Breastfeeding not contraindicated
Clinical Features:
Affected neonates are mostly asymptomatic.
Later Develop chronic antigenemia with mild and often
persistent liver enzyme elevations beginning at two to six
months of age
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40. OTHER PERINATAL INFECTIONS
DISEASE TRANSMISSION SYMPTOMS DIAGNOSIS TREATMENT
Chickenpox
VZV
1st 20wks of
Pregnancy
• Cicatricial lesions
• Limb hypoplasia
• Microcephaly
• Cataract
PCR of
Vesicular fluid
• Acyclovir
• VZIG
Syphilis
T,Pallidum
Between 1st &
2nd Trimester of
Pregnancy
• Skeletal
abnormalities
• Pseudoparalysis
• Persistent rhinitis
• Maculopapular
rash
Specific IgM
fluorescent
antibody
• Benzathine
Penicillin G
Malaria
P.Vivax &
Falciparum
Infected blood
administration
• Stillbirth/IUGR
• Hemolytic Anemia
• Jaundice
Blood Smear • Chloroquine
Phosphate
Parvo Virus
B19
Within the first
20 weeks
• Abortion/ Anemia
• Hydrops
• Slapped Cheek
rash
PCR of Blood • Supportive
• IVIG
Coxsackie B Intrauterine
exposure
• Carditis
• Orofacial clefts
Cord serum for
specific IgM
Supportive
care
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41. DIAGNOSTIC TECHNIQUES FOR DIAGNOSIS
OF COMMON PERINATAL INFECTIONS
PATHOGEN TEST OF CHOICE
RUBELLA Isolation – Viral Culture of Urine/ Throat swab
Cord serum for IgM & specific IgM fluorescent
antibodies
HSV PCR of skin lesion, blood, or CSF
CMV PCR urine/saliva
Spin-enhanced urine culture (shell vial)
HIV DNA PCR – Blood if mother is HIV Infected
HBV HBsAg of blood
DNA PCR of blood
VZV PCR of skin lesion
TOXOPLASMA Specific IgM & IgA fluorescent antibody by ELISA/
ISAGA
PCR - CSF
SYPHILIS Specific IgM fluorescent antibody
Paired Maternal & Cord sera for RPR/VDRL 41
42. TAKE HOME MESSAGE
CMV, Rubella, Toxoplasma are the most common cause of
chronic intrauterine infections in the newborn.
Congenital TB should be suspected in newborns who have
Non-resolving pneumonia, persistent fever & HSM, in
absence of any of the bacterial pathogen isolated on culture.
DNA PCR to detect HIV should be conducted in a neonate 6
weeks after cessation of breastfeeding.
Timely diagnosis of perinatally acquired infections is crucial to
the initiation of appropriate therapy, development of care
plan, prognosis, and family counseling.
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but the second dose can be given after 8 weeks interval.
It will be ideal to administer the second dose at 5th year along with DTP booster and OPV.
After adsorption and penetration into host cells, viral replication proceeds, resulting in cellular swelling, hemorrhagic necrosis, formation of intranuclear inclusions, cytolysis, and cell death.
Multinucleated Giant cells with Intranuclear inclusions
< 2%
50,000 units/kg, intramuscularly [IM] as a single dose
(Maternal history of infection, skin rash, IUGR, Microcephaly, cataract, HSM, Jaundice, Petechiae & Meningoencephalitis)