INFECTIONS IN PREGNANCY
URINARY TRACT INFECTIONS
-RUBELLA INFECTIONS
-TOXOPLASMA INFECTIONS
-CMV VIRUS INFECTIONS
URINARY TRACT INFECTIONS
Urinary tract infections are one of the most common diseases faced by gynecologists and obstetricians. It is estimated that approximately 10% of patients presenting to the gynecologist have a urinary tract infection problem. On the other hand, 15-20% of all women get urinary tract infection at some point in their lives.
Approximately 8% of pregnant women have urinary tract infections. This infection can be asymptomatic bacteriuria, bladder infection (cystitis) or kidney infection.
Although urine is a substance that transports the body's waste materials to the outside world, it is sterile, ie it does not contain any germs. This is due to the mechanical cleaning of the urine produced in the kidneys during the excretion of the urine into the bladder and the outside world. In order for the urinary tract to be infected, germs must somehow enter the urinary tract and accumulate and multiply there. The most suitable way for such a situation is that the microbes enter the urethra via the vagina (the tubular section between the bladder and the outside world and the urine is made) and then go up to the bladder, and after the proliferation in the bladder, they reach the kidneys via the pipes called the ureter between the kidneys and the bladder. These bottom-up infections are called ascending infections. If there is urine in the bladder, it creates a reproductive environment suitable for germs.
Another way to reach the urinary tract of microbes is through the blood. Infection agents in another part of the body can reach the blood and kidneys, where it can lead to a second infection. However, this is extremely rare.
Women are much more prone to urinary tract infections because of their anatomical structure. Since the structure called the urethra between the bladder and the outside world is shorter in women, germs can easily and easily reach the bladder from here. However, in women who drink a lot of water and urinate frequently, the germs in the urethra are thrown out and mechanical cleaning occurs and thus the chance of infection decreases.
Why are urinary tract infections more common during pregnancy?
Pregnant women are at greater risk of developing urinary tract infections than non-pregnant women. Urinary tract infections in pregnant women usually begin to occur in 6 weeks, the most common 22-24. occurs in weeks.
During pregnancy, 90% of women have an enlargement of the ureters that carry the urine produced in the kidneys into the bladder, which continues until birth. As in all smooth muscles, the smooth muscles in the urinary tract are loosened due to the secreted hormones, resulting in a decrease in the flow rate of the urine. This is called urinary stasis. Again, with similar hormonal causes, urinary reflux (reflux) occurs from the bladder to the ureters.
On the other hand, most of the pregnant women have glucose in the urine. This is a completely normal condition but provides a suitable breeding ground for bacteria. In addition, the concentration of urine during pregnancy increases. When estrogen and progesterone hormone are added to urine, the ability of the urinary tract to fight bacteria decreases.
Bacteriology
Microorganisms that cause urinary tract infection in pregnant women are similar to those who are not pregnant. Escherichia coli is the responsible microbe in 80-90% of the cases. This bacterium, also known as coli bacillus, is found in the feces. Proteus mirabilis are also common bacteria in Klebsiella pneumoniae. Group B streptococcus and Staphylococcus saprophyticus are rare bacteria. Very rarely are microorganisms responsible for urinary tract infection in Gardnerella vaginalis and Ureaplasma ureolyticum.
Complaints and findings
Urinary tract infections can be seen in three different ways. These include asymptomatic bacteriuria, cystitis (bladder infection) and pyelonephritis (kidney infection).
Asymptomatic bacteriuria
If there are no more than 100.000 bacterial colonies per milliliter in urine culture, asymptomatic bacteriuria is diagnosed. It is detected in approximately 10% of pregnant women. It is suggested that there is an increased risk of pyelonephritis when left untreated. Therefore, some authors recommend urine culture in every pregnant woman at the first visit.
The probability of asymptomatic bacteriuria leading to cystitis or pyelonephritis varies between 30-50%. On the other hand, it is suggested that this may cause low birth weight infants or intrauterine growth retardation.
