Post on 26-Jan-2017
Perinatal Infections: Update on Diagnosis & Management
Dr. Padmesh
• INTRODUCTION:
• Important cause of still births and morbidity
• Many diseases go undiagnosed
• Appropriate treatment can prevent morbidity/mortality
• 1971: Andres Nahmias proposed acronym ToRCH • 1975: Harold Fuerst added Syphilis to the acronym.
• ACRONYM: TORCHES CLAP
-TOxoplasmosis -Chickenpox-Rubella -Lyme disease-CMV -AIDS-Herpes simplex -Parvovirus B19-Enterovirus-Syphilis
• Latest addition: Zika virus
Toxoplasmosis
• Toxoplasma:
• Diagnosis :• IgG, IgM, IgA (Serum/CSF)• PCR • Ophthalmologic, auditory, and neurologic
examinations• CT Brain
Redbook American Academy of Pediatrics. 2012. p. 720–8.
• Toxoplasma:
Investigations
Normal
Negative
Abnormal
TREAT FOR 12 MONTHS
Positive
Repeat IgG after 6 months
• Toxoplasma:
• Treatment :
• Pyrimethamine, sulphadiazine and folinic acid for a duration of 1 year.
• Toxoplasma:
• Prevention- counselling :– Avoid raw/undercooked meat– wash hands after gardening– wash raw vegetables– minimise contact with young kittens and their litter etc
Rubella
• Rubella:
• In Maternal infection: - No treatment available
1st Trimester: Consider termination.2nd Trimester: Consider fetal testing.After 20 wks gestation: Rarely causes CRS
• Rubella:
• Diagnosis :• Isolation of virus by PCR or culture
• Rubella-specific IgM (False positivity +/-) • Increasing IgG over first 7 to 11 months of life.• Avidity testing of IgG
• Rubella virus RNA by reverse transcriptase PCR in nasopharyngeal swabs, urine, CSF, and blood at birth
• Rubella:
• Diagnosis : Avidity:• Strength with which IgG binds to antigenic epitropes
expressed by a specific protein.
• Gradually matures over months.
• IgG produced in first few months following primary infection Low avidity (Bind weakly to Ag)
• Therefore, LOW IgG avidity is a marker of RECENT PRIMARY infection.
• High avidity excludes primary infection in preceding 3 months.
• Rubella:
• Diagnosis : Avidity:
• Rubella:
• Diagnosis :
AT BIRTH:• Ophthalmology screening, • Cardiac screening• Hearing assessments
FOLLOW UP UPTO 12 MONTHS
• Rubella:
• Treatment :
• No specific treatment• Breast feeding not contraindicated
• Prevention:• Vaccination
CYTOMEGALOVIRUS
• CMV:
• Diagnosis :• Virus culture from urine/saliva
• CMV-DNA PCR in urine, blood, saliva and CSF
• CMV IgM antibodies in blood before 3 weeks of age.
• IgG Avidity testing
Rev Med Virol 2010;20(4): 202–13.
• CMV: Treatment :
Virologically proven CMV in Newborn
Underlying Immune disorder
Treat as Life threatening
infection
Immunocompetent
Life threatening symptoms
Non-Life threatening symptoms
No Symptoms
No treatment
Life Threatening infection
IV Ganciclovir for 4-6 weeks
Oral Valganciclovir for 6 months
Non-Life threatening infection
• CMV: Treatment :
Continue for 12 months/ Change in regimen
Viremia at 6 mths
• CMV:
• Treatment :• Foscarnet, Cidofovir for refractory CMV/ Ganciclovir
resistance
HERPES SIMPLEX VIRUS
• HSV:
• Diagnosis :• Surface cultures: HSV culture on swab specimens
from mouth, nasopharynx, conjunctivae, and anus 12-24 hours after birth
• HSV culture & PCR from any skin vesicle present
• HSV PCR on CSF and whole blood
• HSV:
START EMPIRICAL IV ACYCLOVIRDiagnostic evaluation of Newborn
Positive
SEM disease CNS/ Disseminated
Negative
IV Acyclovir for 14 days
IV Acyclovir for 21 days
IV Acyclovir for 10 days
• HSV:
• Treatment:
• After completion of parenteral therapy suppressive course of oral acyclovir for 6 months
• HSV:
• 85% neonatal HSV are acquired perinatally.
