INFECTIOUS DISEASES - DR.

OMNICTIN 2020 Viruses: HSV

- MATERNAL AND FETAL IMMUNOLOGY Intrapartum

- VIRAL INFECTIONS
- BACTERIAL INFECTIONS 1. Maternal exposure
- PROTOZOAL INFECTIONS Bacteria: gonorrhea, chlamydia, group B
- EMERGING INFECTIONS streptococcus, tuberculosis, mycoplasmas
-TRAVEL PRECAUTIONS DURING PREGNANCY Viruses: HSV, HPV, HIV, hepatitis B, hepatitis
- BIOTERRORISM C
- Infections
2. External contamination
MATERNAL AND FETAL IMMUNOLOGY Bacteria: staphylococcus, coliforms
Viruses: HSV, varicella zoster
 Pregnancy-Induced Immunological
Changes Neonatal
 Fetal and Newborn Immunology
Human transmission: staphylococcus, HSV
Pregnancy-Induced Immunological Changes Respirators and catheters: staphylococcus,
coliforms
It is known that pregnancy is associated with
an increase in CD4-positive T cells secreting Neonatal infection, especially in its early
Th2-type cytokines—for example interleukins stages, may be difficult to diagnose because
4, 5, 10, and 13. neonates often fail to express classic clinical
signs.
Th1-type cytokine production—for example,
interferon gamma and interleukin 2— If the fetus was infected in utero, there may
appears to be somewhat suppressed, leading be depression and acidosis at birth for no
to a Th2 bias in pregnancy. apparent reason.

This bias affects the ability to rapidly Fetal and Newborn Immunology
eliminate certain intracellular pathogens
during pregnancy.  active immunological capacity of the
fetus and neonate
--- the Th2 humoral immune response  fetal cell-mediated and humoral
remains intact. immunity begin to develop by 9 to 15
weeks’ gestation.
TABLE 64-1. Specific Causes of Some Fetal  The primary fetal response to infection is
and Neonatal Infections immunoglobulin M (IgM).
 Passive immunity is provided by IgG
Intrauterine transferred across the placenta
1.Transplacental  neonate may suck poorly, vomit, or
Viruses: varicella-zoster, coxsackie, human show abdominal distention
parvovirus B19, rubella, cytomegalovirus, HIV  Respiratory insufficiency may develop
Bacteria: Listeria, syphilis, Borrelia (similarly to idiopathic respiratory
Protozoa: toxoplasmosis, malaria distress syndrome)
 may be lethargic or jittery
2. Ascending infection  The response to sepsis may be
Bacteria: group B streptococcus, coliforms hypothermia rather than hyperthermia,
 and the total leukocyte and neutrophil
counts may be depressed. PROTOZOAL INFECTIONS

By 16 weeks, this transfer begins to increase PROTOZOAL INFECTIONS

rapidly, and by 26 weeks, fetal Toxoplasmosis
concentrations are equivalent to those of the Malaria
mother. Amebiasis
MYCOTIC INFECTIONS
After birth, breast feeding is protective
against some infections, although this BACTERIAL INFECTIONS
protection begins to decline at 2 months of
age. I. Group A Streptococcus