The American Society of Gynecology and Obstetricians recommends that urine culture be performed at the first pregnancy control or 12-16 weeks of gestation and repeated at the last trimester.
Pregnant women should be treated when asymptomatic bacteriuria is detected. For this purpose, antibiotics can be used against the most common microbes, and an ideal antibiogram is used to determine which antibiotics are susceptible to the reproductive bacteria, and which antibiotics are used accordingly. Antibiotics to be used during pregnancy should be selected from a group that is OK.
Due to the habit of using false and unnecessary antibiotics from the past, many microbes have developed resistance to traditional and inexpensive antibiotics, which are now ineffective, and more complex and expensive antibiotics have to be developed to eliminate simple microorganisms. Therefore, the use of antibiotics without a doctor's advice for any illness will have negative consequences in the future.
Although there are different protocols in the treatment of asymptomatic bacteriuria, infection can be eliminated with 7-10 days of treatment.
After treatment, it should be re-cultured to determine whether the treatment is effective.
Acute cystitis
Acute cystitis, that is, bladder infection, asymptomatic bacteriuria when urinating, burning, frequent urination, is characterized by the presence of complaints such as incontinence. The patient does not feel very sick in cystitis and fever is not seen. Very rarely, blood can be seen in the urine. Cystitis occurs in 1-3% of pregnant women.
Generally, in the presence of cystitis, antibiotic treatment is started with empiricol without waiting for culture result. The antibiotic of choice should be one for the most common microorganisms. If the resistance to the antibiotic is detected when culture and antibiogram results are detected, another antibiotic that is found to be susceptible is passed. The classical treatment of cystitis lasts 7-10 days, but there are 3-day treatment protocols and provide similar treatment efficacy for non-pregnant women. However, the impact of these protocols on pregnant women is not yet clear. Pregnant women treated with short protocols seem to be more likely to recur.
Pyelonephritis
Pyelonephritis, a kidney infection, is a very serious systemic disease and can cause maternal blood infection (sepsis) and premature birth in a baby. Diagnosis is usually made by the presence of bacteria in the urine, as well as fever, chills, nausea, vomiting and side pain. Fever is often above 39 degrees. Lower urinary tract infections may not show symptoms such as burning and frequent urination while urinating.
Pyelonephritis is an infection that occurs in 2% of pregnant women and in 20% of them, the disease recurs during the same pregnancy.
Aggressive treatment of pyelonephritis in the early period is critical to prevent complications. It is usually treated by hospitalization and intravenous antibiotics. However, recent studies have shown that effective oral antibiotics can be used.
Treatment starts without waiting for culture and the antibiotic used is changed if necessary. From time to time, two antibiotics for different microorganisms may be used simultaneously. It is important to ensure adequate hydration of the patient during the treatment, ie fluid intake.
The treatment is continued until the patient has fever and the general condition has improved. Most patients respond to antibiotic and fluid therapy within 24-48 hours. The most important factor in the failure of the treatment is the resistance to the antibiotic used, however, the underlying "urinary tract stones" should be investigated in treatment-resistant cases.
Urinary tract infections recur in 4-5% of pregnant women. In such a case, anatomical or functional disorders of the urinary tract should be investigated with a detailed urological examination.
Effects of urinary tract infections on pregnancy
The effects of urinary tract infections on pregnancy and baby are variable. In a study, more than 25,000 pregnant women were examined and it was found that urinary tract infections cause preterm labor, pregnancy-related high blood pressure, anemia, and amniotic inflammation. Urinary tract infections also increase the risk of low son weight and prematurity.
RUBELLA INFECTIONS IN PREGNANCY
Rubella, commonly known as rubella, is a common virus infection. When passed during pregnancy can cause serious problems in the baby.
What is Rubella?
Rubella is a febrile viral infection associated with rashes. In general, rubella in childhood lasts for about 3 days and often lighter than measles. The most important symptoms are typical rash, mild fever, loss of appetite, cough, headache and joint pain that start from the face and spread for three days. Symptoms other than rash are mild and sometimes last for 1-2 weeks. Sometimes the disease is so mild that it is not even clear whether the disease has been passed. Rubella may be more severe in adults and joint pain may occur. . Once the disease has passed, it does not cause permanent damage to the person. The person who is infected gains immunity and never gets rubella again.
