What is Antepartum Infections (Infections during pregnancy)?
Infections before birth are a major cause of health issues and deaths for pregnant women and their unborn babies, particularly in developing countries. Yet, due to increasing distrust of medical professionals and doubts about vaccinations, such preventable infections are becoming more common, even in developed countries. It’s important to understand these infections, how they appear, and how to treat them. This knowledge helps provide care and advice for pregnant women and their families to prepare them for what to expect.
Next, we’ll be talking about infections that pass from the mother to her baby before birth, infections which target the mother’s uterus and birth passage, and infections that affect pregnant women more frequently. This review focuses on these types of infections, but it’s key to remember that any infection common among the general public can also affect pregnant women and potentially impact their pregnancies.
What Causes Antepartum Infections (Infections during pregnancy)?
During pregnancy, a woman’s immune system changes to protect the baby from being attacked by her own body. This makes pregnant women more prone to infections. Some of these infections can be transferred from the mother to the baby either before birth (through the placenta), during birth, or through breastfeeding.
There’s a group of infections called ToRCHS that pregnant women can pass on to their babies in these ways. ToRCHS stands for toxoplasmosis, rubella, cytomegalovirus, human immunodeficiency virus (HIV), and syphilis. Other infections which can harm the baby include herpes simplex virus (HSV), certain types of hepatitis viruses (HBV and HCV), parvovirus B19, and Zika virus. Pregnant women are especially susceptible to Hepatitis E (HEV), and there’s even evidence that this infection can be passed on from a mother to her baby.
Infections in the female reproductive system can also affect pregnancy outcomes, even if they don’t always pass from the mother to the baby. An example of this is bacterial vaginosis, which is often caused by group B streptococci (GBS) bacteria. This kind of infection happens when there’s an abnormal increase in bacteria due to changes in pH levels. While many women carry the GBS bacteria in their urinary tract without any problems, if left untreated during pregnancy, it can lead to serious issues for the baby, including an inflammation and infection of the baby’s chorion and amnion, collectively known as chorioamnionitis.
Risk Factors and Frequency for Antepartum Infections (Infections during pregnancy)
Infections passed from mother to child during childbirth are more common in developing countries. For instance, 11% of childbearing women in Europe test positive for toxoplasmosis while in South America the percentage jumps to 77% in a similar age group. Notably high rates of infections like syphilis, cytomegalovirus (CMV), various types of hepatitis, and HIV can be found in specific regions such as Central Africa, South America, the Middle East, and southern Africa. The Zika virus is an emerging disease of note due to its impact on fetal development, and it has been found primarily in Africa, Asia, South America, and the Pacific islands.
Infections in the female urinary and reproductive system are common globally. For example, bacterial vaginosis is seen in almost a third of women of childbearing age in the U.S, though many do not show symptoms. Chorioamnionitis, a condition where the membranes surrounding the fetus become infected, is more common the earlier a baby is born, with a 94% chance in extremely early deliveries. Certain maternal factors can increase this risk including first-time motherhood, weakened immune system, bacterial vaginosis, certain bacterial colonizations, smoking, alcohol or drug use, and being of African American descent. Labor-related factors such as premature water breaking, the use of internal monitoring during labor, multiple vaginal exams, and epidural anesthesia can also increase this risk. Lastly, between 15 and 35% of childbearing women in the U.S are colonized with Group B Strep in the vagina or rectum.
Signs and Symptoms of Antepartum Infections (Infections during pregnancy)
When discussing the signs related to infections during pregnancy, we need to differentiate between symptoms in the mother’s initial infection and those passed on to the unborn child (or congenital infections). It’s also important to note that an infant may not show signs of congenital infection right after birth. Several signs are common to many congenital infections, such as enlarged liver or spleen, low blood platelet count, and a ruddy rash often referred to as a “blueberry muffin rash”.
Interestingly, an initial infection of toxoplasmosis in a mother often shows no symptoms. Similarly, about 70-90% of infants infected during pregnancy show no symptoms at birth. A collection of symptoms including inflammation of the eye’s internal structures, accumulation of fluid in the brain, and hardening areas in the brain are classical indications of congenital toxoplasmosis, but are rare. More commonly, early signs of this condition in infants include low red blood cell count and platelet count, enlargement of the liver and spleen, seizures and jaundice. Unchecked, this condition later leads to hearing loss, small head size, seizures, movement control issues, and intellectual disability.
Some people infected with rubella as adults might not show any symptoms, while others may experience low-grade fever, sore throat, eye inflammation, and a rash that begins on the face and spreads downwards. Congenital rubella syndrome can lead to hearing loss, heart defects, and eye issues in infants, among other conditions.