Current World Health Organization (2013) -It is the most frequent bacterial cause of
recommendations are to exclusively breast acute pharyngitis and is associated with
feed for the first 6 months of life with partial several systemic and cutaneous infections.
breast feeding until 2 years of age. -S pyogenes produces numerous toxins and
enzymes responsible for the local and
Vertical transmission refers to passage from systemic toxicity associated with this
the mother to her fetus of an infectious organism.
agent through the placenta, during labor or
delivery, or by breast feeding. >streptococcal pharyngitis
>scarlet fever
Preterm rupture of membranes, prolonged >erysipelas
labor, and obstetrical manipulations may
increase the risk of neonatal infection. In the United States, Streptococcus pyogenes
infrequently causes puerperal infection.
Those occurring less than 72 hours after
delivery are usually caused by bacteria -most common cause of severe maternal
acquired in utero or during postpartum infection and death worldwide
delivery, whereas infections after that time
most likely were acquired afterward. -The early 1990s saw the rise of streptococcal
toxic shock syndrome, manifested by
VIRAL INFECTIONS hypotension, fever, and evidence of
multiorgan failure with associated
-Varicella-Zoster Virus bacteremia.
-Influenza
-Mumps Treatment;
-Rubeola (Measles) 1. clindamycin or penicillin therapy
-Rubella—German Measles 2. surgical debridement
-Respiratory Viruses
Vulvar Abscess II. Group B Streptococcus
Listeriosis
Salmonellosis -Streptococcus agalactiae is a group B
Shigellosis organism that can be found to colonize the
Hansen Disease gastrointestinal and genitourinary tract in 20
Lyme Disease to 30 percent of pregnant women.
Tuberculosis
-Throughout pregnancy, is isolated in a intrapartum chemoprophylaxis, rates of
transient, intermittent, or chronic fashion. early-onset sepsis ranged from 2 to 3 per
-is most likely always present in these same 1000 live births.
women
In 2002, the Centers for Disease Control and
III. Maternal and Perinatal Infection Prevention, the American College of
Obstetricians and Gynecologists, and the
-asymptomatic colonization to septicemia. American Academy of Pediatrics revised
- Streptococcus agalactiae has been guidelines for perinatal prevention of GBS
implicated in adverse pregnancy outcomes, disease.
including preterm labor, prematurely
ruptured membranes, clinical and subclinical They recommended universal rectovaginal
chorioamnionitis, and fetal infections. culture screening for GBS at 35 to 37 weeks’
- cause maternal bacteriuria, pyelonephritis, gestation followed by intrapartum antibiotic
osteomyelitis, postpartum mastitis, and prophylaxis for women identified to be
puerperal infections. carriers.

It remains the leading infectious cause of They expanded laboratory identification

morbidity and mortality among infants in the criteria for GBS; updated algorithms for
United States screening and intrapartum chemoprophylaxis
for women with preterm prematurely
Neonatal sepsis has received the most ruptured membranes, preterm labor, or
attention due to its devastating penicillin allergy; and described new dosing
consequences and available effective for penicillin G chemoprophylaxis.
preventative measures.
Culture-Based Prevention.
Infection < 7 days after birth is defined as
early-onset disease and is seen in 0.24/1000 The 2010 Centers for Disease Control and
live births Prevention GBS Guidelines recommend a
culture-based.
Many investigators use a threshold of < 72
hours of life as most compatible with Such a protocol was also adopted by the
intrapartum acquisition of disease . American College of Obstetricians and
Gynecologists (2013c). This approach is
septicemia involves signs of serious illness designed to identify women who should be
that usually develop within 6 to 12 hours of given intrapartum antimicrobial prophylaxis.
birth
>include respiratory distress, apnea, and Women are screened for GBS colonization at
hypotension 35 to 37 weeks’ gestation, and intrapartum
antimicrobials are given to women with
Late-onset disease caused by GBS is noted in rectovaginal GBS-positive culture
0.32 per 1000 live births and usually
manifests as meningitis 1 week to 3 months more rapid techniques such as DNA probes
after birth. and nucleic acid amplification tests are being
IV. Prophylaxis for Perinatal Infections developed (Chan, 2006; Helali, 2012).

As GBS neonatal infections evolved beginning A previous sibling with GBS invasive disease
in the 1970s and before widespread and identification of GBS bacteriuria in the
current pregnancy are also considered
indications for prophylaxis. Women with GBS during the current
pregnancy and women with a prior infant
with invasive early-onset GBS disease are
also given chemoprophylaxis.

At Parkland Hospital in 1995—and prior to

consensus guidelines—we adopted the risk-
based approach for intrapartum treatment of
women at high risk.

In addition, all term neonates who were not

given intrapartum prophylaxis were treated
in the delivery room with aqueous penicillin
G, 50,000 to 60,000 units intramuscularly.

Intrapartum Antimicrobial Prophylaxis

Prophylaxis administered 4 or more hours

before delivery is highly effective (Fairlie,
2013).
Regardless of screening method, penicillin
remains the first-line agent for prophylaxis,
and ampicillin is an acceptable alternative

Women with a penicillin allergy and no

history of anaphylaxis should be given
cefazolin.

