Genital herpes simplex infections: effect of asymptomatic shedding and latency on management of infections in pregnant women and neonates.

Asymptomatic shedding of herpes simplex virus (HSV) at delivery occurred in 2.4% of women with a past history of recurrent genital infections; using current methods, this could not be predicted in advance. In addition, only 22% of the mothers of infected infants had an elicitable history of recurrent genital infections. Passively derived neutralizing antibody titers of 1:106 to HSV-1 and 1:67 to HSV-2 were found in 22 exposed infants who remained asymptomatic as compared with 1:8 and 1:8, respectively, in ill infants, suggesting that transfer of antibody from the mother may be an important host defense. Among treated infants, a more rapid rise in antibody titer was seen in infants receiving adenine arabinoside than in those receiving acyclovir; two of the latter infants developed a severe infection in a second organ following cessation of the drug. Exposure of infants to HSV appears inevitable at this time. The extreme variability in outcome is probably related to host factors that are poorly understood at present.

Evidence for postpartum toxic-shock syndrome in a mother-infant pair.

Toxic-shock syndrome occurred in a mother and possibly in her infant in the immediate postpartum period. Staphylococcus aureus of identical phage type and antibiogram was recovered from mucous membranes in both patients. Staphylococci were transmitted from mother to infant during parturition. These cases represent the first postpartum clinical description and possible vertical transmission of this disease.

Transmission of hepatitis B virus infection by asymptomatic chronic HBsAg carrier mothers.

The courses of 18 children born to 13 chronic hepatitis B surface antigen (HBsAg) carrier mothers were followed prospectively for serological and biochemical evidence of type B hepatitis. Three children developed transient HBsAg positivity accompanied by the appearance of antibody to the hepatitis B core antigen. Two others had no detectable HBsAg but developed antibody to HBsAg. These serological manifestations of hepatitis B virus infection occurred late--6 to 24 months after birth. None of the children had clinical evidence of hepatitis and none became chronic HBsAg carriers. The infrequency of transmission of infection, the mild course of disease, and the lack of persistence of HBsAg in these children probably reflected the low level of infectivity of the chronic carrier mothers and perhaps the healthy immunologic status of the children.

Chlamydia trachomatis infection in infant delivered by cesarean section.

Neonatal Chlamydia trachomatis infection is thought to be acquired as a result of contact with infected cervical secretions during vaginal delivery. An infant, delivered by cesarean section, who was infected with C trachomatis has been described. At 31 days of age he had conjunctivitis and respiratory distress. Nasopharyngeal aspirate grew C trachomatis and serum IgM antibody titer was 1:32 for serotype J. The patient's mother had serum IgG antibody against C trachomatis serotype J. Her cervical culture was negative for Chlamydia; however, cultures were not taken until two months after delivery and she had received antibiotics for postpartum fever and abdominal pain. The literature has been reviewed and possible modes of transmission have been discussed.

Use of restriction enzymes to investigate the source of a primary cytomegalovirus infection in a pediatric nurse.

The risk of transmission of cytomegalovirus (CMV) infection from congenitally infected infants to nonimmune medical attendants is unknown. The case of a CMV-seronegative, pregnant nurse who seroconverted after caring for an infant with symptomatic CMV infection is reported. She elected to be aborted and the fetal tissue contained CMV. Isolates from the nurse, the fetal tissue, and the infant to whom the nurse was exposed were examined for genetic relatedness by restriction enzyme analysis. As expected, the isolates from the nurse and the fetal tissue were identical. However, the virus isolated from the symptomatic infant was different from the strain infecting the nurse. These data indicate that the nurse acquired her infection from a source other than the index infant, either within the hospital or within the community.

Restriction endonuclease analysis of cytomegalovirus deoxyribonucleic acid as an epidemiologic tool.

The possibility of transmission of cytomegalovirus (CMV) from congenitally infected infants to susceptible medical personnel produces anxiety because the risks have not been defined. A physician conceived her first child while caring for an infant in the intensive care nursery who died with congenital CMV infection. The physician had serologic evidence of active CMV infection confirmed by isolation of virus from multiple sites. She elected to have her pregnancy interrupted. CMV was isolated from the placenta and fetal brain. Restriction enzyme analysis was employed to test all the CMV isolated for genetic relatedness. Virus isolated from the physician and her fetus was identical. The virus from the index nursery infant was different from the strain infecting the physician and her fetus. These data indicate that the physician acquired her virus from a source other than the index infant.