A primary CMV infection often shows no symptoms, which can make it difficult to diagnose in pregnant women. When symptoms do show, they can include a long-lasting fever similar to mononucleosis, sore throat, rash and liver inflammation. Congenital CMV infection can lead to hardening in regions around the brain’s ventricles, small head size, less echo-producing areas in the brain’s bulk, abnormal furrows in the brain, and other brain irregularities. These can often be seen before birth through an ultrasound. Other signs include fluid accumulation in the abdomen, swollen liver and spleen, heart enlargement, and large placenta.
An initial HIV infection is usually asymptomatic as well, though an active infection can present with symptoms similar to the flu. Infants who contract the virus usually show no symptoms right after birth. As the infection develops, failure to grow adequately, oral yeast infection, delayed development, and frequent secondary infections are common. Syphilis infections in adults manifest in three stages: first comes a painless genital or rectal sore, followed by a rash on the hands and feet which can take different forms. The later stage can produce heart inflammation and neurological abnormalities. Congenital syphilis in infants may take many forms including swollen liver, runny nose, inflammation of bone and cartilage, false paralysis, rash, low red blood cell count, and low platelet count. Untreated, it progresses to cause developmental abnormalities, and issues with the bones, joints, teeth, eyes, and skin. The herpes infection causes painful sores grouped together. Infants contracting HSV may have a low birth weight, small head size, inflammation of the eyes’ internal structures, and excess fluid in the brain. They might also show the typical sores. One of the most feared outcomes of HSV in infants is viral inflammation of the brain, causing blindness, development delays, and sometimes death.
Mothers infected with parvovirus may show no symptoms, or they could develop a distinct “slapped cheeks” rash after displaying flu-like symptoms such as fever, fatigue, joint pain, and muscle aches. Signs of this infection in infants include swelling and fluid accumulation in tissues or cavities of the body due to heart failure, severe anemia and low platelet count, and the mother showing symptoms that mirror the fetus’ condition. Acute HBV infection can lead to hepatitis and cirrhosis. Infected infants typically show no symptoms at birth, but some might show signs of clinical hepatitis in their first few months of life, such as jaundice, failure to grow, and vomiting. More commonly, congenital HBV results in subclinical hepatitis and an immune-tolerant carrier state, with progression to chronic infection being rare.
The acute form of HCV infection has symptoms similar to HBV. While most cases of congenital infection are asymptomatic, the majority leads to chronic infection (unlike congenital HBV infection). Primary HEV infection usually causes mild, subclinical hepatitis in the general population, but can quickly progress to life-threatening liver inflammation in pregnant women, especially in the third trimester. Random cases of passing the virus from mother to child have been reported. Primary Zika virus infection may be asymptomatic or present with fever, joint pain, headache, rash, swelling of the extremities, and digestive upset. Congenital infection is characterized by severe small head size and neurological abnormalities.
The diagnosis of chorioamnionitis, or inflammation of the membranes surrounding the fetus, is typically based on clinical findings. Unfortunately, the symptoms of chorioamnionitis are vague and cannot reliably confirm a diagnosis, meaning that a comprehensive look at the patient’s overall condition is crucial. Signs suggestive of this condition include maternal fever, tenderness of the womb, high heart rate in mother or fetus, and unusual or foul-smelling discharge. Bacterial vaginosis is often asymptomatic, but some people may report a “fishy-smelling” discharge or itching in the vagina. Asymptomatic maternal GBS colonization raises the risk of neonatal sepsis or severe infection.
Testing for Antepartum Infections (Infections during pregnancy)
The American College of Obstetricians and Gynecologists (ACOG) has established guidelines to ensure pregnant women get screened for various infections. During the first prenatal visit, aimed to be scheduled around 8-10 weeks of pregnancy, the woman should be screened for hepatitis B, syphilis, and chlamydia. There’s also a recommended HIV screening. This is designed as an “opt-out” system – which means every woman gets tested unless she specifically chooses not to.
Furthermore, between the 35th and 37th week of pregnancy, a pregnant woman should get a vaginal and rectal culture for Group B Streptococcus (GBS). If a woman is at high risk of giving birth prematurely, she should get tested before the 35th week.
Later in the pregnancy, around the third trimester, there should be repeat tests for HIV and syphilis, particularly for women who may be at high risk of these infections. Women with a likelihood of exposure to contaminated food, water, or cat litter should be checked for toxoplasmosis.
If a woman has a past that includes intravenous drug use, or blood transfusion or organ transplant before 1992, screening for hepatitis C is advised. A cytomegalovirus (CMV) screen is recommended for women in frequent contact with children, like daycare workers, pediatricians, and teachers. This also applies to teenagers with a history of sexually transmitted infections or multiple sexual partners. Herpes Virus (HSV) screening is recommended for women with a history of sexually transmitted diseases or those with a compromised immune system.
