Overview

TORCH (infectious diseases that can pass to baby) → toxoplasmosis, other (syphillis, parvovirus, hepatitis, varicella, HIV), rubella, cytomegalovirus, herpes simplex.

• TOXOPLASMOSIS

  • Infection with the **toxoplasma gondii ****parasite. Spread by contamination with cat faeces.
  • Risk of vertical transmission increases with gestational age.
  • Congenital Toxoplasmosis (4 C’s) → intracranial calcification + hydrocephalus + chorioretinitis + convulsions.
  • 1st Line Abx → Spiramycin for 3 weeks.
  • Foetal Infection → treat baby for up to 1 year after delivery.
  • Prevention → avoid eating raw meat, avoid handling cats and cat litter, wear gloves and wash hands when gardening or handling soil.

• OTHER (SYPHILIS)

  • Refer to GUM clinic for appropriate contact tracing.
  • 1st Line Abx → IM Benzylpenicillin for 14 days.
  • If woman is not treated during pregnancy, treat the baby immediately after delivery.
  • Congenital Syphillis → rash on soles of feet and hands, bloody rhinitis.

• OTHER (PARVOVIRUS B19)

  • Risk period for vertical transmission <20 weeks. Crosses placenta and destroys RBCs = hydrops foetalis (foetal oedema on ultrasound).
  • If pregnant woman come into contact with infected individual (erythema infectiosum) → next step is to check IgM antibodies to see if she has been infected (ONCE MATERNAL INFECTION CONFIRMED THEN FOETAL SURVEILLANCE IS REQUIRED).
    • If exposed after 20 weeks, no need for investigations as very low risk.
  • Conservative management of mother → rest, fluids, paracetamol.
  • Urgent referral to foetal medicine specialist for regular foetal surveillance → serial (fortnightly) foetal ultrasounds and doppler assessment (of middle cerebral artery → allows detection of foetal anaemia). 30% risk of transmission to fetus.
  • If evidence of Foetal Anaemia or Hydrops Foetalis ⇒
    • Expectant Management → spontaneous resolution in 50% of cases with no long-term sequelae.
    • In Utero Blood Transfusion → offer if infection occurs in first 20 weeks of pregnancy (as risk of foetal loss is 10%). Also allows for complete recovery.

• OTHER (HEPATITIS B)

  • Antenatal ⇒
    • Refer to hepatologist.
    • Offer tenofovir if high HBV viral load.
  • Postnatal ⇒
    • Offer hepatitis B immunoglobulin [IgG] (if mother is surface antigen positive) and hepatitis B vaccine (if mother is surface antigen positive or high risk for hep B) to the newborn.
      • Vaccine → at birth, 1 month, 6 months.
      • IVIG → within 12 hours of birth.
    • Encourage breastfeeding (no risk of transmission) (BREASTFEEDING = SAFE).

• OTHER (VARCICELLA ZOSTER)

  • Chickenpox vaccine → contraindicated in pregnancy.
  • Exposed + unsure if past history → first step is check for IgG.
  • Mx of non-immune woman EXPOSED to chickenpox with no past history of chickenpox ⇒
    • <20 wks pregnant OR >20 wks pregnant with no rash → VZ Ig ASAP. Effective when given up to 10 days after contact. Advise to avoid contant with other pregnant women and neonates.
  • Mx of chickenpox INFECTION ⇒
    • If >20 wks and presents within 24 hrs onset of rash → oral aciclovir for 7 days. VZ Ig offers no benefit once chickenpox has developed.
    • Delivery → if infection within last 4 weeks of pregnancy, elective delivery should be delayed until 7 days after the onset of the rash.
    • Postnatal → arrange neonatal opthahalmic examination after birth.

  <aside> 💡 EXPOSED (if <20/40 or >20/40 with no rash) → VZ Ig. INFECTION (if >20/40 and within 24hrs of rash) → oral aciclovir for 7 days.

  </aside>

  • Foetal Varicella Syndrome → cutaneous scarring, limb hypoplasia, and CNS defects.
  • If mother affected 4 weeks before or 1 week after birth → child should recieve VZIG prophylaxis.

• OTHER (HIV)

  • Antenatal ⇒
    • Joint HIV physician and obstetric clinic every 1-2 weeks.
    • Monitor CD4 counts at baseline and delivery (twice) + HIV viral load every 2-4 weeks, at gestation and at delivery (eight times total).
    • All women should be offered combined antiretroviral therapy by 24 weeks and continuing lifelong.
  • Intrapartum ⇒
    • Mode of delivery depends on viral load at 36 weeks gestation → <50 copies/mL = vaginal delivery. >50 copies/mL (or co-existent hepatits C) = C-section with intrapartum IV zidovudine.
    • Foetal blood sampling is contraindicated.
  • Postpartum ⇒
    • Advise women not to breastfeed. (can offer cabergoline to women to suppress lactation).
    • Treat newborn with ART within 4 hours of birth, and continue treatment (Zidovudine) for 4-6 weeks.
    • Check HIV status in neonate with direct viral amplification by PCR (at birth, discharge, 6 weeks and 12 weeks).

• RUBELLA

  • If contracted during pregnancy there is a risk of congenital rubella syndrome (sensorineural defects + congenital cataracts [blindness] + cardiac abnormalities [PDA]).
  • If pregnant woman not immune to rubella → offer MMR vaccine in post-natal period.
  • (Now rare due to uptake of MMR vaccine, but common in immigrant communities)

• CYTOMEGALOVIRUS

  • No prenatal treatment available. 90% asymptomatic (10% develop SNHL).
  • Refer to foetal medicine speciailist → regular surveillance with foetal USS every 2-4 weeks.
  • Mx → posnatal antiviral therapy (valganciclovir or ganciclovir) for baby for 6 months + audiology F/U + opthalmology F/U.
  • Congenital CMV → fetal growth restriction, microcephaly, hearing loss (sensorineural deafness), vision loss, learning disability, seizures.

• HERPES SIMPLEX

  • Refer to GUM clinic.
  • First episode of Genital HSV ⇒
    • Tx with oral aciclovir (400mg TDS for 5 days).
    • If infection occured in 1st or 2nd trimester (<26w) → daily oral aciclovir from 36/40 until delivery + offer vaginal delivery.
    • If infection occured in 3rd trimester (>26w) → oral aciclovir immediately until delivery. Recommend delivery by C-section.
  • Recurrent episode of Genital HSV ⇒
    • 400mg TDS oral aciclovir from 36/40 until delivery.
    • Offer vaginal delivery.
  • Neonatal Herpes → development of vesicles and pustules involving the face and mouth.

Making Diagnosis

Clinical Features

Investigations

Management Plan