Penyakit Infeksi

dan
Kesehatan Reproduksi

dr. Akhmad Jufan

 Bacterial infections
• Fever during pregnancy : infections, tissue trauma,
malignancy, epidural analgesia, and endocrine or
immunologic disorders.
• Infection is the most common cause (skin, periodontal
tissues, respiratory and genitourinary tracts)
• Complications : preterm labor, premature rupture of
membranes, abortion following pelvic inflammatory
disease, chorioamnionitis, neonatal infections,
cervicitis, urethritis, ectopic pregnancy, low
birthweight, stillbirth, pneumonia, septicemia, and
both maternal and neonatal death.
• Urinary tract bacterial infections :
recommend screening and eradication of
these silent infections as routine prenatal
practice .
• Antibiotic treatment during pregnancy is
beneficial in reducing neonatal and maternal
morbidity/mortality, and most bacterial
infections are preventable and treatable .
 Maternal and fetal implications
• Sepsis : significant cause of maternal death in
underdeveloped countries.
• In pregnancy : decreases in immunoglobulin G levels,
lymphocyte count, and impaired lymphocyte activity,
a change in the balance of Th1/Th2-type cytokines
favors T helper type 2 immunity place the
parturient at added risk for infection.
• Maternal complications of sepsis : pneumonia,
adult respiratory distress syndrome (ARDS),
disseminated intravascular coagulation (DIC),
pulmonary edema, septic pulmonary emboli, septic
shock, decreased left ventricular function, and
cardiac arrest.
• The fetus at risk of early preterm delivery :
chorioamnionitis
• An increased risk of septicemia and puerperal
fever in women undergoing cesarean section
(C/S) is one reason why vaginal delivery is the
preferred delivery mode for healthy women.
 Viral infections
• Maternal viral infection is associated with an
increased risk for adverse perinatal outcome.
• The acronym TORCH is frequently applied to
agents known to cause serious congenital
infections. Except for Toxoplasma gondii, all
TORCH agents are viruses: Rubella,
Cytomegalovirus, Herpes simplex ( + herpes
varicella zoster and HIV)
– Use standard precautions : wearing gloves, using eye
protection, and taking care when handling blood and
body fluids.
 Toxoplasmosis
• Congenital infections from vertical transmission  fetal and
neonatal morbidity and mortality.
• Toxoplasma gondii : protozoan parasite, caution in pregnancy
and in the immunocompromised host

• Infants have developed seizures, significant cognitive and

motor deficits, and diminution in cognitive function over time.
• infants treated for a year with pyrimethamine and
sulfadiazine still have cognitive function
 Toxo…
• Pregnant women should avoid exposure to risk
factors such as raw or undercooked meat, unwashed
fruits or vegetables, and cat excrement.
• As most cases of maternal toxoplasmosis are
asymptomatic, or marked only by nonspecific
lymphadenopathy, fever  screening may be the
only way to identify infection.
• Less common signs of disease in the mother :
myalgia, hepatitis, maculopapular lesions, and
pharyngitis.
 HIV/ AIDS
• Greatest health crisis of the twentieth and early twenty-first
century.
• Pneumonia the commonest cause of death
• Risk factors include: homosexuality, i.v. drug use, sex with an
i.v. drug abuser, blood transfusion, sexually transmitted
disease, multiple sexual partners, and tattoo of body surfaces.

– The enzyme-linked immunoabsorbant assay (ELISA) and

the Western Blot
– Measures of CD4þ T-lymphocytes are used to guide
clinical and therapeutic management
HIV impact on pregnancy and the fetus
• Children infected from their mother while in utero,
during delivery, or postpartum.
• Antiretroviral therapy significantly reduces the risk of
transmission.
• Breastfeeding significantly increases the risk of HIV
transmission.
• 35% of all HIV-infected children had been infected
through breastfeeding (breast milk viral load; and the
presence of mastitis)
 HIV..
• A neonatal evaluation at 12 months of age is required to be
certain of the HIV status of a child born to a HIV positive
mother
• HIV-infected babies have the same frequency of congenital
abnormalities as those not infected and there is no consistent
pattern of defects.
• Precautions to reduce the risk of transmission include
removal of all maternal blood and fluids immediately after
delivery, and avoiding vacuum or forceps delivery.
 C/S vs vaginal delivery
• Although C/S produces higher rates of septicemia and
puerperal fever compared with vaginal delivery, a C/S in the
HIV parturient has the advantage of reducing the time of
contact between maternal and the neonate.
• elective C/S is an efficacious intervention for prevention of
mother-to-child transmission of HIV in those not taking anti-
retroviral drugs
– The cervical mucus plug has antimicrobial properties and
represents a physical/chemical barrier against bacterial
(and viral?) invasion.
– Rupture of membranes for ~4 hours is also another risk
factor.
 Herpes simplex viruses (HSV)
• Dysuria is the most common complaint (80% of patients).
• 70% had vulvar ulceration, 66% had tender inguinal lymph
nodes, and 46% had a cervical ulcer.
• Women with asymptomatic or unrecognized HSV-2 infection
are at risk of delivering babies who develop neonatal herpes.
• Most fetal complications result from ascending infection after
rupture of membranes or passage of the neonate through an
infected birth canal.