The incubation period of the disease is 14-23 days. In other words, symptoms occur 14-23 days after contact with a patient.
Rubella virus is found in the nose and throat of the sick person. The disease is transmitted by direct contact with nose and throat secretions or by viruses that spread to the air by coughing and sneezing by the sick person. A sick person is contagious 1 week before the rash appears and within 4 days following the rash.
Rubella is a largely preventable disease today and the only way to prevent it is to vaccinate. After vaccination, permanent immunity develops. A large proportion of adults in the reproductive age are immune to rubella either because they are in childhood or because they are vaccinated.
The presence of immunity to rubella can easily be determined by a serological examination in the blood. A Rubella IgG positive indicates that the person is immune to rubella.
What are the effects of rubella on the baby during pregnancy?
Rubella infection can cause serious damage or miscarriages to the baby when passed during pregnancy. As a result of the epidemic in 1964-65 in the United States, more than 20,000 babies were born with anomalies and more than 10,000 pregnancies resulted in miscarriage.
Since the introduction of the Rubella vaccine in 1969, major outbreaks have been prevented. However, small-scale outbreaks can still occur in different parts of the world. Today, the incidence of congenital defects due to rubella has decreased considerably due to the fact that many women of reproductive age are immune to this disease.
Approximately one quarter of babies whose mothers have rubella in the first trimester of pregnancy are born with one or more congenital defects. This condition is called congenital rubella syndrome. The most common birth defects include eye problems, hearing loss, heart abnormalities, mental retardation, and cerebral palsy, which can result in visual loss and complete blindness.
A significant number of children with congenital rubella syndrome have difficulty walking and learning in later life.
On the other hand, rubella during pregnancy often causes miscarriages and stillbirths.
The risk of congenital rubella syndrome in the infant is closely related to the period of the disease during pregnancy. The earlier the disease is passed, the higher the risk. The greatest risk is rubellla in the first trimester. In such a case, the risk of the baby being affected or miscarried varies between 25-80%. When passed at the beginning of the second trimester, the risk of congenital rubella decreases to around 1%. After twentieth week, it rarely causes birth defects.
Some infants may experience non-permanent health problems. The most common of these is low birth weight. In addition, dietary problems, diarrhea, zaaturre, meningitis and anemia may be seen from time to time. Purple-red spots may be present on the skin due to temporary bleeding disorders. liver and spleen enlargement can be detected in the baby.
How is congenital rubella syndrome treated?
Unfortunately, there is no specific treatment for congenital rubella syndrome. Common problems in the newborn period, such as blood and liver problems, often heal spontaneously without treatment. Some of the visual and hearing problems can be corrected by early surgery. or at least improved.
Can congenital rubella syndrome be prevented?
Yeah. Rubella syndrome can be prevented with congenitis. For this reason, it will be useful for all mothers who do not know whether they have had rubella in their childhood or not. Vaccination before conception is an appropriate approach in immunocompetent individuals.
Vaccination cannot be given in women who have been subjected to rubella screening after conception and have no immunity. In such a case, the person should stay away from people who have had rubella during her pregnancy.
How soon can you become pregnant after the rubella vaccine?
Pregnancy was not allowed for 3 months in women who were planning and vaccinating pregnancy until recently. Although the American Center for Disease Control (CDC) was unable to obtain any evidence of any congenital defect in their study of babies born to women who had been vaccinated but who had been pregnant within a 3-month period, it was advised not to conceive for 3 months due to potential risks. However, as a result of the data obtained from the latest researches which examined women who had vaccinated within 3 months before conception or in the early stages of pregnancy, the risk of developing congenital rubella syndrome due to vaccine was found to be between 0.5-1.3%. Since this risk is much lower than the 25% risk encountered in case of infection in the early stages of pregnancy, it is accepted that it is sufficient to protect it for 28 days after the rubella vaccine.