Clindamycin-sensitive but erythromycin-

resistant isolates should have a D-zone test
performed to assess for inducible
FIGURE 64-5 Indications for intrapartum clindamycin resistance.
prophylaxis to prevent perinatal group B
streptococcal (GBS) disease under a universal If clindamycin resistance is confirmed,
prenatal screening strategy based on vancomycin should be administered.
combined vaginal and rectal cultures
obtained at 35 to 37 weeks’ gestation. (From Erythromycin is no longer used for penicillin-
Centers for Disease Control and allergic patients.
Prevention,2010.)

Risk-Based Prevention. REGIMEN TREATMENT

RECOMMENDED PEN G 5 MILLION
Intrapartum chemoprophylaxis is given to UNITS IV INITIAL
women who have any of the following: DOSE, THEN 2.5 - 3
delivery < 37 weeks, ruptured membranes ≥ MILLION UNITS IV
18 hours, or intrapartum temperature ≥ EVERY 4 HRS UNTIL
100.4°F (≥ 38.0°C).
 DELIVERY
ALTERNATIVE AMPICILLIN 2g IV
initial dose, the 1g
IV q 4 hrs or 2g q 6
hrs until delivery
PENICILLIN
ALLERGIC
1. Patients not at Cefazolin, 2g IV initil
high risk for dose, then 1g IV
anaphylaxis every 8 hrs until
delivery
2. Patients at high Clindamycin, 900 mg
risk for anaphylaxis IV every 8 hrs unril
and with GBS delivery
susceptible to
clindamycin
3. Patients at risk for Vancomycin, 1g IV
anaphylaxis and every 12 hrs until
with GBS resistant delivery
to clindamycin or
susceptibility
unknown
Methicillin-Resistant Staphylococcus Aureus

Further recommendations for management - Staphylococcus aureus is a pyogenic gram-

of spontaneous preterm labor, threatened positive organism and is considered the most
preterm delivery, or preterm prematurely virulent of the staphylococcal species.
ruptured membranes are shown in Figure 64- -It primarily colonizes the nares, skin, genital
6. Women undergoing cesarean delivery tissues, and oropharynx.
before labor onset with intact membranes do -Approximately 20 percent of normal
not need intrapartum GBS individuals are persistent carriers, 30 to 60
chemoprophylaxis, regardless of GBS percent are intermittent carriers, and 20 to
colonization status or gestational age. 50 percent are noncarriers (Gorwitz, 2008).
Colonization is considered the greatest risk
factor for infection (Sheffield, 2013).
FIGURE 64-6 Sample algorithm for
prophylaxis for women with group B Methicillin-resistant S aureus (MRSA)
streptococcal (GBS) colonizes only 2 percent of people but is a
disease and threatened preterm delivery. significant contributor to the health-care
This algorithm is not an exclusive course of burden (Gorwitz, 2008).
management, and variations that incorporate
individual circumstances or institutional MRSA infections are associated with
preferences may be appropriate. IV = increased cost and higher mortality rates
intravenous. (Adapted from Centers for compared with those by methicillin-sensitive
Disease Control and Prevention, 2010.) S aureus (MSSA).

Community-associated MRSA (CA-MRSA) is

diagnosed when identified in an outpatient cases in which a patient develops recurrent
setting or within 48 hours of hospitalization superficial infections despite optimal hygiene
in a personwithout traditional risk factors. measures .

MRSA and Pregnancy Decolonization measures include nasal

treatment with mupirocin, chlorhexidine
Anovaginal colonization with S aureus is gluconate baths, and
identified in 10 to 25 percent of obstetrical oral rifampin therapy.
patients.
Vulvar Abscess
Skin and soft tissue infections are the most
common presentation of MRSA in pregnant Labia majora infections, which begin as
women. cellulitis, have the potential for significant
expansion and abscess formation.
Mastitis has been reported in up to a fourth
of cases of MRSA complicating pregnancy. Risk factors include diabetes, obesity,
perineal shaving, and immunosuppression.
Management
early cellulitis: sitz baths and oral antibiotics
The Infectious Diseases Society of America small abscess –incision and drainage, wound
has published guidelines for the treatment of cultures obtained, abscess cavity packed, oral
MRSA infections (Liu, 2011). antibiotics