Prospective study of maternal and infantile infection with Chlamydia trachomatis.

We examined the prevalence of chlamydial infection in a population of pregnant women and observed their infants to determine the risk of development of ocular or respiratory infection. We examined endocervical and serum specimens from 322 pregnant women for Chlamydia trachomatis and chlamydial antibody. The cultures were obtained at the first prenatal visit. Six (2%) of the women were infected with C trachomatis. Chlamydial antibody was present in the genital secretions of 47% and 73% of the serum samples. The six infants born to infected women, 61 infants born to women who were culture-negative, but local antibody-positive, and 28 control infants born to culture-negative, antibody-negative women were followed for up to six months. Four of six infants born to infected women developed chlamydial infection: two developed culture-positive conjunctivitis, one had asymptomatic nasopharyngeal infection, and one infant developed pneumonitis. Three of 61 infants born to mothers who were culture-negative and local antibody-positive developed conjunctivitis due to C trachomatis. None of the 28 control infants developed chlamydial infection. Most (79%) of the infants had chamydial antibody in their serum at 2 to 4 weeks of age. The correlation between maternal and infant serum antibody titer was r=0.71 suggesting that antibody was placentally transferred.

Microcephaly and congenital cytomegalovirus infection: a combined prospective and retrospective study of a Swedish infant population.

Microcephaly and its etiology were studied in an unselected Swedish urban infant population. Virtually, all live-born infants (14,724) born between October 1977 and December 1983 in the city of Malmö, Sweden, were included in the study. Special attention was given to the role of congenital infections, particularly to cytomegalovirus infection. The infant population was studied from two points of view. One part of the study was prospective and based on regular cytomegalovirus isolation in urine within the first week of life. About 80% of the newborns were adequately studied by this test. None of 56 infants shown to be cytomegalovirus excreters (congenitally infected) and followed up were born with or developed microcephaly (head circumference smaller than 3 SD below the mean for age and sex) during the first 1 to 7 years of life. However, two of the 56 infants had a head circumference of -2 SD. In the beginning of 1985, an inventory was made of the presence of symptomatic microcephaly in the above mentioned population still living in the city or deceased there. Of about 10,000 such children, 12 were found to have symptomatic microcephaly. By studies of personal, clinical, and laboratory data and by retrospective serologic studies of frozen pre- and postconceptional maternal sera, a possible explanation or a recognized syndrome was obtained in ten of the 12 cases. In one of them, the mother had a primary cytomegalovirus infection, possibly in early pregnancy. Although the infant had symptoms compatible with a congenital infection, no laboratory evidence of transmitted infection was found. In no case were congenital rubella virus or Toxoplasma gondii infections suspected.

Primary cytomegalovirus infection in adolescent pregnancy.

In a prospective study of 3,253 pregnant adolescents, 1,404 were seronegative for cytomegalovirus (CMV). Specimen collection at each antenatal visit, including urine for viral culture and serum for complement-fixing antibody, allowed definition of primary CMV infection in 14 subjects (1%). Seven of 14 subjects delivered congenitally infected infants, including 5/7 subjects with third trimester infections, and 2/5 subjects with second trimester infections. The single mother with a first trimester infection delivered an uninfected infant, despite recurrent maternal viremia. The mean birth weight of congenitally infected infants did not differ significantly from the mean birth weight of uninfected infants. None of the infants had stigmata of cytomegalic inclusion disease. One infected infant died suddenly at 6 weeks of age from pneumonia. Follow-up examinations of the six living children failed to detect cognitive, behavioral, or audiologic sequelae. These data demonstrate that primary maternal CMV infection occurs in 1% of susceptible women and is associated with a 50% risk of intrauterine infection. Fetal infection, particularly if it occurs late in pregnancy, is not invariably accompanied by fetal damage.

Case reports. Intrauterine echovirus type II infection.

