Infections in pregnancy
It can happen at expectant mothers sometimes feeling more tired, experiencing muscle aches or having a low-grade fever. Attention should be paid to these symptoms, because often many of the infections acquired during pregnancy have a subtle or sometimes symptom-free course in the mother, but they can be transmitted to the newborn and generate even serious results. This phenomenon can therefore cause confusion in mothers and ensure that the pregnant woman does not undergo checks, which are instead necessary.
Many of the harmful effects on the newborn, caused by diseases contracted during pregnancy, could be reduced, sometimes zeroable, if screening and prevention were carried out in the right time and in the right measure and if access to the various prevention services were simple, even for the most disadvantaged social categories. Let's think, for example, of the immigration problem in Del Paese and how many women have difficulty in taking advantage of the numerous existing prevention activities, due to cultural, language or access to health services difficulties. From the frequency of the main infectious diseases communicable to the fetus, reported by national and international studies, it is estimated that in Del Paese about one child in 100 is born with a congenital infection. Out of a total of approximately 450 children who are currently born in the country (ISTAT 2022 data), congenital infections considered globally, symptomatic or not, affect 4.000 to 6.000 children every year. Considering that many of the infections harmful to the newborn (Group B Streptococcal infection, Syphilis, Toxoplasmosis) are treatable successfully and without fetal harm during pregnancy, the number arouses some concern.
We talk about it with Cinzia Auriti, Neonatologist of the Neonatal Intensive Care Unit of the Bambino Gesù Hospital in the city, Head of the High Specialization for the Prevention and Treatment of Neonatal Infections at the Department of Medical and Surgical Neonatology.
In this article
- Infections in pregnancy, how to recognize them
- Infections in pregnancy, the Cytomegalovirus
- Infections in pregnancy: toxoplasmosis
- Infections in pregnancy: Group B beta hemolytic streptococcus
- Infections in pregnancy: syphilis
- Infections in Pregnancy and Guidelines
- Pregnancy and vaccinations
- Infections in pregnancy and miscarriage
Infections in pregnancy, how to recognize them
"Through informed information and targeted prevention actions many outcomes in the newborn can be prevented - said the neonatologist -. For this reason, the cultural integration between professionals from different disciplines, such as Obstetrics and Neonatology, linked by the common goal of the well-being of the fetus and the newborn, is important. An integrated obstetric and neonatological culture guarantees the accompaniment of future mothers in the period of gestation, when it is important that the obstetrician carries out the screening of diseases to treat them early. In the post partum, the neonatologist, aware of what happened during gestation, to better manage the needs of this category of newborns. Working according to diagnosis and therapy protocols shared between obstetricians and neonatologists it is therefore very important. Some congenital infections have an acute onset in the newborn, requiring hospitalization. This is the case of early infection with Group B beta hemolytic streptococcus (Streptococcus agalactiae), actually a connatal infection because it is mainly contracted at the time of childbirth, which causes septicemia, pneumonia and meningitis, with devastating outcomes on the newborn, almost completely avoidable if the screening of mothers with vaginal and rectal swabs in the third trimester of gestation and the antibiotic prophylaxis protocol during childbirth are activated at the right times. Infections with Cytomegalovirus they are very common in pregnant women and congenital infection due to this virus is recognized as the second cause of congenital deafness in the child, after congenital deafness of genetic origin. We still do not have a therapy for this virus, which can be safely administered during pregnancy, nor is a vaccine available, but early diagnosis of infection in mothers allows you to correctly evaluate the newborn at birth and treat him with antiviral drugs, which have been shown to reduce the chances of deafness and distant neurological defects ".
"Yet, Syphilis, an infection that we thought was part of the past has shown a resurgence in recent years and when left untreated it can lead to miscarriage, birth mortality, bone deformation. We think that with two doses of penicillin, given to the infected pregnant mother, all this mostly does not happen. Equally the Toxoplasmosis, a dangerous infection for the newborn, if contracted from the pregnant mother, can cause serious neurological and ocular damage in the newborn, which can be avoided with antibiotic therapy administered to the mother. These infections often occur in the pregnant woman without symptoms or in a sneaky way and for this reason it is essential to follow the indications for physiological pregnancy, also contained in the guidelines of our Ministry of Health"
Read also: Miscarriage: the causesInfections in pregnancy, the Cytomegalovirus
"Having contracted the disease in the past it has no value fully protective in the case of the Cytomegalovirus - clarifies the specialist - and about 80% of adults in the world have specific antibodies against Cytomegalovirus, with different prevalence depending on social status and geographical area. Once contracted, this virus remains at the latent state inside the organism, that is to say that the virus is there but cannot be seen and can reactivate. What changes is the probability of transmission to the fetus. Infection in pregnancy can be primary, when you first contract it during gestation, and in this case it is more likely that it will be transmitted to the fetus. Transmission to the fetus is much less frequent, however, when the virus is reactivated during pregnancy in a mother who had already contracted the infection in the past (non-primary infection) ".