If a mother is HIV positive or if her HIV status is unknown, her newborn babies should be tested for HIV using special tests called nucleic acid tests. It’s crucial to do these tests within 48 hours of the baby’s birth. Additional checks should be done when the baby is two weeks old, between 4 – 6 weeks old, and again between 4 – 6 months old.
Chorioamnionitis is a condition diagnosed by examining fetal membranes. While diagnosis usually happens after examining the mother’s placenta after delivery, it’s crucial not to delay treatment waiting for this. A significant number of white blood cells in the mother might indicate chorioamnionitis; however, this is not a definite sign. Babies exposed to chorioamnionitis have an increased risk of neonatal sepsis, so blood cultures, a complete blood count and C-reactive protein should be checked at birth to assess this risk.
Finally, the United States Preventative Services Task Force (USPSTF) does not recommend routine checks for bacterial vaginosis in pregnant women not at risk of preterm labor. Even for women at risk of early labor, there’s not enough proof to recommend routine checks. However, women showing symptoms should be examined with a microscopic evaluation of vaginal discharge. The presence of specific cells (“clue cells”) in this discharge can confirm bacterial vaginosis.
Treatment Options for Antepartum Infections (Infections during pregnancy)
For pregnant women who test positive for toxoplasma and are under 18 weeks into their pregnancy, the treatment of choice is a drug called spiramycin. If tests show that the baby is also infected, additional drugs like pyrimethamine sulfadiazine and folinic acid are also given. These treatments have shown to decrease the baby’s infection and protect against severe neurological damage.
When it comes to rubella, there’s no specific medication. Prevention is key, which means every child who isn’t allergic to the MMR vaccine should get it. Pregnant women who aren’t immune to rubella should receive the vaccine after their child is born. It’s important they do not get pregnant within a month of being vaccinated.
For CMV infection in pregnant women, treatments are generally supportive. If the baby contracts CMV, the medication options are ganciclovir and valganciclovir. These drugs help reduce hearing loss and improve weight gain and head size in infants infected with CMV.
Infants born to HIV-positive mothers need to receive antiretroviral drugs as prevention. If the mother closely followed HIV treatment throughout her pregnancy and kept the virus under control, the baby can be given a drug called zidovudine for four to six weeks. If the mother didn’t follow HIV treatment during her pregnancy, the baby would need additional treatment. Regardless of the situation, if the baby tests positive for HIV, treatment must begin immediately to reduce mortality and improve their growth and motor skills. The method of delivery and feeding choice depends on the mother’s viral load.
For pregnant women with syphilis, the only accepted treatment is penicillin. Penicillin-allergic patients need desensitization before getting the treatment. For babies born with syphilis, they need to be treated with penicillin for ten days.
For pregnant women with a new outbreak of herpes (HSV), antiviral drugs like acyclovir, famciclovir, or valacyclovir are recommended. From the 36th week, women with recurring genital herpes should be offered suppressive therapy. Vaginal delivery is possible unless there are active genital lesions at the time of birth. Newborns suspected of having the HSV infection should receive acyclovir intravenously.
For hepatitis B, treatment is supportive. Babies born to infected mothers should be vaccinated against the virus within 12 hours and also given immunoglobulin. Families should be encouraged to complete the vaccination program for their baby. While antiviral treatments are available for hepatitis C, these treatments haven’t been tested on pregnant women, so it’s not recommended to prevent transmission to the baby. Treatment for hepatitis E infection is supportive too.
Parvovirus infection treatment is also generally supportive. For infected babies, the common form of treatment is a blood transfusion while still in the uterus.
For Zika virus infection, treatment is supportive too. There are no specific drugs, but several vaccines are in development.
If a patient has a premature rupture of the fetal membranes, antibiotics are given to protect against common bacteria. These antibiotics also reduce the risk of neonatal diseases and increase the delivery time.
Bacterial vaginosis in pregnant women should be treated with a 7-day course of the antibiotics metronidazole or clindamycin.
If pregnant women are carrying GBS bacteria, they should receive antibiotics during labor. The common choice is penicillin G unless the patient is allergic. Alternatives like cefazolin and clindamycin are also available depending on the severity of the patient’s allergy.
What else can Antepartum Infections (Infections during pregnancy) be?
If a pregnant woman has a high fever, it could be due to various reasons apart from pregnancy-related infections. It could also be because of infections that anyone could get. Here are some of the illnesses that doctors would think about in pregnant women with an infection:
- Pneumonia
- Skin infection, or cellulitis
- Infections of the urinary tract
- Blockage in the lung’s main artery, or pulmonary embolism
- Illnesses caused by an overdose of drugs that increases body temperature
If a baby is born with signs that suggest a birth defect due to infection, it could also be due to some genetic disorders. So, in these cases, the family should consider getting genetic counseling and testing.