Uncomplicated superficial infections are For severe infections, especially in

managed by drainage and local wound care. immunosuppressed or pregnant patients,
hospitalization and intravenous antimicrobial
The benefits of antibiotic treatment in this therapy are often warranted due to
setting are unproven, and most studies have increased risks for necrotizing fasciitis.
not shown improved outcomes with the
addition of MRSA-appropriate antibiotics. Large abscesses are best drained in the
operating room with adequate analgesia or
Most CA-MRSA strains are sensitive to anesthesia.
trimethoprim-sulfamethoxazole.
Cysts of the Bartholin gland duct usually
Clindamycin treatment unilateral, sterile, need no treatment during
Rifampin --should not be used for pregnancy.
monotherapy. Linezolid– expensive
If a cyst is sufficiently large to obstruct
Doxycycline, minocycline, and tetracycline, delivery, then needle aspiration is an
although effective for MRSA infections, appropriate temporary measure.
should not be used in pregnancy. With gland duct infection, a localized
Vancomycin remains the first-line therapy for unilateral vulvar bulge, tenderness, and
inpatient MRSA infections. erythema are present.

-- appropriate hand hygiene and prevention Treatment : broad-spectrum antimicrobials

of skin-to-skin contact or contact with wound drainage
dressings.
Decolonization should be considered only in Listeriosis
 infection, even preterm gestations.
Caused by Listeria monocytogenes
is an uncommon but probably Chorioamnionitis is common with maternal
underdiagnosed cause of neonatal sepsis. infection, and placental lesions include
Route of infection: multiple, well-demarcated macroabscesses
1. stool
facultative intracellular gram-positive bacillus Treatment:
can be isolated from the feces of 1 to 5
percent of adults 1. ampicillin plus gentamicin
2. food-borne 2. Trimethoprim-sulfamethoxazole --
penicillin-allergic women
Outbreaks have been caused by raw
vegetables, coleslaw, apple cider, melons, No vaccine is available, and prevention is by
milk, fresh Mexican-style cheese, smoked washing raw vegetables and cooking all raw
fish, and processed foods, such as pâté, food .
hummus, wieners, and sliced deli meats. Salmonellosis

Listerial infections are more common in the Infections from Salmonella species continue
to be a major and increasing cause of food-
-very old or young borne illness
-pregnant women (Pequ
-immunocompromised es, 2012).

It is unclear why pregnant women still Six serotypes account for most cases in the
account for a significant number of these United States, including Salmonella subtypes
reported cases. typhimurium and enteritidis.
HYPOTHESIS:
1. One hypothesis is that pregnant women Non-typhoid Salmonella gastroenteritis is
are susceptible because of decreased cell- contracted through contaminated food.
mediated immunity. Symptoms including nonbloody diarrhea,
abdominal pain, fever, chills, nausea, and
2. That placental trophoblasts are vomiting begin 6 to 48 hours after exposure
susceptible to invasion by Listeria
monocytogenes Diagnosis is made by stool studies.
Intravenous crystalloid is given for
Maternal and Fetal Infection rehydration.
Antimicrobials are not given in
may be asymptomatic uncomplicated infections because they do
may cause a febrile illness that is confused not commonly shorten illness and may
with influenza, pyelonephritis, or meningitis prolong the convalescent carrier state.
If gastroenteritis is complicated by
Diagnosis--- blood culture positive bacteremia, antimicrobials are given .
Rare case reports have linked Salmonella
Occult or clinical infection also may stimulate bacteremia with abortion.
labor (Boucher, 1986).
Infection is spread by oral ingestion of
Discolored, brownish, or meconium-stained contaminated food, water, or milk. In
amnionic fluid is common with fetal pregnant women, the disease is more likely
to be encountered during epidemics or in and clofazimine is recommended for
those with HIV infection. treatment and is generally safe during
pregnancy
In former years, antepartum typhoid fever -Duncan (1980) reported an excessive
resulted in abortion, preterm labor, and incidence of low-birthweight newborns
maternal or fetal death among infected women.
-Vertical transmission is common in
Fluoroquinolones and third-generation untreated mothers
cephalosporins are the preferred treatment.
LYME DISEASE
Typhoid vaccines appear to exert no harmful
effects when administered to pregnant Caused by the spirochete Borrelia burgdorferi
women and should be given in an epidemic Lyme disease is the most commonly reported
or before travel to endemic areas. vectorborne illness in the United States