In our country, rubella vaccine is administered to all children together with mumps and measles vaccines.
TOXOPLASMOSIS IN PREGNANCY
Many have heard stories of a woman having a miscarriage or stillbirth due to a cat-borne illness. Because of these stories, pregnant women often try to avoid pets such as cats and dogs. Even those who feed such pets in their homes before pregnancy either leave these friends forever or try to give them to an acquaintance. During their pregnancy, they do not visit homes that feed cats or dogs.
This disease, which is widely believed to be transmitted from cats, is called toxoplasmosis. To be realistic, cats are the least to blame for toxoplasmic infections transmitted to humans.
What is toxoplasmosis?
Toxoplasmosis is an infection caused by a parasite called Toxoplasma gondii. It was first discovered in 1908 in a rodent called gondi in Africa. It causes infection in many species of vertebrates, including humans, all over the world. In contrast, only the female and male in the intestine of domestic cats can come together to reproduce. Reproduction is not possible elsewhere. These infective parasites are excreted in the feces of the cat and are transmitted to other animals by the digestive system. In other words, the infection must enter through the mouth to infect humans or other animals.
How is toxoplasmosis transmitted?
Cats also receive this parasite when they eat an infected animal (such as a mouse) raw. The parasite then grows in the cat's bowel for about 2 weeks. In the following period, it is thrown out with the cat's faeces. In order for these parasites to be infectious, they must spend 24 hours in the outside world. They're not contagious before. An infected cat throws parasites with feces for about 2-3 weeks. There is no parasite in the cat's faeces in the following period. Once a toxoplasma infection occurs, the cat gains immunity and will not be re-infected later, nor does it carry infectious properties. A similar feature exists in humans. Once infected, a person gains immunity and does not get sick again.
Stray cats usually get this infection very early in life and gain adulthood. For this reason, infection from large stray cats is far from the possibility of infection.
The parasites that are thrown into the soil with cat's faeces and become contagious within 24 hours pass into the digestive system of animals such as cattle, sheep, cows during feeding (for example in pastures). It then passes through the muscle tissue and infects the animal. When the meat of such an animal is eaten by a person without cooking or undercooking, it directly causes infection in that person. Another way of transmission is to eat fruits and vegetables that have come into contact with the soil with toxoplasma without proper washing.
As can be seen, toxoplasma can be transmitted to man in 3 basic ways.
To contact an infected cat's feces and then bring the contact to the mouth without washing
Eat the meat of an infected animal without thoroughly cooking
Eat without washing thoroughly a food containing parasite
There is another way of transmission in humans:
Infected baby from an expectant mother during pregnancy
How often is it seen
There is no clear statistics about the incidence of toxoplasmosis worldwide. However, it is estimated that approximately 25-50% of people are in contact with the parasite and infected at any time in their lives. It is seen more in temperate climates. It is estimated that in France, where the disease is most common, 65% of people have this infection.
What are the symptoms?
Toxoplasma infections do not usually show much symptoms in adults. Most of the time, it is avoided as a mild cold, which does not require a visit to a doctor. Symptoms such as mild muscle and joint pain, weakness, fatigue, swelling of the lymph nodes may occur. Symptoms spontaneously regress within a few weeks to a few months. It can rarely cause eye infections.
Immune-suppressed leukemia, lymphoma, AIDS patients and organ transplant patients may be much more severe and may even cause death.
How is it diagnosed?
Toxoplasmosis is established in the blood by detecting the presence of antibodies produced by the body's immune system against this parasite. In the examination, IgG positivity against toxoplasma means that the disease has been passed before and is immune. In such a case, it is not possible to catch the toxoplasm again. The presence of IgM in the blood may indicate the presence of an active new infection. In such a case, the diagnosis is made and treated with repeated increases in IgM levels. In both IgG and IgM negativity, there is no disease and the person has never experienced this disease before and precautions should be taken in order to avoid toxoplasmosis.
What are the risks for the baby?
