By the Medical Society
In this month of February, prenatal infections are at the center of our attention. Every year, prenatal viral infection cause high rates of maternal and fetal mortality. Prenatal viral infections are infections of the fetus via an intact placenta.
In this article we will be focusing on major viral infections, limiting our focus to the different symptoms, diagnoses and treatments.
Zika:
In light of the recent Zika outbreak in 2015/2016, I am sure the name sounds familiar. Here, I will tell you exactly what this virus is.
Before 2007, there were only 14 known diagnosed cases of Zika, most notably in South Africa. However, since 2015 it has spread through the Americas, the Caribbeans and the Pacific. Zika is a virus transported by mosquitoes infected by the disease; they can be passed on by either pregnant women to their fetus, sexual relations or blood transfusions. The symptoms of Zika once you have been exposed include, but are not limited to: fever, rash, headache, joint pain, red eyes and muscle pain.
The symptoms don’t strictly show that one has the Zika virus, Zika is only deadly in extreme cases, and once someone is infected, they are protected from other infections. Zika is most dangerous for pregnant women, as they also pass it on to their child. If a fetus is infected, it will be born with a birth defect called microcephaly and other severe brain defects, such as slow cognitive development. Microcephaly causes the head of a child to be abnormally small because the fetus’ brain stops growing. Severe microcephaly is linked to many post-birth symptoms such as seizures, developmental delay, intellectual disability and problems with movement and balance. There is currently no way of treating Microcephaly; it is a lifelong condition that can hinder a person’s quality of life. Microcephaly is only one of many prenatal conditions that can be caused by Zika. It is therefore extremely important for pregnant women to prevent being infected by Zika. As there are no vaccines against Zika, the only way to escape the disease is by avoiding mosquito bites, and use protection (such as condoms) when having participating in sexual intercourse. Zika can be diagnosed with a blood or urine test, and the treatment includes rest and hydration as well as medication for stomach headache and muscle pain.
Cytomegalovirus:
Cytomegalovirus (CMV) is the most common congenital viral infection and is also known as the human herpesvirus 5. As a member of the Herpesviridae family, it also resembles the virus which causes chicken pox. Most people affected by the virus do not experience any symptoms, however once an individual has been affected, the virus will remain dormant in the body forever. The virus can cause more severe symptoms in people who are immunocompromised (such as by HIV infections, organ and bone marrow transplants or those receiving high doses of steroids). Such symptoms include retinitis (blurred vision), painful swallowing, pneumonia, diarrhea or weakness/numbness in legs. CMV is transmitted through the contact of bodily fluids of an infected individual. This is especially dangerous for pregnant women since the virus will be passed onto the baby which leads to congenital CMV infection. The transmission of the virus can occur at any stage of a pregnancy, however the effects on the child will be more severe the earlier it is passed on. About 90% of the CMV congenital infections will result in no symptoms. The other 10% are symptomatic, which can result in the child having an abnormally small head, a low platelet count, swelling of the spleen and liver or not growing to a normal body weight. Devastatingly, 30% of infants suffering from a CMV infection will die, and of the survivors, more than half experience neurological defects in their lifetimes. To diagnose a congenital CMV infection, a DNA, saliva or blood test must be taken no later than 3 weeks after the baby is born. Afterwards, with no current cure or vaccination, treatment includes administering antivirals (medication used to treat viral infections) to babies who are symptomatic at birth.
Herpes simplex virus:
The herpes simplex virus (HSV) commonly known as herpes, is classified into 2 types: simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2). Both these infections are lifelong and usually cause oral or genital herpes. Around 3.7 billion people are infected with herpes worldwide. However, neonatal herpes is rare, 14’000 babies were affected between 2010 and 2015. In neonatal herpes, HSV is transmitted during childbirth 90% of the time, meaning the child is infected in the birth canal. Otherwise, the other 10% are directly infected in the womb. 70% of the time, HSV-2 is responsible for neonatal herpes. Babies infected during childbirth have a 70% chance of having the virus spread from its origin causing three different consequent diseases. The first and most prevalent is localised skin, eye or mouth disease. The second, in 30% of cases, the virus causes a central nervous system disease (such as meningitis or encephalitis) with the certain presence of HSV DNA in the spinal fluid. Thirdly, the virus could become a disseminated disease (which means it spreads around the body infecting multiple organs). Otherwise, infection while in the womb may cause preterm labour, miscarriage or intrauterine growth restriction. Symptoms of infection usually present within four weeks of birth. To diagnose neonatal herpes, most frequently, an HSV culture is used. Treatment for infected neonates include medication (specifically Parenteral acyclovir) and supportive measures such as appropriate IV fluids, alimentation, respiratory support, correction of clotting abnormalities and controlling seizures.