Symptoms
Symptoms of congenital infection of the newborn can be acute symptoms, or, as happens more frequently, the newborn is born infected, but without symptoms and develops in a percentage of cases up to 15% permanent long-term outcomes, such as deafness.
Prevention and treatment
"Knowing the history of the pregnant woman is important for the neonatologist: there are drugs that can be administered to the newborn and have been shown to be effective in reducing the incidence of these long-term outcomes. Serological screening at the beginning of pregnancy, with the dosage of the IgG and specific IgM, it allows to know the infectious situation of the mother and to plan the following checks ".
Read also: Cytomegalovirus (CMV) in pregnancy, 8 things to knowInfections in pregnancy: toxoplasmosis
"The toxoplasmosis, if contracted during pregnancy and not properly treated, it causes very serious risks for the newborn - explains Cinzia Auriti -. Toxoplasmosis can be contracted during pregnancy through cat feces or the consumption of unwashed and raw vegetables and is treatable with drugs that can be administered to the pregnant woman without toxic effects on the fetus. The fetal damage risks associated with Toxoplasmosis are highlighted above all if the mother becomes ill at the beginning of pregnancy, because the embryo is in formation and the effect of the germ is greater on the fetal tissues. The damage caused by the transmission of the virus to the fetus is mainly cerebral and visual ".
Prevention and treatment
"Serological screening tests carried out at the beginning of pregnancy or in anticipation of conception can provide useful information on the state of health of the mother and allow for early therapy that greatly reduces its frequency and severity".
Read also: Toxoplasmosis in pregnancy: 7 things to knowInfections in pregnancy: Group B beta hemolytic streptococcus
"Group B Strep infection can be transmitted from mother to child during childbirth - adds the doctor -, generating infections with very early clinical onset, within the first 12-24 hours of life, and very serious, fatal in 2% of infected infants. This bacterium also causes late infections, which occur within a few weeks of life, which are also very serious. In the past, before the activation of the prevention measures, this infection was frequent, due to the high frequency of maternal vaginal, rectal or urinary tract colonization (in the country 10-20% of women of childbearing age are colonized without manifesting symptoms)".
Prevention and treatment
In the last 20 years the frequency of this infection of the newborn has drastically decreased due to the activation of the universal screening of pregnant women using vagino-rectal swabs, which must be carried out from the 35th to the 37th week of pregnancy (34 ° -36 ° in pregnancies twins) and administration of intravenous antibiotics during childbirth, in case of positive swabs.
Read also: Strep throat sore throat: EVERYTHING YOU NEED to knowInfections in pregnancy: syphilis
"Syphilis is a very infection dangerous in pregnancy, because it passes to the baby through the placenta, in all stages of gestation, causing very serious consequences and in this case we are talking about Congenital syphilis - explains Auriti -. Luckily the infection is preventable and treatable: the probability of transmission to the fetus for an infected mother not treated with Penicillin is 80% -100%, while if treated this probability of transmission is reduced to 1,8%. Early abortion is very common in women with a recent infection. Currently this disease is re-emerging in Del Paese (this phenomenon has also been observed in the United States). There is probably a relationship with sexual habits, the immigration of women from countries where antenatal care is not available or lacking and there is no attention in the screening of these diseases among young people. We are observing a number of girls of childbearing age or at the beginning of pregnancy with positive serological tests, without having any awareness of it and without knowing how to go back to the time of the infection. If the infected mother is not treated with Penicillin during pregnancy, very often it is necessary to hospitalize the baby, carry out a whole series of diagnostic tests, including lumbar puncture, and treat him with intravenous Penicillin, because congenital syphilis is devastating.
A pregnant syphilis infected mom, if carefully treated, is almost certainly will have a completely healthy child, the therapies are inexpensive, effective and do not harm the fetus or the newborn baby ".
Pregnancy and vaccinations
Expectant mothers, for a physiological situation of depression of immunity, they are predisposed to contract infections. The active immunization of the pregnant woman through vaccination is a winning strategy in preventing or mitigating some infections and the risk for the newborn that will be born. Not all vaccines can be administered during pregnancy, in particular those with attenuated living virus are contraindicated (Measles, Rubella, Mumps, Varicella, anti-tuberculosis vaccine, non-inactivated influenza). On the other hand, some vaccines are universally recommended for pregnant women by many scientific societies and by the US Advisory Committee on Immunization (ACIP).
Two vaccines in particular should be of interest to every pregnant woman:
- the inactivated one against seasonal flu
- and that with reduced doses of toxoid against diphtheria, tetanus and acellular against pertussis.