SHIGELLOSIS Lyme borreliosis follows tick bites of the

genus Ixodes. Early infection causes a
-Bacillary dysentery distinctive local skin lesion, erythema
-caused by Shigella migrans, which may be accompanied by a flu-
-common like syndrome and regional adenopathy.
-highly contagious cause of inflammatory
exudative diarrhea in adults. If untreated, disseminated infection follows
in days to weeks.
-is more common in children attending day- Multisystem involvement is frequent, but
care centers and is transmitted via the fecal- skin lesions, arthralgia and myalgia, carditis,
oral route and meningitis predominate.

Clinical manifestations range from mild Native immunity is acquired, and the disease
diarrhea to severe dysentery, bloody stools, enters a chronic phase.
abdominal cramping, tenesmus, fever, and IgM and IgG serological testing is
systemic toxicity. recommended in early infection and is
followed by Western blotting for
-self-limited confirmation.
-treatment of dehydration
-severe cases: secretory diarrhea exceeded
10L/day! Treatment and Prevention
Antimicrobial therapy:
fluoroquinolones, ceftriaxone, or For early infection, treatment with
azithromycin doxycycline, amoxicillin, or cefuroxime is
recommended for 14 days, although
HANSEN DISEASE doxycycline is usually avoided in pregnancy.

-known as leprosy A 14- to 28-day course of IV ceftriaxone,

-chronic infection is caused by cefotaxime, or penicillin G is given for
Mycobacterium leprae complicated early infections that include
-rare in the United States meningitis, carditis, or disseminated
-Diagnosis is confirmed by PCR. infections.
-Multidrug therapy with dapsone, rifampin,
No vaccine is commercially available. fourfold increased preterm delivery rate
Avoiding areas with endemic Lyme disease before 37 weeks (Freeman, 2005).
and improving tick control in those areas is
the most effective prevention. Toxoplasmosis serotype NE-II is most
Self-examination with removal of commonly associated with preterm birth and
unengorged ticks within 36 hours of severe neonatal infection (McLeod, 20120)
attachment reduces infection risk (Hayes,
2003). The incidence and severity of fetal
For tick bites recognized within 72 hours, a toxoplasmosis infection depend on
single 200-mg oral dose of doxycycline may gestational age at the time of maternal
reduce infection development. infection.

Transplacental transmission has been the severity of fetal infection is much greater
confirmed, but no congenital effects of in early pregnancy, and these fetuses are
maternal borreliosis have been conclusively much more likely to have clinical findings of
identified. infection

PROTOZOAL INFECTIONS Clinically affected neonates usually have:

a.Generalized disease-----
1. Toxoplasmosis low birthweight
hepatosplenomegaly
obligate intracellular parasite Toxoplasma jaundice
gondii has a life cycle with two distinct stages anemia
b. Neurological disease—
The feline stage takes place in the cat—the intracranial calcifications
definitive host—and its prey. hydrocephaly or microcephaly
Unsporulated oocysts are secreted in feces. c. Develop chorioretinitis and exhibit
learning disabilities
In the nonfeline stage, tissue cysts containing
bradyzoites or oocysts are ingested by the classic triad:
intermediate host, including humans.
1. Chorioretinitis
Humoral and cell-mediated immune defenses 2. Intracranial calcifications
eliminate most of these, but tissue cysts 3. Hydrocephalus- is often accompanied by
develop convulsions

Human infection is acquired by eating raw or Screening and Diagnosis

undercooked meat infected with tissue cysts
or by contact with oocysts from cat feces in The American Academy of Pediatrics and the
contaminated litter, soil, or water. American College of Obstetricians and
Gynecologists (2012) do not recommend
Maternal and Fetal Infection prenatal screening for toxoplasmosis in areas
of low prevalence, including the United
Maternal symptoms may include fatigue, States.
fever, headache, muscle pain, and sometimes
a maculopapular rash and posterior cervical With IgG antibody confirmed before
lymphadenopathy. pregnancy, there is no risk for a congenitally
Maternal infection is associated with a infected fetus (Montoya, 2004).
 vegetables
Screening should be performed in - cleaning all food preparation surfaces and
immunocompromised pregnant women, utensils that have contacted raw meat,
regardless of country of residence. poultry, seafood, or unwashed fruits and
vegetables
Anti-toxoplasma IgG develops within 2 to 3 -wearing gloves when changing cat litter, or
weeks after infection, peaks at 1 to 2 months, else delegating this duty
and usually persists for life—sometimes in -avoiding feeding cats raw or undercooked
high titers. meat and keeping cats indoors

