Sofie Rifayani Krisnadi

Bagian Obstetri Ginekologi

RSUP Dr. Hasan Sadikin Bandung
 TOXOPLASMA
RUBELLA
CYTOMEGALOVIRUS
HERPES SIMPLEX
T-O(OTHER INFECTIONS)-R-C-H
Syphilis,HSV,Varicella,HBV,
Parvovirus B19
Frequently ask questions :

What is Toxoplasmosis ?
How is it caught ?
Who is at risk ?
How would I know if I have got it ?
What is the problem if caught during
pregnancy ?
What can be done if I got it ?
How to prevent ?
Infection cause by
Toxoplasma gondii
Intracellular parasite
Infected almost
mammalia & aves
Serious problem in
pregnant women &
immunocompromised
people
Is the mother infected ? When ?
Is the fetus infected? If yes, shows she/he
symptoms of the disease?
Is the newborn infected? Shows she/he
symptoms?
Long term follow up
Serological in case of
maternal (swollen lymph gland,fever) or
fetal symptoms (detected in USG)
Serological screening
to detect asymptomatic infections
 Serological Monitoring of Toxoplasmosis in Pregnant Women
45 % 5 50
Sample 1 lgG+/ lgM- %+ / lgM+
lgG lgG +%/ lgM+

Immune - recent primary infection Non Immune Patient

patient - old infection with residual lgM ?

Ask the laboratory to

continue with lgG Avidity Follow up must be continued until
the end of pregnancy
lgG Avidity

High Avidity Low Avidity lgG- / lgM- lgG+ / lgM+ lgG- / lgM+ **

Infection Non
acquired > 4 Immune
months ago Patient *
if the test is taken in
second half of Follow up
pregnancy, look must be
on the titer of lgG continued
until the end
of pregnancy Recent
Primary
Low lgG High lgG Infection Infection
acquired < 4 Additional Guidelines :
Old Probable months ago First sample should be collected early in pregnancy and
Infection Recent preferably tested with both lgG & lgM
Infection * if lgG-/lgM- : non immune patient, follow up must be
continued until the end of pregnancy
** if lgM+ without lgG, it may be the beginning of infection,
Confirmatory test needed reset 2-3 weeks later, if the result unchange : unspecific lgM
lgG, lgM

-Prenatal Diagnosis - Treatment - Follow up mother and newbornns

Find adequate treatment (antiparasitic drug)
Avoid unnecessary treatment
Amniocentesis & PCR
Ultrasound (hydrocephalus, calcification)
Diagnosis in the newborn
Abortion
Trias :
Hydrocephalus
Calcification
Chorioretinitis
 Treatment of pregnant women

Before 16 weeks gestation

4 weeks spiramycine
After 16 weeks gestation Spiramycine until get result
of fetal diagnostic, or Fetus infected, or No fetal
diagnostic available
Alternating to birth 4 weeks combination of
Pyrimethamin, Sulfadiazin, Folinic acid ;
4 weeks Spiramycine
Tertiary Prevention
Treatment newborn
The effects are no more severe for pregnant women
Teratogenic effect on the fetus
First trimester 50% - 90% affected
Newborn ~ infectious, shed virus for months
Expanded Rubella Syndrome for years
Disease Rubella Measles Dengue Erythema Roseola
Fever infectosum infantum

Causative agent Rubella Measles Dengue Parvovirus Human herpes

Virus Virus Virus B19 Virus 6

Incubation period (days) 14-23 7-18 2-12 4-20 10

Fever Yes Yes Yes Yes Yes

Rash Yes Yes Yes Yes Yes

Conjunctivitis Yes Yes Yes Yes No

Coryza Yes Yes Yes Yes No

Joint Symptoms Yes No Yes Yes No

Postauricular adenopathy Yes No No No Yes

Diagnostic test IgM IgM IgM IgM Igm

Result of infection
during pregnancy :
Stillbirthr Yes Yes Yes Yes No
Birth defect Yes No No No No

Vaccine preventable Yes Yes No No No

 Serological Monitoring of Rubella in Pregnant Women
Suspected Contact With Virus or Clinical Symptom
1st Sample lgG+/ lgM- lgG + / lgM+/- lgG+ / lgM+

Immune
patient Retest 1 - 4 weeks later
- primary infection ?
- old infection with residual lgM ?