Rubella:
Rubella is a virus which can cause an intrauterine infection (infections within the womb) with some of the more devastating effects on the child. Rubella is an endemic disease, and usually occurs in epidemics every 6-9 years. Infections occurring in non-immune pregnant women can cause Congenital Rubella Syndrome (CRS). CRS is classified by the certain symptoms it causes, such as: intrauterine growth restriction, a smaller sized head, abnormal deposition of calcium salts on the cranium, cataracts, heart defects, bone inflammation and swelling of the liver and spleen. Neonates infected with rubella often present purple sores on the skin at birth. These complications are caused by the mother being infected by rubella within the first 16 weeks of pregnancy. Rubella is transmitted by direct contact of secretions from the throat or nasal of infected individuals. Diagnosis of CRS requires laboratory tests to detect the rubella virus which can be done though a serologic assay (a study of blood or other bodily fluids). However the treatment for CRS is mainly supportive, and aims to keep the baby stable by treating the defects presented after birth. Today, congenital rubella is a rare occurrence (except for in epidemics), and is only reported to occur in around 7-23 cases per year.
Parvovirus B19:
Parvovirus B19 is a pathogenic virus, responsible for generally benign infections. Omnipresent & contagious, the infections are seen in temperate climates every 3-4 years, generally between winter and spring. It is possible that some people are immune to this virus. Infections are more important in kids under 10 years of age, thus women that are not immune are very susceptible to getting the virus from young children. This virus has a physic-chemical resistance, meaning it had an absence of envelop around the virus, making it resistant to pH between 3 and 9 and resistant to heat below 56°C; this causes problems for treatment.
Transmission of this virus is made principally by airway, such as sneezing, coughing & physical contact. The transmission may also occur through the placenta from the mother to the fetus, and occurs in 1/3 of the cases. The transmission may also occur by blood transfusion. An infected individual may not show symptoms during the first 7-10 days of infection.
Symptoms of parvovirus B19 include faintness, headaches, fevers, and muscle cramps. After 2 to 3 weeks of infection, a whole-body rash and joint pains occur, mainly in little kids and pregnant women.
During pregnancy, the infection may cause: spontaneous abortion, fetal anemia or in utero death. To prevent those from happening, the pregnant women will need to verify her serological (testing of blood serum to detect the presence of antibodies against a specific antigen) status and absences of specific antibodies. If the contamination has happened during pregnancy, the baby will need weekly checkups to look for potential malformations.
Since it’s a benign virus, women and children in good health heal without treatment. Specific treatment or vaccines do not exist.
Varicella Zoster virus:
Varicella Zoster virus (VZV) is highly contagious and infectious virus that leads to chickenpox: common childhood illness. While the complications of chickenpox are rare, the potential for significant feto-maternal morbidity and even mortality may happen.
Vaccination against VZV is available but is not currently included in the standard childhood immunization programmes nor is it recommended for non-immune adult women.
Prevention strategies include plans to manage the exposure of people to contagious individuals. When chickenpox infects the mother and hence the child, antiviral therapy either alone or in combination with VZIG’s are recommended. The use of antivirals decreases the risk of mortality and morbidity.
Risks during pregnancy infection include intrauterine growth restriction (IUGR) (cause of perinatal morbidity as well as of impaired growth during childhood), which occurs in approximately 23% of cases, and low birth weight.