Only 30-40% of women who suffer from toxoplasma infection during pregnancy pass on this disease to their babies.
The risk of maternal infection affecting the baby is directly related to gestational age. This risk is higher in the last trimester of pregnancy and can reach up to 70%, while this rate is around 15% in first trimester infections. However, in the first trimester, although the baby is unlikely to get an infection, the baby will have more harm.
In other words, it is easier to infect the baby in the last 3 months but the possibility of harm is extremely low, while the infection which is very difficult in the first 3 months causes more serious problems.
Early toxoplasma can cause miscarriages or stillbirths. Other effects of toxoplasmosis include brain damage, brain water retention (hydrocephalus), visual and hearing disorders, developmental delay, mental retardation and nervous system disorders such as epilepsy.
What to do if toxoplasma infection is detected during pregnancy?
Detection of toxoplasma infection in the mother during pregnancy does not necessarily mean that the baby will be a problem. In such a case, detailed ultrasonography is used to determine whether the infection is damaging the baby. After the 20th week of gestation, blood can be taken from the baby's umbilical cord (cordocentesis) and definitive diagnosis can be made. Here, the presence of IgM in infant blood is a definite sign of infection in the infant.
Treatment
Treatment of toxoplasmosis in a non-pregnant woman is done with antibiotics. It is not clear whether the antibiotic administered in pregnant women prevents possible damage to the baby.
If severe sequelae is detected in the baby, the method of choice is termination of pregnancy.
What should be done if it is determined that there is no immunity to toxoplasmosis during pregnancy?
In such a case, toxoplasma prevention measures should be taken into consideration and periodically to determine whether antibodies against toxoplasmosis in the blood.
Ways of protection from toxoplasmosis
The most effective way to protect from toxoplasmosis is to comply with hygiene rules
Wash your hands frequently.
If you are dealing with soil, always wear gloves.
Do not eat raw or undercooked meat (salami, sausage etc.)
Wash hands after contact with raw meat
Do not cut any raw material without washing thoroughly with the knife you cut raw meat
Do not carry out any further processing until you have thoroughly washed the cutting boards where you cut raw meat.
Wash raw vegetables and fruits very well
Preferably do not eat green leafy salads outside
Do not drink unpasteurized milk, do not use products made from such milk
Do not change the sand if there are cats at home
Make sure the cat's sand changes every 24 hours
Don't leave your cat out
Don't feed your cat raw meat
Toxoplasmosis from the domestic cat is extremely rare and you do not need to send your cat at home when you become pregnant. Is it safe to feed cats during pregnancy? I recommend reading
CMV VIRUS INFECTIONS IN PREGNANCY
Cytomegalovirus (Cytomegalovirus, CMV) is a virus of the herpes family. Other viruses in this family are the herpes simpllex virus that causes herpes and the virus that causes chickenpox.
The infection caused by this virus in all geographical regions is one of the most common infections. It is estimated that between 50 and 85 out of every 100 people in the United States are infected by this virus until they reach the age of 40.
CMV is also one of the most common infections transmitted from the mother to the unborn baby. It is accepted that 1 out of every 100 babies born in the United States has CMV infection and CMV is the most common congenital infection.
It is more common in developing countries and in societies with low socioeconomic status.
CMV infections can be seen as primary (first-time) or recurrent (recurrent) infections.
Once the person has been infected and survived the acute phase, as in the whole herpes group, the virus is located in any part of the body and remains silent for years. However, recurrence of the disease is extremely rare and is usually reactivated when the immune system is severely suppressed due to drug use or systemic disease (such as AIDS). CMV infections are not included in the major diseases group because they do not cause problems in the majority of people.
On the other hand, there are some risk groups where the disease may have serious effects. These:
Unborn babies with active infection in their mother
Women working in nursery and schools
Individuals with severe immune suppression such as organ transplant patients or AIDS patients
Ways of transmission
CMV infections can affect people of all ages, including children. This virus, which is usually transmitted from children to adults, spreads through direct contact since it is also found in body fluids such as urine, saliva, tears, semen and milk. Since it is also found in semen and vaginal fluids, it is also possible to transmit it through sexual intercourse. Very rarely, transmission can also occur during a transfusion. One of the important ways of transmission is the transmission from a pregnant woman to the unborn baby.
