Infection of the fetus can result in embryonic death, stillbirth, prematurity, intrauterine growth retardation, developmental abnormalities or congenital disease.

Clinical findings are rarely disease specific but include:

See also: Hepatitis C  and HIV 

Toxoplasmosis

• 85% of congenitally infected infants appear normal at birth.
• Only 75% of congenitally infected children will produce detectable specific IgM.
• Maternal infection in first trimester less likely to infect fetus (10%) but if it does the damage is more severe. Mid or late trimester infection more likely to infect fetus (30-50%) but the effects are milder.

The following samples will enable search for toxoplasma DNA (by PCR) in baby's blood, placenta and amniotic fluid.

The newborn blood and maternal blood will allow direct comparison of maternal/fetal antibody levels, i.e, is there any evidence of fetal infection as revealed by fetal antibody production? Cord blood is proving unreliable for antibody titration.

• Cord blood - label clearly 'cord blood'.
• Plain (red top) blood 5ml.
• CPD (yellow top) blood 5ml.

• Placenta - 100g placenta (fetal side near umbilical cord): place sterilely in sterile disposable plastic container. Keep chilled.
• Amniotic fluid - please collect where available as this may be very informative - 10ml in sterile plastic container.
• Newborn serum - 1ml plain blood (red top) for toxoplasma IgG and IgM. Label clearly 'newborn serum - not cord blood'.

All these samples should be sent to:

• Department of Virology & Immunology
• Level 2, Building 31
• LabPlus

If suspected after delivery:

• Maternal serum for toxoplasma IgG and IgM
• Infant serum (red top) for toxoplasma IgG, IgM and infant blood (CPD or EDTA tube) for PCR
• Head ultrasound
• CSF for M, C and S, protein, glucose and toxoplasma PCR

Refer to Paediatric Infectious Diseases Team for treatment and follow up.

Rubella

• Infection of the fetus is CHRONIC, so congenitally infected infants will shed virus at high titre for many months.

Investigations

Isolation

• Contact isolation required: consider infectious for first year of life
• Only those known to be immune should care for the baby in hospital and pregnant visitors at home should be warned.

Cytomegalovirus

• There may be a history of maternal 'mono'-like illness.
• Most infected infants are asymptomatic but may have later deafness or learning disability.
• Approximately 15% of infants born after primary infection of mothers will have one or more sequelae of intrauterine infection.
• CMV infection may show more marked liver involvement than congenital toxoplasmosis with hepatosplenomegaly and jaundice.

Investigations

• Urine culture for CMV (must be in first two weeks of life to confirm congenital infection). Urine must be chilled and transported immediately to the lab on melting ice.
• Cord or infant blood for CMV PCR (EDTA or CPD tube).
• Head ultrasound.
• Long term: serial audiology and developmental assessment, head circumference, ophthalmology.

Click here to link to Nursing Care of Infants who are CMV positive

Herpes Simplex Virus

• Only 30% of mothers whose infants have neonatal herpes have a history of symptomatic genital herpes.
• Most infections are acquired at birth. Intrapartum/post natal infection can become manifested up to 4-6 weeks, disseminated infection usually in first two weeks, localised CNS or SEM (skin, eye, mucous membrane) during second and third week.
• The risk of HSV infection in an infant born vaginally to a mother with a first episode or primary genital infection is 33-50% (hence caesarean section usually performed) and such infants may warrant acyclovir treatment once cultures have been taken. Alternatively cultures can be taken at 24-48 hours if the infant is asymptomatic and acyclovir only initiated if HSV is identified.
• The risk from recurrent genital HSV infection is 3-5% at most and empiric therapy is not recommended.
• Scalp electrodes must be avoided wherever there is suspicion of active HSV in the mother.

Investigations

• Skin vesicles: swab for viral culture and HSV PCR.
• Swabs from eyes, mouth/nasopharynx for HSV culture.
• WBCs (CPD or EDTA tube) for HSV PCR.
• CSF - cells, protein, glucose, culture, viral culture and HSV PCR.
• Head CT/EEG may localise disease but not essential.
• Subtype specific (HSV1 and 2) serology may be useful on mother and baby.
• Ophthalmic consultation.

Consult Paediatric Infectious Disease Team

Isolation

• Contact isolation required, especially if skin lesions present.
• Isolate infants born vaginally to mothers with active genital infection for four weeks. Room-in with mother in isolation if possible. Advise mother re handwashing.

Observation/Surveillance

• Known exposed infants require careful observation.
• Take eye, mouth, nasopharyngeal +/- skin swabs at 24-48 hours
• The family must be educated regarding the symptoms and signs of neonatal HSV.

Syphilis

• Trans-placental infection can occur at any stage of pregnancy, during any stage of maternal disease.
• NB: Testing of cord blood/infant serum is not adequate for screening because these tests may be non-reactive when mother is positive. Therefore mother's serology must be reviewed/performed in all suspected cases.

Evaluation of newborn for syphilis is indicated if:

• Maternal syphilis not or inadequately treated or treated with inadequate follow up.
• Syphilis in pregnancy treated with non-penicillin regime (e.g. erythromycin).
• Syphilis treated within one month prior to delivery.

Or if any of the following clinical features present:

• Osteochondritis/periostitis.
• Snuffles, haemorrhagic rhinitis.
• Condylomata lata.
• Bullous lesions, palmar/plantar rash.
• Mucous patches.
• Hepatomegaly/splenomegaly.
• Jaundice.
• Non immune hydrops fetalis (NB: check for parvovirus).
• Generalised lymph adenopathy.
• CNS signs, elevated cell count or protein in CSF.
• Haemolytic anaemia, DIC, thrombocytopenia.
• Pneumonitis.
• Nephrotic syndrome.
• Unexplained enlarged placenta.
• IUGR; failure to thrive.

Investigations

• FBC, LFTs and syphilis serology on infant blood.
• Maternal syphilis serology.
• CSF for VDRL, cells protein and glucose.
• Long bone radiographs.
• Darkfield microscopy of skin lesions, nasal discharge, placental tissue or amniotic fluid may show spirochaetes (but majority of cases have none of these).

Refer to Paediatric Infectious Disease Team for treatment and follow up.