• True intrauterine infection 5%
• Careful speculum examination for active genital HSV
• Caesarean section reduces risk of HSV transmission
SYPHILIS
• Syphilis:
• Diagnosis :• Adequacy of maternal treatment
• Examination of placenta/umbilical cord for pathology
• Dark field microscopy of suspicious lesions/body fluid
• Clinical findings suggestive of syphilis: Non immune hydrops/ jaundice/ hepatosplenomegaly/ rhinitis/ skin rash
• Quantitative VDRL / RPR (FTA-ABS or TPHA not required)
BMC Public Health 2011;11(Suppl 3):S9.
• Syphilis: Treatment :
PHYSICAL EXAMSUGGESTIVE OF CONGENITAL SYPHILIS
BABY’S VDRL/RPR4 TIMES HIGHER TITRE THAN MOTHER
MOTHER NOT TREATED OR INADEQUATELY TREATED
INJ. PENICILLIN G OR PROCAINE PENICIILIN FOR 10 DAYS
ADDL TESTS: CSF VDRL, LONG BONE XRAY, OPHTHAL EVALUATION, BERA
• Syphilis: Treatment :
PHYSICAL EXAMNORMAL
BABY’S VDRL/RPRLESS THAN 4 TIMES MOTHER’S TITRE
MOTHER NOT TREATED OR INADEQUATELY TREATED
INJ. PENICILLIN G OR PROCAINE PENICIILIN FOR 10 DAYS
ADDL TESTS: CSF VDRL, LONG BONE XRAY, OPHTHAL EVALUATION, BERA
+
• Syphilis: Treatment :
PHYSICAL EXAMNORMAL
BABY’S VDRL/RPRLESS THAN 4 TIMES MOTHER’S TITRE
MOTHER NOT TREATED OR INADEQUATELY TREATED
INJ. BENZATHINE PENICILLIN 50000 U/Kg/dose IM SINGLE DOSE
ADDL TESTS: CSF VDRL, LONG BONE XRAY, OPHTHAL EVALUATION, BERA
I
• Syphilis: Treatment :
PHYSICAL EXAMNORMAL
BABY’S VDRL/RPRLESS THAN 4 TIMES MOTHER’S TITRE
MOTHER ADEQUATELY TREATED DURING PREGNANCY
NO TREATMENT REQUIRED IF FOLLOW-UP IS CERTAIN
ELSE, INJ. BENZATHINE PENICILLIN 50000 U/Kg/dose IM SINGLE DOSE
NO FURTHER EVALUATION
VARICELLA
• Varicella:
-7 -5-6 -2-4 -3 +1-1 +3+2 +4
ONSET OF RASH IN MOTHER
• Varicella:
-7 -5-6 -2-4 -3 +1-1 +3+2 +4
Newborn will have protective antibodiesLikelihood of severe disease is low
- Do not separate baby from mother- Continue breast feeding- No VZIG-Acyclovir if baby develops rash
• Varicella:
-7 -5-6 -2-4 -3 +1-1 +3+2 +4
Newborn will not have protective antibodiesLikelihood of severe disease is high
-Separate baby from mother-If baby devps rash stay with mother-VZIG within 72 hours-Acyclovir
• Varicella:
-7 -5-6 -2-4 -3 +1-1 +3+2 +4
Newborn will not have protective antibodiesBut, likelihood of severe disease is low
-Separate baby from mother-If baby devps rash stay with mother-No VZIG -Acyclovir if baby develops rash
TUBERCULOSIS
• TB: MOTHER WITH TB
ON TREATMENT/ NO TREATMENT
TREATMENT COMPLETED
LOOK FOR CLINICAL EVIDENCE OF CONGENITAL TB
ABSENT PRESENT ABSENT
CXR, 3 GASTRIC ASPIRATES
CXR, LP3 GASTRIC ASPIRATES
Treat : HRZE
INH PROPHYLAXIS MANTOUX AT 3 MONTHS
FOLLOW UP AND EVALUATE FOR CLINICAL EVIDENCE TILL 6 MONTHS++
-
• TB:
• Reassure the mother to breast feed the baby
• Separation of mother & baby required only if mother – is sick– non adherent to treatment– has MDR TB
• CONCLUSION:
• Universal vaccination.
• Prompt recognition and management.
• Public health measures: antenatal screening for syphilis, HIV and hepatitis B .
• Good hygiene
THANK YOU !