What to expect with Antepartum Infections (Infections during pregnancy)
Except for the Hepatitis E virus (HEV), the chances of a mother recovering successfully from infections including toxoplasmosis, rubella, CMV, parvovirus, and Zika virus are very high in individuals with a healthy immune system. The harmful effects from these infections on the mother’s health are rare.
However, an acute Hepatitis B and C infection can proceed to a chronic stage, increasing the risk of liver failure and liver cancer in these patients.
In pregnant individuals with HEV, the risk of a sudden, severe liver failure, and death ranges from 30-100%. But on a positive note, HIV-positive individuals with appropriate antiretroviral therapy (cART) can have a life expectancy similar to those who are not infected.
The outlook of infections passed from mother to child during birth mainly relies on how severe the condition is in the newborn.
Possible Complications When Diagnosed with Antepartum Infections (Infections during pregnancy)
The most serious outcome for a fetus from a congenital (present from birth) infection can be spontaneous abortion or fetal death, but it’s hard to determine how often this happens. There are specific illnesses that can cause complications in newborns. For instance, congenital toxoplasmosis, rubella, CMV (cytomegalovirus), and HSV (herpes simplex virus) can lead to babies being born with low weight, not growing as they should, and developmental delays related to movement and learning. HSV encephalitis (brain inflammation) can also cause blindness. Another condition, congenital parvovirus, is linked with heart inflammation (myocarditis) and heart failure in unborn babies.
Some infections can have long term effects. Congenital HBV (hepatitis B virus) can progress to severe hepatitis and, rarely, to a chronic HBV infection. Congenital HCV (hepatitis C virus) has a high risk of becoming chronic HCV which can lead to liver scarring (cirrhosis) and a higher risk of liver cancer.
Certain infections can specifically impact pregnant women. HEV (hepatitis E virus) infection has a significantly higher risk of progressing to fulminant hepatic failure (sudden severe liver failure) and death in pregnant women compared to others. If bacterial vaginosis isn’t treated, there’s an increased risk of giving birth too early, chorioamnionitis (inflamed amniotic fluid and membranes), and endometritis (uterine infection).
Complications for the baby if the mother has chorioamnionitis include a higher risk of preterm birth, neonatal sepsis (a dangerous infection in newborns), interventricular hemorrhage (bleeding in the brain), periventricular leukomalacia (brain injury), and cerebral palsy. The relationship between chorioamnionitis and bronchopulmonary dysplasia or respiratory distress syndrome (both lung conditions) is unclear.
Mother’s complications from chorioamnionitis include potential cesarean section and associated risks, increased risk of endometritis, wound infection, postpartum hemorrhage (excessive bleeding after birth), bacteremia and sepsis (blood infections), and continued postpartum hemorrhage.
Preventing Antepartum Infections (Infections during pregnancy)
Recently, there has been a growing movement against vaccinations that’s leading to the comeback of diseases that were nearly eradicated from the world. This trend started with a study in 1998 by Andrew Wakefield which linked MMR vaccinations to autism. Despite the fact that this study has been retracted and proven false many times, skepticism towards vaccinations and the medical profession continues to persist. This means there are many adult women who haven’t been vaccinated, putting them at a higher risk of infections during pregnancy. Screening and discussing vaccination concerns during health check-ups can help protect these women and their future children, and contribute to the health of the general population.
It’s also important to note that HIV, HSV, and CMV, three serious viruses, can be passed on to babies through breast milk. Women with HIV are generally advised not to breastfeed to reduce the risk of passing the virus onto their babies. This can be tough, and these mothers should also be given counselling and support. Women who have HSV without any active infections can breastfeed as normal, but they should stop breastfeeding if they develop any infection on their breasts to avoid spreading the virus to their babies. Women infected with CMV aren’t specifically advised against breastfeeding as healthy babies who get infected usually experience no significant symptoms. But, doctors should explain that babies that are born very prematurely or with a very low birth weight are at a higher risk of developing symptomatic CMV infection. The risks versus benefits of breastfeeding should be considered carefully and steps like freezing and pasteurizing breast milk can also help to reduce the risk of these infections.
Finally, pregnant women are advised to avoid traveling to places with high rates of HEV and Zika virus infections and to avoid behaviors that increase the risk of contracting diseases such as syphilis, HIV, HSV, HBV, and HCV. By avoiding these risks, pregnant women can help safeguard their health and the health of their unborn babies.
