Perinatal infections- Diagnosis & Management - Dr Padmesh - Neonatology
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This document discusses TORCHES infections which are an important cause of stillbirths and morbidity in newborns. It provides details on the diagnosis and treatment of various infections including Toxoplasmosis, Rubella, CMV, HSV, Syphilis, and Varicella. For each infection, it outlines recommended diagnostic tests, treatment guidelines based on symptoms and severity of infection, and prevention methods. The conclusion emphasizes the importance of universal vaccination, prompt recognition and management of infections, and public health measures like antenatal screening to help prevent morbidity and mortality in newborns from TORCHES infections.
Perinatal infections- Diagnosis & Management - Dr Padmesh - Neonatology
- 1. Dr. Padmesh
- 2. • INTRODUCTION: • Important cause of still births and morbidity • Many diseases go undiagnosed • Appropriate treatment can prevent morbidity/mortality • 1971: Andres Nahmias proposed acronym ToRCH • 1975: Harold Fuerst added Syphilis to the acronym.
- 3. • ACRONYM: TORCHES CLAP -TOxoplasmosis -Chickenpox -Rubella -Lyme disease -CMV -AIDS -Herpes simplex -Parvovirus B19 -Enterovirus -Syphilis • Latest addition: Zika virus
- 5. • Toxoplasma: • Diagnosis : • IgG, IgM, IgA (Serum/CSF) • PCR • Ophthalmologic, auditory, and neurologic examinations • CT Brain Redbook American Academy of Pediatrics. 2012. p. 720–8.
- 6. • Toxoplasma: Investigations Normal Negative Abnormal TREAT FOR 12 MONTHS Positive Repeat IgG after 6 months
- 7. • Toxoplasma: • Treatment : • Pyrimethamine, sulphadiazine and folinic acid for a duration of 1 year.
- 8. • Toxoplasma: • Prevention- counselling : – Avoid raw/undercooked meat – wash hands after gardening – wash raw vegetables – minimise contact with young kittens and their litter etc
- 10. • Rubella: • In Maternal infection: - No treatment available 1st Trimester: Consider termination. 2nd Trimester: Consider fetal testing. After 20 wks gestation: Rarely causes CRS
- 11. • Rubella: • Diagnosis : • Isolation of virus by PCR or culture • Rubella-specific IgM (False positivity +/-) • Increasing IgG over first 7 to 11 months of life. • Avidity testing of IgG • Rubella virus RNA by reverse transcriptase PCR in nasopharyngeal swabs, urine, CSF, and blood at birth
- 12. • Rubella: • Diagnosis : Avidity: • Strength with which IgG binds to antigenic epitropes expressed by a specific protein. • Gradually matures over months. • IgG produced in first few months following primary infection Low avidity (Bind weakly to Ag) • Therefore, LOW IgG avidity is a marker of RECENT PRIMARY infection. • High avidity excludes primary infection in preceding 3 months.
- 13. • Rubella: • Diagnosis : Avidity:
- 14. • Rubella: • Diagnosis : AT BIRTH: • Ophthalmology screening, • Cardiac screening • Hearing assessments FOLLOW UP UPTO 12 MONTHS
- 15. • Rubella: • Treatment : • No specific treatment • Breast feeding not contraindicated • Prevention: • Vaccination
- 17. • CMV: • Diagnosis : • Virus culture from urine/saliva • CMV-DNA PCR in urine, blood, saliva and CSF • CMV IgM antibodies in blood before 3 weeks of age. • IgG Avidity testing Rev Med Virol 2010;20(4): 202–13.
- 18. • CMV: Treatment : Virologically proven CMV in Newborn Underlying Immune disorder Treat as Life threatening infection Immunocompetent Life threatening symptoms Non-Life threatening symptoms No Symptoms No treatment
- 19. Life Threatening infection IV Ganciclovir for 4-6 weeks Oral Valganciclovir for 6 months Non-Life threatening infection • CMV: Treatment : Continue for 12 months/ Change in regimen Viremia at 6 mths
- 20. • CMV: • Treatment : • Foscarnet, Cidofovir for refractory CMV/ Ganciclovir resistance
- 22. • HSV: • Diagnosis : • Surface cultures: HSV culture on swab specimens from mouth, nasopharynx, conjunctivae, and anus 12-24 hours after birth • HSV culture & PCR from any skin vesicle present • HSV PCR on CSF and whole blood
- 23. • HSV: START EMPIRICAL IV ACYCLOVIR Diagnostic evaluation of Newborn Positive SEM disease CNS/ Disseminated Negative IV Acyclovir for 14 days IV Acyclovir for 21 days IV Acyclovir for 10 days
- 24. • HSV: • Treatment: • After completion of parenteral therapy suppressive course of oral acyclovir for 6 months
- 25. • HSV: • 85% neonatal HSV are acquired perinatally. • True intrauterine infection 5% • Careful speculum examination for active genital HSV • Caesarean section reduces risk of HSV transmission
- 27. • Syphilis: • Diagnosis : • Adequacy of maternal treatment • Examination of placenta/umbilical cord for pathology • Dark field microscopy of suspicious lesions/body fluid • Clinical findings suggestive of syphilis: Non immune hydrops/ jaundice/ hepatosplenomegaly/ rhinitis/ skin rash • Quantitative VDRL / RPR (FTA-ABS or TPHA not required) BMC Public Health 2011;11(Suppl 3):S9.