The case described herein represents the first laboratory-confirmed case indicating intrauterine infection due to echovirus type II. The virus was recovered from the vagina of the mother and from the blood from the umbilical cord and nasopharynx of an apathetic newborn (all cultures were taken within 60 minutes of birth in the delivery room) with a generalized maculopapular exanthem. When the infant was 15 days of age, results of all laboratory tests and physical examinations were normal.

Vertical transmission of Ureaplasma urealyticum in full term infants.

Ureaplasma urealyticum is a common inhabitant of the urogenital tract of pregnant women. Although colonization of newborn infants with U. urealyticum has been documented previously, the actual rate of vertical transmission has not been determined. Cervical cultures for U. urealyticum were performed on 1315 pregnant women on admission to the labor suite. A positive culture was found in 810 (62%). Eye, nasopharyngeal and/or throat, vaginal and rectal cultures were obtained in the first 5 days of life from 132 full term infants born to mothers colonized with U. urealyticum. Fifty-nine infants (45%) had at least one culture site positive for U. urealyticum (eye, 4%; nasopharynx 24%; throat, 16%; vagina, 53%; and rectum, 9%). None of the infants had evidence of disease caused by U. urealyticum during the nursery stay. Vertical transmission was not affected by the method of delivery. However, among the vaginally delivered infants, rupture of membranes greater than 1 hour correlated with an increased rate of vertical transmission of U. urealyticum (52%) compared with rupture of membranes less than or equal to 1 hour (22%) (P less than 0.05). Because vertical transmission of U. urealyticum occurs frequently, caution must be exercised when attributing disease to U. urealyticum based solely on positive cultures of mucosal surfaces.

Papillomavirus. Effects upon mother and child.

Papillomaviruses are widespread, sexually transmitted agents with an increasing prevalence. They are associated with a significant risk of genital carcinoma in infected women. Because they can be transmitted to the fetus before or during birth, they are also a risk to the infant born to an infected woman. Laryngeal HPV infections, while presumably much less prevalent than genital tract infections, are associated with a high degree of morbidity and a significant degree of mortality when they cause laryngeal papillomas. Therefore, transmission of these viruses to the fetus is a major problem. Much more information regarding mode of transmission and possible cure for this infection is needed in order to reduce the risk of laryngeal papillomatosis in infants in the future.

Rarity of cesarean delivery in cases of juvenile-onset respiratory papillomatosis.

Papillomas of the respiratory and genital tracts are caused by the same papillomavirus genotypes, and mothers of children with respiratory papillomatosis often have a history of genital warts. Only one of 109 cases reviewed gave a history of birth by cesarean section, whereas ten cesarean deliveries would have been the expected number for this group on the basis of national rates. The single case was delivered by elective cesarean section before the rupture of the membranes, and the child developed respiratory papillomatosis in the first year of life. These findings suggest that in juvenile-onset disease, the transmission of infection from mother to child occurs most often during passage through an infected birth canal, but that intrauterine infection of the fetus is also possible. Papillomavirus infection of the female genital tract is common, but respiratory papillomatosis is rare. On the basis of crude estimates of annual number of children born to infected mothers and of new cases of juvenile-onset disease, the risk of developing disease for a child born to an infected mother was calculated to be one in several hundred exposures.

Rubella, the Trojan horse of obstetrics.

Documentation has been provided that health care personnel working in prenatal clinics have exposed their patients to the rubella virus. Various states have instituted rules and regulations toward the prevention of spread of rubella to pregnant women. These regulations have been ineffectual as rubella antibody testing and immunization programs do not include all health care providers. Cogent reasons for rubella antibody testing and immunization of all susceptible health care providers, whether they are physicians, nurses, or students, are presented.

Rubella exposure in an obstetric clinic.

Despite a massive national rubella immunization program, rubella infection remains a public health problem. When a nurse employed in a hospital-based obstetric clinic became ill with rubella, a crisis was precipitated. The hospital staff implemented a plan to inform the exposed 151 patients and 44 employees of the potential danger to themselves and their fetuses. To identify persons at risk, a program of rubella antibody testing of contacts was instituted. In 3 distinct attempts to obtain blood specimens, patient compliance rates fell progressively from 79 to 14%. One additional infected employee was detected. A list of recommendations designed to prevent or lessen the impact of future rubella exposures in hospitals is presented.

Impact of primary prevention on the incidence of toxoplasmosis during pregnancy.