IgM antibodies appear by 10 days after Maternal and Fetal Infection

infection and usually become negative within
3 to 4 months, they may remain detectable Clinical findings are fever, chills, and flu-like
for years. symptoms including headaches, myalgia, and
malaise, which may occur at intervals.
IgA and IgE antibodies are also useful in Symptoms are less severe with recurrences.
diagnosing acute infection.
Malaria may be associated with anemia and
Prenatal diagnosis of toxoplasmosis is jaundice, and falciparum infections may
performed using DNA amplification cause kidney failure, coma, and death. That
techniques and sonographic evaluation. said, many otherwise healthy but infected
adults in endemic areas are asymptomatic.
Sonographic evidence of intracranial Pregnant women, although often
calcifications, hydrocephaly, liver asymptomatic, are said to be more likely to
calcifications, ascites, placental thickening, develop traditional symptoms.
hyperechoic bowel, and growth restriction
has been used prenatally to help confirm MALARIA
diagnosis.
Malaria remains a global health crisis.
Management
In 2010, there were an estimated 219 million
Treatment has been associated with a cases and
reduction in rates of serious neurological 655,000 deaths, mainly in sub-Saharan Africa
sequelae and neonatal demise (Chico, 2012; World Health Organization,
2011).
Prenatal treatment is based on two regimens
—spiramycin alone or a pyrimethamine– Malaria has been effectively eradicated in
sulfonamide combination with folinic acid. Europe and in most of North America, and
worldwide mortality rates have fallen more
Pyrimethamine–sulfadiazine with folinic acid than 25 percent.
is selected for maternal infection after 18
weeks or if fetal infection is suspected. In the United States, most cases of malaria
are
Prevention: no vaccine for toxoplasmosis imported—some in returning military
personnel (Centers for Disease Control and
Efforts include: Prevention, 2013j).
- cooking meat to safe temperatures
- peeling or thoroughly washing fruits and Transmitted by infected Anopheles
mosquitoes, five species of Plasmodium uncomplicated falciparum malaria.
cause human disease —falciparum, vivax,
ovale, malariae, and knowlesi (White, 2012). The Centers for Disease Control and
Prevention (2013g) recommends using
Malarial infections during pregnancy— atovaquone-proguanil or artemether-
whether symptomatic or asymptomatic—are lumefantrine only if other treatment options
associated with increased rates of perinatal are not available or tolerated.
morbidity and mortality.
The Centers for Disease Control and
Adverse outcomes include stillbirth, preterm Prevention (2013g) recommends that
birth, low birthweight, and maternal anemia. pregnant women diagnosed with
uncomplicated malaria caused by P vivax, P
Maternal infection is associated with 14 malariae, P ovale, and chloroquinesensitive P
percent of low-birthweight newborns falciparum should be treated with
worldwide (Eisele, 2012). chloroquine or hydroxychloroquine.

Infections with P falciparum are the worst, For women infected with chloroquine-
and early resistant P falciparum, mefloquine or quinine
infection increases the risk for abortion sulfate with clindamycin should be used.
(Desai, 2007).
Chloroquine-resistant P vivax should be
The incidence of malaria increases treated with mefloquine.
significantly in the latter two trimesters and Chloroquinesensitive P vivax or P ovale
postpartum (Diagne, 2000). should be treated with chloroquine
throughout pregnancy and then primaquine
Overall, congenital malaria occurs in < 5 postpartum.
percent of neonates born to infected
mothers. The World Health Organization (2011) allows
for the use of intermittent preventative
therapy
Diagnosis during pregnancy. This consists of at least
two treatment doses of sulfadoxine-
1. Identification of parasites by microscopical pyrimethamine in the second and third
evaluation of a thick and thin blood smear trimesters. The rationale is that each dose
remains the gold standard for diagnosis. will clear placental asymptomatic infections
2. Malaria-specific antigens are now being and provide up to 6 weeks of posttreatment
used for rapid diagnostic testing. prophylaxis. This ideally will decrease the
rate of low-birthweight newborns in endemic
areas.