If lesions are present at the time of delivery

then C/S is recommended.
 Cytomegalovirus
• CMV is the major pathogen detected in cases of
placental infection associated with fetal death.
• Clinical manifestations of virus replication are seldom
seen, except in immunocompromised individuals.
• Congenital CMV infection is the leading cause of
mental retardation and hearing impairment.
• Significant risk of transmission to infants through
breast feeding.
– Elective C/S is recommended for infected individuals since
cervical contamination is usually responsible for neonatal
infection
 Human papillomavirus
• vaccines will significantly reduce future morbidity and
mortality from carcinoma of the cervix.
• Multiparity, oral contraceptives, and smoking are risk factors
for persistence and progression of the disease.

• Condyloma from HPV infection begin as small, verrucose

growths, usually on the vulva or genital area.
• tendency for the lesions to become more prominent during
pregnancy and to coalesce into cauliflowerlike or raspberry-
like masses occasionally so extensive as to cause
obstruction of the birth canal.
 HPV..
• Massive vulvar lesions may expose the parturient to
lacerations, sepsis, and significant bleeding during
vaginal delivery  elective C/S may be preferable.
• Neonatal infection may occur transplacentally, but
there may be greater risk of transmission from
vaginal delivery.
• Prolonged labor is associated with a two-fold
greater risk of disease transmission.
• all personnel should wear special face masks and eye
protection.
 Varicella-zoster virus (chickenpox)
cacar air = cangkrangen

• A day after onset of fever, a nonsynchronous maculopapular

rash appears on the skin and mucosa. The lesions undergo
vesiculation and appear as pruritic, superficial thin-walled
vesicles
• Pregnant women are more likely to develop hypoglycemia,
pneumonia, encephalitis, hepatitis, pancreatitis, and nephritis
after chickenpox infection.
• In-utero infection can produce congenital varicella syndrome,
postnatal herpes zoster
• Maternal viremia leads to transplacental infection of the fetus
in 25% of cases.
 Varicella ..
• Congenital varicella syndrome occurs when the fetus
is infected during the first half of pregnancy.

•  Intrauterine growth restriction (IUGR) and skin

changes, e.g. hypertrophy, erythema, and scar
formation (cicatrix), brain malformations (e.g.
cortical atrophy and dilated ventricles), hypoplastic
limbs, and an array of other defects
 Rubeola (measles)
Campak = gabagen
• Measles is a highly contagious exanthematous viral
illness caused by a paramyxovirus (Morbillivirus).
• Its incidence worldwide has decreased dramatically
since the introduction of effective vaccines
• Still remains the fifth leading cause of mortality
among children < 5 yrs
• This clinical definition includes generalized rash,
cough, conjunctivitis, and temperature greater than
38,8 C at >3 days
 Rubeola (measles)
Campak = gabagen