Maternal vaccination involves the passing of antibodies to the fetus in utero and therefore the newborn will be protected against the disease at birth. Let's think for example of whooping cough. The immunity given by the contracted disease or by vaccination is not a perennial immunity and more and more frequently we observe young people and women of childbearing age susceptible to the disease. Pertussis is contracted by the newborn usually by family members and therefore by exposure to the germ immediately after birth, before being vaccinated. The symptoms of whooping cough in the newborn are very serious, requiring hospitalization, and can even lead to death. By vaccinating the pregnant mother this situation is prevented. All obstetricians and gynecologists should be familiar with the indications for vaccinations during pregnancy.
Read also: Pertussis vaccine in pregnancyInfections in Pregnancy and Guidelines
"The Ministry of Health periodically updates the Ministry of Health Guidelines on physiological pregnancy "- explains the neonatologist of the Child Jesus -: here the indications are provided at a national level and also infectious diseases such as that from
- Toxoplasma,
- Group B streptococcus
- or like HIV.
The programs of the Health Service for the protection of pregnancy provide for the necessary serological screenings. Also there are the protocols developed by the Scientific Societies (Del Paesena Society of Neonatology, Del Paesena Society of Pediatrics, Obstetrics and Gynecology and others) who have elaborated indications on obstetric-neonatological pathways for the main communicable diseases to the fetus. If the existing indications were disseminated and rigorously applied, we could drastically reduce the number of births with congenital infection and long-term outcomes. Sensitivity to the problem is essential, shared between Obstetricians and Neonatologists and sharing as well as cultural as well as operational. A Prenatal Diagnosis Service is active at the Bambino Gesù Hospital, directed by Dr. Leonardo Caforio, where a team of obstetricians and neonatologists diagnose infections in pregnancy and the related prenatal counseling; the assistance process then continues with treatment of the child after birth. Newborns are followed up in a multidisciplinary day hospital service for up to two years of life. The mothers who come to us are always very confused and distressed, more than one considers abortion, because they do not have a clear diagnosis and above all they do not have clear possible outcomes on the newborn. Lack of information can weigh heavily on families on a psychological level. In fact, children who are born sick require care and continuous checks, even in the long term ".
"To disseminate information and operational protocols on neonatal infections, the Neonatal Infectious Disease Study Group of the Del Paesena Society of Neonatology is organizing an online course on congenital infections, with indications addressed to obstetricians, "Diagnostic clinic and therapy of neonatal infections: updates on diagnostic methods and therapy protocols". These distance learning activities are a very useful tool for making specialists dialogue and making intervention on women more effective. In addition, on the portal of the Bambino Gesù Hospital, we have a dissemination system with cultural "pills", easy to understand for everyone, on issues related to the most common infections of pregnancy ".
Read also: Leukorrhea gravidarumInfections in pregnancy and miscarriage
"All these infections they can generate abortion in different ways - clarifies the neonatologist -. The Cytomegalovirus it can be fatal if contracted early in pregnancy, even the Toxoplasma and Syphilis they have the ability to determine miscarriage and significant fetal mortality. The Streptococcuson the other hand, it generally does not carry this risk because it is contracted at the time of delivery by the vaginal route and in the term baby the development is completed.
Il Toxoplasm is a strange germ: it can cause serious damage when contracted at the beginning of pregnancy, but in these early stages the infection is transmitted to the fetus with a low probability, while when it is contracted near the end of gestation the probability of passing through the placenta is much higher, but the damage to the newborn is much milder.
Infection with Cytomegalovirus can cause miscarriage.
Finally, the Syphilis maternal causes abortion very frequently. From the data estimated by the World Health Organization, relating to the whole world, the cases of abortion for maternal syphilis were 305.000 in 2008, the cases of congenital syphilis each year vary from 728 thousand to 1 million and 520.000. In Del Paese, a 2022 study estimated the prevalence of syphilis in pregnancy to be 0,17% compared to a prevalence in Western Europe of 0,02% and cases of congenital syphilis in neonatal 20 / 100.000 live births per year " .
The interviewee
Cinzia Auriti è neonatologist of the Neonatal Intensive Care Unit ofInfant Jesus Hospital of the city, head of the High Specialization for the prevention and treatment of neonatal infections at the Department of Medical and Surgical Neonatology, secretary of the National Study Group of Neonatal Infectivology of the Del Paesena Society of Neonatology.
References
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Kenneson A, Cannon MJ.Rev Med Virol 2007; 17: 253-76.
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Stagni L, et al. Mem Inst Oswaldo Cruz.2009; 104 (2): 374-7
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Brown ZA, et al. JAMA 2003; 289 (2): 203–9.
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Tridapalli et al. Arch Dis Child Fetal Neonatal Ed published online September 24, 2022
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Ministry of Health guidelines: Physiological pregnancy, guideline 20
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CDC: Prevention of Perinatal Group B Streptococcus MMWR 19 November 2022
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Care pathways in Obstetrics and Gynecology Syphilis Cytomegalovirus Toxoplasma
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ACIP Guidelines: Guidance for Vaccine Recommendations in Pregnant and Breastfeeding Women. Update 2022.
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