Prevention and Chemoprophylaxis

Management Malaria control and prevention relies on

chemoprophylaxis when traveling to or living
The World Health Organization recommends in endemic areas.
all infected patients living in or traveling from Vector control is also important.
endemic areas be treated Insecticide-treated netting, pyrethroid
with an artemisinin-based regimen for insecticides, and N,Ndiethyl- m-toluamide
(DEET)-based insect repellent decrease
malarial rates in endemic area. These are collectively defined as infectious
If travel is necessary, chemoprophylaxis is diseases that have newly appeared or
recommended. increased in incidence or geographic spread ,

Chloroquine and hydroxychloroquine At this time, emerging infections include

prophylaxis is safe and well tolerated in -West Nile virus,
pregnancy. -coronavirus, and
-several influenza A strains
For travelers to areas with chloroquine- -bioterrorism agents
resistant P falciparum, mefloquine remains
the only chemoprophylaxis recommended. WEST NILE VIRUS

Primaquine and doxycycline are mosquito-borne RNA flavivirus

contraindicated in pregnancy, and there are is a human neuropathogen
insufficient data on atovaquone/proguanil to
recommend them at this time. The year 2012 was the second worst
outbreak of total cases in the United States
AMOEBIASIS (Centers for Disease Control and Prevention,
2013b).
Most persons infected with Entamoeba
histolytica are asymptomatic. are typically acquired through mosquito bites
in late summer or perhaps through blood
Amebic dysentery, may take a fulminant transfusion (Harrington, 2003).
course during pregnancy, with fever, incubation period is 2 to 14 days, and most
abdominal pain, and bloody stools. persons have mild or no symptoms.

Prognosis is worse if complicated by a Fewer than 1 percent of infected adults

hepatic abscess. Diagnosis is made by develop meningoencephalitis or acute flaccid
identifying E paralysis (Granwehr, 2004).
histolytica cysts or trophozoites within a Presenting symptoms may include fever,
stool sample. Therapy is similar to that for mental status changes, muscle weakness,
the nonpregnant woman, and metronidazole and coma
or tinidazole is the preferred drug for amebic
colitis and invasive disease. Diagnosis :
based on clinical symptoms and the
Noninvasive infections may be treated with detection of viral IgG and IgM in serum and
paromomycin. IgM in cerebrospinal fluid.

MYCOTIC INFECTIONS There is no known effective antiviral

treatment, and management is supportive.
Disseminated fungal infection—usuall
pneumonitis—during pregnancy is The primary strategy for preventing exposure
uncommon with coccidiomycosis, in pregnancy is the use of insect repellant
blastomycosis, cryptococcosis, or containing DEET. This is considered safe for
histoplasmosis. use around pregnant women (Koren, 2003).

EMERGING INFECTIONS Avoiding outdoor activity and stagnant water

and wearing protective clothing are also IgG
recommended. seroconversio
n and a
CORONAVIRUS INFECTIONS declining viral
load.
are single-stranded RNA viruses that are
prevalent worldwide Progression at
this stage is
are associated with 10 to 35 percent of thought to be
common colds, usually in the fall, winter, and due to an
early spring. overexuberant
host immune
In 2002, an especially virulent strain of response.
coronavirus—severe acute respiratory
syndrome (SARS–CoV) was first noted in
China. Radiographic lung findings include ground-
glass opacities and airspace consolidations
It rapidly spread throughout Asia, Europe, that can rapidly progress within 1 to 2 days.
and North and South America.
Transmission is through droplets or contact TRAVEL PRECAUTIONS DURING PREGNANCY
with infected secretions, fluids, and wastes.
Pregnant travelers face obstetrical risks,
The Coronavirus Infections general medical risks, and potentially
incubation period is 2 to 16 days, and there hazardous destination risks.
appears to be a triphasic pattern to its clinical
progression. The International Society for Tropical
Medicines has comprehensive information
available at:
http://www.istm.org.