An immune response occurs after infection, but this is not a complete answer and unlike many other viral infections, such as chicken pox, mumps, the infection does not guarantee that it will not be re-passed. However, there is no new infection when the same virus is encountered again. A person's latent infection can be activated.
The main route of transmission is direct contact with body fluids. If this virus gets into the oral or nasal mucosa, the disease is transmitted. Therefore, washing hands after contact with body fluids of persons suspected of being infected greatly prevents contamination. For example, washing the hands thoroughly after changing the diaper of a child is a very effective method of protection.
symptoms
CMV infections are usually passed without any specific symptoms. Most of the time, the person does not understand that they have had an infection. The most common complaints are similar to upper respiratory tract infections. Sore throat, mild fever, diffuse muscle and joint pain and weakness. In immunocompromised individuals such as AIDS, serious effects such as visual impairment may occur.
Diagnosis
CMV is diagnosed by serological tests in the blood. The presence of antibodies to CMV in the blood is sought. In the presence of antibodies suggestive of acute active infection, serial examinations are performed to determine whether there is an increase. The presence of immunglobulin G (IgG) in the blood means that the virus has already been encountered and immunity has occurred. However, a 4-fold increase in these values also makes the diagnosis of infection.
Primary CMV infection during pregnancy
The probability of primary CMV infection in the mother is 0.4-0.7%. The transition from mother to baby is between 24-75% in different studies and is accepted as 40% on average. Congenital CMV infection is mentioned in fetuses infected during pregnancy.
Only 10% of infected 40% infants develop symptoms due to congenital CMV infection. In other words, only 4 of every 100 mothers who have primary CMV infection during their pregnancy have problems in their babies, while 36 do not have any problems at birth. .
The affected newborn has a general infection. The most commonly affected organs are the brain, eyes, liver, spleen, blood and skin. Calcifications in the brain, smaller than normal head (microcephaly), growth in liver and spleen are common findings. These babies survive with supportive therapies, but 80-90% have long-term effects during the first years of life.
Long-term effects include hearing loss, mental retardation, developmental delay and visual disturbances.
Long-term effects may occur in 10-15% of 90% of the infants (36 infants in the above example), which do not show signs at birth.
Recurrent infection during pregnancy
The probability of recurrent CMV infection during pregnancy is much higher than the probability of primary infection and is encountered between 1-14%. In contrast, the risk of recurrent infections leading to congenital infection in the infant is much lower and varies between 0.2-2%. In parallel, findings occur only in 1% of infants with congenital CMV infection. However, the risk of long-term effects of 10-15% is also present in recurrent infections.
The gestational age has no predictive value for the risk of CMV transmission from the mother to the baby. However, there is a higher risk of developing problems before the 20th week.
Is there any treatment for CMV during pregnancy?
Unfortunately, as with most viral infections, there is no effective treatment option for CMV infections that occur during pregnancy or at other times. Although some antiviral agents have been tried, the efficacy of these agents is still controversial.
Ways of protection
As with all infections, personal hygiene is the most effective way to prevent CMV infections. In case of contact with any body fluids such as changing the baby's diaper, the hands should not be taken to the mouth before washing with soap. This is the most effective method of protection.
To summarize, although CMV infections are very common infections, they are extremely rare in pregnancy and do not pose a serious risk. However, women who experience the virus for the first time during pregnancy have a potential risk, even at a low level, in their babies. In women who have had previous infections, this risk is reduced to a negligible level if the infection is reactivated. .
Whether CMV antibody screening is required before or during pregnancy is controversial. However, my personal opinion is that this test should be performed. Once the test has been established that the mother has already had this infection, it can be concluded that the possibility of harm to the infant is extremely low, since the re-infection occurs during pregnancy, since it is a recurrent infection.
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