Enterovirus:
Enteroviruses usually affects the digestive system and cause intestinal flu and diarrhea. However, EV-D68 is primarily associated with respiratory diseases and, therefore, more closely resembles human rhinovirus. Children under 5 years of age and children with asthma seem to be most at risk of infection, but the virus can also infect adults with asthma and those with weakened immune systems.
The virus can be transmitted from one person to another through saliva. If an infected person touches a surface or coughs or sneezes on a surface, the surface may be contaminated. Others who touch this surface may be infected.
Enterovirus D68 may cause symptoms ranging from mild to severe, depending on the risk factors of the infected person, such as having a weakened immune system. The mild symptoms can range from difficulty breathing; a runny nose; general soreness and muscle aches; sneezing; fever and/or coughing.
These respiratory symptoms can lead to other complications such as pneumonia and even respiratory failure (when one stops breathing on their own). EV-D68 may also cause symptoms shared by other enteroviruses, such as: diarrhea; abdominal pain and/or rashes. Paralysis of one limb or more is a rare complication that has been reported in 2 children in California.
Because many of the symptoms of EV-D68 infection resemble those of other respiratory conditions, EV-D68 should be sought after these other conditions have been eliminated or if symptoms worsen.
No specific treatment exist to this day. If a pregnant woman is infected with a non-polio enterovirus shortly before delivery, there is a chance she can pass the virus to her baby. These babies usually have only mild illness, but in rare cases they may show severe symptoms.
Measles:
Measles is a virus that is characterized by an infection of the respiratory system, the immune system, and the skin. This virus can be deadly, especially in young children and the elderly, but luckily a vaccine has been developed to prevent this. The initial symptoms of measles are fevers, spots, malaise, runny nose, red eyes, and loss of appetite. This is extremely contagious, and can be transmitted through breathing the same air as someone with the virus. Once someone has had measles, there is only a very small risk that they will do so again as the body builds up immunity against it.
Measles pose a large risk on a patient’s health, but pose greater risk if the patient is pregnant. Many serious complications will be caused by this such as pneumonitis, hepatitis, premature labor, fetal loss, and maternal death. If a treatment is successfully carried out, the baby should not be born with any birth defects.
The diagnosis will usually be done when the patient is already feeling very ill, as this is what would’ve caused them to see a doctor. The diagnosis is made up of a visual analysis of the rash, which is very characteristic. If this is not enough to diagnose the patient, a blood test may be done to confirm whether this is the case.
Measles can be treated by a post-exposure vaccination if the patient is diagnosed within 72 hours after infection. If the diagnosis is done after this time frame, there are medications that can be given to the patient to treat the symptoms. Fever reducers, antibiotics, and vitamin A can all be taken, and will reduce the severity of the symptoms. It is also advised to drink lots of fluids, have proper rest, and use a humidifier to relieve the pain experienced with a sore throat.
Lymphocytic choriomeningitis virus:
Lymphocytic choriomeningitis is a rodent-borne disease, and is typically found in the common house mouse. It is transmitted through exposure to the rodent’s urine, saliva, droppings, or nesting materials. The main symptom of this is neurological disease, but there are two separate phases of symptoms present. The first set begins about 10 days after exposure, and consists of fever, malaise, lack of appetite, muscle ache, headache, nausea, and vomiting. Once these symptoms are no longer present, a second set of symptoms is experienced. This may consist of an inflammation of the brain (meningitis, encephalitis, meningoencephalitis) and increased fluid on the brain (acute hydrocephalus).
While this disease can be very threatening towards adults, it is even more so during pregnancy. The infant may experience the previously mentioned symptoms as well as visual impairment, and intrauterine death (death of the baby inside the uterus).
Lymphocytic choriomeningitis is diagnosed through a white blood cell count and a platelet count, as well as other laboratory diagnosis methods.
A patient who presents with this disease will have to be hospitalized, and will be given anti-inflammatory drugs based on the severity of their condition.
In conclusion, there are a number of viral infections that can have a very large impact on both the mother’s and the baby’s health. This article should raise awareness of the fact that these cases can happen, and it is advised to have frequent check-ups during pregnancy to prevent this.
If ever you notice these symptoms in a pregnant woman, please advise them to visit the doctor immediately to prevent any consequences and to enable fast treatment.