Also, the Centers for Disease Control and

Prevention have extensive travel
information regarding pregnancy and breast
The first During the The third, feeding at its websites listed on page 1257.
week is second week, and at
characterize patients may times, lethal BIOTERRORISM
d by suffer phase—  Smallpox
prodromal recurrent seen in  Anthrax
symptoms of fever, watery about 20
diarrhea, and percent of Bioterrorism involves the deliberate release
fever, a dry patients— of bacteria, viruses, or other infectious
myalgias, nonproductive agents to cause illness or death.
headache, cough with is
and mild dyspnea. progression These natural agents are often altered to
diarrhea. to SARS increase their infectivity or their resistance to
These are medical therapy.
coincident
with Clinicians should be alert for significant
increases in the number of persons with forming, aerobic bacterium.
febrile illnesses accompanied by respiratory
symptoms or with rashes not easily It can cause three main types of clinical
associated with common illnesses. anthrax: inhalational, cutaneous, and
gastrointestinal
SMALLPOX
The bioterrorist anthrax attacks of 2001
The variola virus is considered a serious involved inhalational anthrax (Inglesby,
weapon because of high transmission and 2002).
overall 30-
percent case-fatality rate. Spores are inhaled and deposited in the
alveoli. They are engulfed by macrophages
The last case of smallpox in the United States and germinate in mediastinal lymph nodes.
was reported in 1949, and worldwide it was
reported in Somalia in 1977. The incubation period is usually less than 1
week but may be as long as 2 months.
Transmission occurs with prolonged contact
with infected persons, infected body fluids, Initial symptoms are nonspecific and include
or contaminated objects such as clothing. low-grade fever, nonproductive cough,
malaise, and myalgias.
Smallpox presents with an acute-onset fever
that is followed by a rash with firm, deep- Within 1 to 5 days of symptom onset, the
seated vesicles or pustules. second stage is heralded by the abrupt onset
of severe respiratory distress and high fevers.
The case-fatality rate of smallpox in
pregnancy is 61 percent if the pregnant Mediastinitis and hemorrhagic thoracic
woman is unvaccinated. lymphadenitis are common, and there is a
widened mediastinum on chest radiograph.
There is a significant increase in stillbirth,
abortion, preterm labor and delivery, and Case fatality rates with inhalational anthrax
neonatal demise in pregnancies complicated are high, even with aggressive antibiotic and
by smallpox infection. supportive therapy.

Because the smallpox vaccine currently Regimens for postexposure anthrax

available is made with live vaccinia virus, prophylaxis are given for 2 months.
pregnancy should be delayed for 4 weeks in
recipients. The American College ofObstetricians and
Gynecologists (2009) and the Centers for
It is generally not given to pregnant women Disease Control and Prevention (Wright,
because of 2010) recommend that asymptomatic
the risk of fetal vaccinia, a rare but serious pregnant and lactating women with
complication. documented exposure to B anthracis be
given postexposure prophylaxis with
ciprofloxacin, 500 mg orally twice daily for 60
days.
ANTHRAX
Amoxicillin, 500 mg orally three times daily,
Bacillus anthracis is a gram-positive, spore- can be substituted if the strain is proven
sensitive.

In the case of ciprofloxacin allergy and either

penicillin allergy or resistance, doxycycline,
100 mg orally twice daily, is given for 60 days.

Risks from anthrax far outweigh any fetal

risks from doxycycline (Meaney-Delman,
2013).

The anthrax vaccine (AVA) is an inactivated,

cell-free product that requires five injections
over 18 months.

Vaccination is generally avoided in pregnancy

because there are limited safety data.
Reports of inadvertent vaccination of
pregnant women with AVA have not found a
significant increase in fetal malformations or
miscarriage rates (Ryan, 2008c; Wiesen,
2002).

Anthrax vaccine is an essential adjunct to

postexposure antimicrobial prophylaxis, even
in pregnancy (Wright, 2010).

OTHER BIOTERRORISM AGENTS

Other category A bioterrorism agents include

Francisella tularensis—tularemia,
Clostridium botulinum—botulism,
Yersinia pestis—plague, and
viral hemorrhagic fevers—for example,
Ebola,Marburg, Lassa, and Machupo.
Multiple agents are also listed as category B
and C.