• Measles in pregnancy follows a more complicated course

than in nonpregnant women.
• Measles during pregnancy : 2 X as likely to be admitted to a
hospital, 3X as likely to be diagnosed with pneumonia, and >6
X as likely to die from measles’ complications.
• presented before 24 weeks’ gestation  ended in abrupt
spontaneous abortion or stillbirth.
• presented after 25 weeks’ gestation  ended in live term
deliveries, but two of the four neonates had congenital
measles.
 Rubella (German measles)
• a self-limiting low-risk maternal viral infection that has the
potential to cause serious fetal disease including the
congenital rubella syndrome (CRS).
• Maternal postauricular adenopathy may be detectable a
week prior to development of a characteristic
maculopapular rash and may persist for one to two weeks
after disappearance of the rash. A high incidence of
arthritis has been described.
• Congenital rubella syndrome will occur in infants born to
mothers infected during the first half of pregnancy and may
result in miscarriage, stillbirth, mental retardation,
sensorineural deafness, cataracts, and heart disease.
 Dengue virus
• About 20–30% of those with DHF develop dengue shock
syndrome (DSS) that, if untreated, has a mortality of 50%.
• Dengue is transmitted by mosquitoes (Aedes aegypti) that
carry dengue virus types 1, 2, 3, or 4. Most cases involve
type 1.
• Dengue hemorrhagic fever is characterized by intense,
sustained abdominal pain; persistent vomiting; sudden
change from fever to hypothermia; and marked
restlessness or lethargy. After resolution of the disease,
mental depression and fatigue generally persist.1
• Confirmatory diagnostic tests include capture ELISA, rapid
immunochromographic tests, and polymerase chain
reaction (PCR).
 DHF
• infection during pregnancy causes teratogenicity,
abortion, or IUGR.
• Anti-dengue activity was found in the lipid
component of human milk and colostrum. This
suggests that breast feeding will protect the infant
from the dengue virus in the endemic area of dengue
infection.
• Mother and fetus are at risk from hemorrhagic
events when dengue infections occur near the time
of delivery.
 DHF
• Vertical transmission of dengue fever is sporadic and
most often the neonate recovers uneventfully.
• neonatal death from uncontrolled intracerebral
hemorrhage and multiorgan failure has been
reported.
• A self-limited dengue fever should be treated
symptomatically.
• Emergency C/S usually requires GA
 Plasmodium species (malaria)
• Malaria is a tropical parasitemia transmitted by
mosquitoes (Anopheles spp.) infected with
Plasmodium spp. (vivax, falciparum, malariae, or
ovale).
• The disease predominates in the rainy season or near
water sources.
• Malaria in pregnancy increases maternal and
perinatal morbidity and mortality.
 Malaria
• pregnant women are three times as likely to develop
severe disease than nonpregnant women in the
same area.
• The placenta appears to be a preferential site for
parasite sequestration and replication.

• Malarial infection may lead to miscarriage,

premature delivery, low birthweight, congenital
infection, and/or perinatal death.
 Malaria…
• Most malarial infections may be treated with
chloroquine or quinine and clindamycin. Optimal
therapy depends on knowledge of the area where
the disease was acquired and likely drug resistances.
• Alternative drugs, e.g. mefloquine and primaquine,

• Complications : cerebral malaria, pulmonary edema

or renal failure occur
 Mycobacterium tuberculosis
• Tuberculosis (TB) is estimated to infect one-third of the
world’s population, with most of those affected living in
developing countries.
• About 10% of infected patients will develop symptoms of
disease
• Each year approximately 2 million deaths occur
worldwide from TB, 98% of them in developing countries.
• Clinical manifestations : unremitting cough, fatigue,
weight loss, loss of appetite, fever, hemoptysis, and night
sweats.
 TBC
• Tuberculosis may include both pulmonary and
extrapulmonary disease, and it mimics many disease
states.
• Tuberculosis should be considered in the differential
diagnosis of postpartum fever of unknown origin.
• Sputum microscopy is the most important
conventional test for TB and is adequately specific
but lacks sensitivity.
• More ideal diagnostic procedures, e.g. polymerase
chain reaction (PCR) assays with excellent specificity
and sensitivity for bacilli detection
 TBC
• Pregnancy does not change the course of tuberculosis but,
unless treated  the worse manifestations
• Infants born to women with untreated TB may be of lower
birthweights than normal and, rarely, a baby may be born
with TB.
• Although drugs used in the initial treatment regimen cross the
placenta, they do not appear to have harmful fetal effects.
• Nonpulmonary TB (peritonitis, spinal TB, and genital TB) is
common in reports of TB during pregnancy.
 Typhoid fever
• Gl gram-negative bacterial disease (S. typhi and S. paratyphi)
• Ingestion of contaminated food is followed in 6–48 hours by
abdominal cramps, bacteremia, high fever, vomiting and
diarrhea, and occasionally colonic perforation.
• multiple organ dysfunction : renal failure, hepatitis,meningitis,
diffuse cerebral edema, brain abscesses, and epidural
abscesses.
• 14 day of chloramphenicol or 3 day of ceftriaxone = effective
• S. typhi can cross the placenta and lead to neonatal infection,
miscarriage, or fetal death  early treatment with ceftriaxone
should be initiated.