lgG- / lgM- lgG+ / lgM+ lgG- / lgM+ lgG Avidity

2nd Sample

Not Primary Non

Infected Infection Spesific lgM
High Low

Infection Infection
acquired > 4 acquired < 4
months ago months ago

Additional Guidelines :
Primary infection in pregnancy depending on gestational week of bloodsample collection
No treatment exists in pregnancy, but interruption of pregnancy may be an option if infection
occurs before 17th week of gestation
If infection occurs after 17th week of gestation is not harmful for the fetus
 Serological Monitoring of Rubella in Pregnant Women
Prenatal Screening (first half of Pregnancy)
Determination of lgG

lgG + lgG -

Immune Patient Non Immune patient second

sample should be collected at
17-20th
week of pregnancy

lgG +
lgG -

Seroconversion
Not infected

lgM detection

lgM + lgM +

Primary infection is harmful to the

Testing should Testing should fetus before 17th week of pregnancy
be repeated be repeated Abortion is today only option
Category Spesific Manifestation

General Fetal loss (Spontaneous abortion and stillbirth

Low birthweight
Mental retardation

Auditory system Sensorineural deafness : unilateral or bilateral

Central auditory deafness
Speech defeets

Cardiovascular system Patent ductus arteriosus

Pulmonary stenosis
Ventricular septal defects
Complex congenital heart disease

Occular system Pigmented retinopathy

Cataracts : pearly, dense, nuclear, 50% bilateral, very
often with retinopathy
Microphtalmos

Transient neonatal manifestations Thrombocytopaeni with or without purpura

(extensive infection; high mortality) Hepatosplenomegaly
Meningoencephalitis
Bony radioluscencies
Adenopathies
Late emerging or developmental Late-onset interstitial pneumonitis
No specific therapy
The best is prevention
(Live attenuated vaccine) to all children and
adult women
Pregnant women are not vaccinated
If infection during first trimester
therapeutic abortion
Common virus, infects most people in the
world
Most infections are silent
Public health problem because it causeevere
disease to unborn babies and people with a
weakened immune system
Infected fetus any time in pregnancy
Person-person contact
Transplant and transfusion
Mother to newborn baby
Mother to unborn baby
 Primary infection
Producing antibodies & immune cells
Excreted in body fluids
Latent / inactive state
Possible to reactivate
Viral shedding may reoccur
 Symptoms and Signs acquired CMV
Infection

90% not any signs or symptoms

Occasionally flue like symptoms
Mononucleosis like symptoms (fever, sore throat,
fatigue, swollen glands)
Severe in persons weakened immune system
(pneumonia, retinitis, hepatitis, esophagitis,
colitis,meningoencephalitis, death)
 All pregnancies

99% of fetuses 1% of fetuses

not infected infected

90% are asymptomatic 10% are symptomatic

at birth at birth

85% of neonates 15% of develop Most severe neurologic

remain normal late disabilities complications
 Serological Monitoring of CMV Infection in Pregnant
App : 2 ( 1 - 8) %
Woman 98 ( 92 - 100) %

1st Sample Determinan of lgG

lgG - lgG +

Preventive measure to be given Old infection

no more testing
For Women at high risk :
Retesting later in pregnancy for lgG to identify
primary maternal infection

lgG - lgG +

no infected Confirmatory test :

Note :
* Routine serologic screening is not recommended before
lgG+, lgM+, lgG safe anti CMV therapy is available. However, on individual
Avidity low basis, it may be important to know the immune status.
** IgG avidity is new test which can differentiate between
recent (<3 months) and old infection
Primary
infection
Microcephaly
Low birth weight
Petechiae
Hepato/Splenomegaly

Jaundice
Anaemia/Thrombocytopenia
Seizure, blindness, deafness
Physical/motor impairment
 Antiviral
Do not kiss toddlers on the mouth
Do not share food/ drinks/ utensils
Wash hands after contact with child
excrete
Wash toys
HSV-1 & HSV-2
Primary infection symptomatic
Systemic symptoms +/-
Virus become latent
Reactivate periodically
Blistering/ulcerations genitalia externa
Pain, dysuria
Vaginal/Urethral discharge
Local lymphadenopathy
Systemic symptoms (fever, myalgia)
Could be asymptomatic
Antivirals
Supportive treatment
Continue acyclovir in the last 4 weeks
If symptoms occurs during 6 weeks before labour,
consider cesarean section
Cesarean section for women with lesions at the
onset of labour
 Symptomatic herpes in pregnancy (First Episode)
Collect blood sample immediately, testing for HSV2 Antibodies

Determination of lgG

lgG - lgG +

New sample should be Recurrent

tested 2 weeks later infection

lgG +

Primary infection *

Note :
Management of primary and recurrent infection at the end of pregnancy is different :
Primary infection : High risk of mother to child transmission
Recurrent infection : Low risk of mother to child transmission
 Serological Testing of the Pregnant Woman
without a History of Genital Herpes and her Partner
Testing for HSV2 and HSV1 Antibodies
Pregnant Woman Her Partner

lgG - Should be tested

for lgG

lgG + lgG -

Retest lgG Educate couple about HSV

in late pregnancy transmission and recommend
condom use or partner suppression
treatment HSV1 : avoid orogenital
contact
lgG + lgG -

seroconversion
primary infection not infected
*