- 28. • Syphilis: Treatment : PHYSICAL EXAM SUGGESTIVE OF CONGENITAL SYPHILIS BABY’S VDRL/RPR 4 TIMES HIGHER TITRE THAN MOTHER MOTHER NOT TREATED OR INADEQUATELY TREATED INJ. PENICILLIN G OR PROCAINE PENICIILIN FOR 10 DAYS ADDL TESTS: CSF VDRL, LONG BONE XRAY, OPHTHAL EVALUATION, BERA
- 29. • Syphilis: Treatment : PHYSICAL EXAM NORMAL BABY’S VDRL/RPR LESS THAN 4 TIMES MOTHER’S TITRE MOTHER NOT TREATED OR INADEQUATELY TREATED INJ. PENICILLIN G OR PROCAINE PENICIILIN FOR 10 DAYS ADDL TESTS: CSF VDRL, LONG BONE XRAY, OPHTHAL EVALUATION, BERA
- 30. • Syphilis: Treatment : PHYSICAL EXAM NORMAL BABY’S VDRL/RPR LESS THAN 4 TIMES MOTHER’S TITRE MOTHER NOT TREATED OR INADEQUATELY TREATED INJ. BENZATHINE PENICILLIN 50000 U/Kg/dose IM SINGLE DOSE ADDL TESTS: CSF VDRL, LONG BONE XRAY, OPHTHAL EVALUATION, BERA
- 31. • Syphilis: Treatment : PHYSICAL EXAM NORMAL BABY’S VDRL/RPR LESS THAN 4 TIMES MOTHER’S TITRE MOTHER ADEQUATELY TREATED DURING PREGNANCY NO TREATMENT REQUIRED IF FOLLOW-UP IS CERTAIN ELSE, INJ. BENZATHINE PENICILLIN 50000 U/Kg/dose IM SINGLE DOSE NO FURTHER EVALUATION
- 33. • Varicella: -7 -5-6 -2-4 -3 +1-1 +3+2 +4
- 34. • Varicella: -7 -5-6 -2-4 -3 +1-1 +3+2 +4 Newborn will have protective antibodies Likelihood of severe disease is low - Do not separate baby from mother - Continue breast feeding - No VZIG -Acyclovir if baby develops rash
- 35. • Varicella: -7 -5-6 -2-4 -3 +1-1 +3+2 +4 Newborn will not have protective antibodies Likelihood of severe disease is high -Separate baby from mother -If baby devps rash stay with mother -VZIG within 72 hours -Acyclovir
- 36. • Varicella: -7 -5-6 -2-4 -3 +1-1 +3+2 +4 Newborn will not have protective antibodies But, likelihood of severe disease is low -Separate baby from mother -If baby devps rash stay with mother -No VZIG -Acyclovir if baby develops rash
- 38. • TB: MOTHER WITH TB ON TREATMENT/ NO TREATMENT TREATMENT COMPLETED LOOK FOR CLINICAL EVIDENCE OF CONGENITAL TB ABSENT PRESENT ABSENT CXR, 3 GASTRIC ASPIRATES CXR, LP 3 GASTRIC ASPIRATES Treat : HRZE INH PROPHYLAXIS MANTOUX AT 3 MONTHS FOLLOW UP AND EVALUATE FOR CLINICAL EVIDENCE TILL 6 MONTHS
- 39. • TB: • Reassure the mother to breast feed the baby • Separation of mother & baby required only if mother – is sick – non adherent to treatment – has MDR TB
- 40. • CONCLUSION: • Universal vaccination. • Prompt recognition and management. • Public health measures: antenatal screening for syphilis, HIV and hepatitis B . • Good hygiene
Editor's Notes
- #6: The classic triad of congenital toxoplasmosis are chorioretinitis, intracranial calcifications and hydrocephalus.
- #7: If positive after 6 months, it is still treated as asymptomatic congenital infection
- #12: Rubella-specific IgM, which is usually positive at birth to 3 months for congenital infection. Rubella-specific IgM (false positives can occur)
- #15: Rubella-specific IgM, which is usually positive at birth to 3 months for congenital infection. Rubella-specific IgM (false positives can occur)
- #19: life threatening: viral sepsis, pneumonia, myocarditis, severe hepatitis, severe refractory thrombocytopenia
- #28: Rapid Plasma Reagin. Fluorescent treponemal antibody absorption. treponema pallidum hemagglutination assay.