Until now, it was assumed that primary prevention of congenital toxoplasmosis was possible by means of specific hygienic measures. A prospective survey of pregnant women was made at a hospital in Brussels over the period 1979-1986 to assess the impact of such a prevention program. In the first study period (1979-1982), when no prophylactic measures were taught, 2986 consecutive women demonstrated a seroconversion rate of 1.43% among the nonimmunized subjects; 1.07% of the seropositive patients had high antibody levels in their first serum sample. In the second study period (1983-1986), all 3563 patients were instructed to adopt prophylactic measures. The seroconversion rate in seronegative patients and the percentage of patients with high initial antibody level were 0.95 and 1.26%, respectively. Although the percentage of seroconversion was reduced by 34% in the second study period, this difference did not attain significance. These results indicate that the impact of a primary prevention program aimed at reducing congenital toxoplasmosis is limited.

Transplacental transmission and fetal parasitosis of Trypanosoma cruzi in outbred white Swiss mice.

Two strains of Trypanosoma cruzi, isolated from humans and assayed for their biological capacity to kill outbred white Swiss mice (HaM/CR-CD) following reticuloendothelial system blockade with thorium dioxide, were used in these experiments: the Maria Cristina strain, which killed all blocked mice at a rate following a rectangular dose-response curve, and the José Cardoso strain, which did not kill blocked mice at comparable dosages. When inoculated into pregnant HaM/CR-CD mice, the non-pathogenic José Cardoso strain did not cross the placental barrier, in either blocked or unblocked mice, to cause fetal parasitosis. The pathogenic Maria Cristina strain did not cross the barrier in non-blocked mice, but in thorium-dioxide blocked mice it produced an incidence of fetal parasitosis of 8.9% (7 of 79 fetuses). These results indicate that the transplacental transmission of T. cruzi was dependent on two restrictions: pathogenicity of the strain of T. cruzi, and blockade of phagocytic activity by thorium dioxide, suggesting that transplacental transmission of T. cruzi is related to interference with the phagocytic activity of the placenta.

Maternal and infant sexually transmitted diseases.

Sexually transmitted infection may result in serious damage to the reproductive tract of the mother, damage to the fetus, wastage of pregnancy, or illness or death of the infant. The effects of gonorrhea, Chlamydia trachomatis infection, mycoplasmal infections, group B streptococcus infections, syphilis, and viral infections are discussed separately for both mother and infant.

Hepatitis B serology--help in interpretation.

This review discusses the serologic markers of hepatitis B virus (HBV) infection. Interpretation of various serologic profiles is provided, and the importance of maternal screening for interruption of perinatal transmission of HBV infection is stressed.

Liver diseases in pregnancy.

Mild abnormalities of liver function tests are frequently seen in pregnancy but return to normal after delivery. A raised serum alkaline phosphatase is common, along with a decline in the serum albumin, but the aminotransferases remain within normal limits. The physician must interpret abnormal liver function tests in pregnancy with these changes in mind, but most liver diseases in pregnancy result in more marked alterations. Viral hepatitis is the most common cause of jaundice in pregnancy, and the maternal prognosis is generally good. Perinatal transmission of hepatitis B virus is likely when the mother is positive for HBsAg. Concurrent administration of hepatitis B vaccine and HBIG to the infant has an efficacy of 90 per cent in preventing transmission to the infant. ICP is the second most common cause of jaundice in pregnancy. The condition is generally benign, although maternal and fetal mortality occasionally result, probably due to premature delivery and the bleeding tendency of cholestatic patients. Vitamin K administration may correct the coagulopathy, and cholestyramine is effective in controlling pruritus. AFLP is rare but carries a high mortality rate for both the mother and the fetus. Early diagnosis, correction of the coagulopathy, and prompt delivery may improve the outcome significantly. Patients with cirrhosis have reduced fertility, and in those who become pregnant, fetal loss is high. The effect of pregnancy or hepatocellular function is variable, but, when evidence of liver failure is present in the first trimester, termination should be considered. Variceal size and the risk of bleeding may be assessed by endoscopy. Pregnant cirrhotic patients with large esophageal varices and a history of bleeding can undergo shunt surgery. Conservative management may be appropriate for patients with small varices and no history of bleeding.