摘要:

Evaluation of the patient at risk for fetal infection is challenging. Serologic studies may be inconclusive and often do not provide meaningful information about prognosis. Recent technologic advances have expanded the role of prenatal ultrasound in both anomaly detection and guidance for invasive diagnostic procedures. For the patient with a known or suspected fetal infection, sonographic identification of characteristic abnormalities can provide useful information for counseling and perinatal management. Demonstration of such findings in the low-risk patient may serve to identify the fetus with a previously unsuspected infection.This article reviews the sonographic manifestations of fetal infection and the role of ultrasound in the evaluation of the fetus at risk for congenital toxoplasmosis, rubella, cytomegalovirus (CMV), and the herpesviruses (TORCH infections), and syphilis.

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

The purpose of antepartum and neonatal therapy for congenital infections is to reduce the potential for short-term and long-term morbidity and mortality. The degree of clinical acceptance of antepartum and/or neonatal therapy varies greatly among the congenital infections classified as "TORCH" (Toxoplasma,rubella, cytomegalovirus, herpes simplex) infections. The use of acyclovir to prevent or reduce the severity of neonatal herpes infections is considered standard therapy for infants with potential perinatal exposure. Maternal antepartum therapy for syphilis with penicillin targeting achievement of adequate fetal drug levels is considered the standard of care to reduce the sequelae of congenital syphilis. Although there is no real "therapy" for congenital rubella, the prevention of sequelae of congenital rubella is best achieved by primary prevention (preventing maternal infection) by vaccination of all women of childbearing age with rubella vaccine before conception (because it contains a live-attenuated virus, rubella vaccine is contraindicated during pregnancy). The status of antepartum therapy and primary prevention to decrease the sequelae of congenital cytomegalovirus (CMV) and toxoplasmosis is much less clear than for the other TORCH infections. To validate the utility of antepartum or neonatal therapy in reducing the sequelae of congenital infection, one must first understand the patterns of morbidity (both short-term and long-term) and mortality associated with a specific congenital infection in the absence of treatment. This must include an understanding of the severity as well as the frequency of each of the significant sequelae reported for that type of infection. Only after exploring the natural history of congenital infection can we proceed to determining the efficacy of potential therapeutic regimens.Congenital infections can produce a wide variety of sequelae, some immediately apparent (structural defects, intrauterine fetal demise), others discovered only after the passage of time (developmental delay, progressive sensory loss). Congenital rubella is associated with structural defects, and congenital syphilis may cause fetal demise. Congenital infections with CMV andToxoplasma gondiiare more commonly linked with long-term sequelae that may not be apparent at birth and even until the child reaches school age. The long-term sequelae associated with congenital CMV and toxoplasmosis can be categorized into sensory deficits, developmental delay/mental retardation, and central nervous system lesions. Ocular abnormalities including chorioretinitis, optic nerve atrophy, and retinal detachment occur more commonly after congenital toxoplasmosis. In contrast, sensorineural hearing loss due to cochlear or eighth nerve lesions occurs more typically as a sequelae of congenital CMV.1Central nervous system lesions that may occur after either CMV or toxoplasmosis include intracranial calcifications, microcephaly, hydrocephalus, and periventricular radiolucencies (low brain substance density extending from the frontal and occipital horns to surround the lateral ventricles). Central nervous system lesions can be diagnosed by ultrasound (intrauterine or neonatal), computed tomography (CT), or magnetic resonance imaging (MRI). Developmental delay and mental retardation commonly are assessed using the Bayley Scales of Infant Development and/or the Wechsler Primary and Preschool Scale of Intelligence.2Ocular abnormalities are detected by fundoscopic examination, pupillary reflexes, visual acuity, and refractive status.1Sensorineural hearing loss must be differentiated from conductive hearing loss (due to external or middle ear lesions) by Auditory Evoked Brainstem Responses or Impedance Audiometry. For both CMV and toxoplasmosis, we will describe prevalence, modes of transmission, mechanisms of congenital infection, immediate and long-term sequelae of congenital infection, potential for antepartum prophylaxis/therapy to reduce neonatal sequelae, and methods for primary prevention by prevention of maternal infection.

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Much has been learned about the human B19 parvovirus since it was first identified by Cossart et al1in 1975 while developing a counterimmunoelectrophoresis assay for hepatitis B surface antigen. Indeed, it was the location of the "false-positive" precipitin line on the electrophoresis gel that gave the human parvovirus its B19 designation. There are no other human parvoviruses known. Numerous diseases in humans have been linked to human B19 parvovirus including aplastic crisis in patients with chronic hemolytic anemias, erythema infectiosum or fifth disease, arthritis, chronic anemias in the immunocompromised, necrotizing vasculitis, and generalized edema. Fetal consequences of maternal parvovirus infection include nonimmune hydrops, anemia, myocarditis, and death. Infection in newborns has been linked to hepatitis and transfusion-dependent anemia. In this article, we will review all aspects of parvovirus infection with emphasis on infection in pregnancy.

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Hepatitis C virus (HCV) is a specific causative agent of what was formerly known as "non-A, non-B hepatitis." Once thought to be a disease of little significance, HCV now is recognized as the most common cause of posttransfusion and chronic viral hepatitis in the Western world and ranks only slightly below chronic alcoholism as a cause of cirrhosis, endstage liver disease, and hepatocellular carcinoma in the United States.1,2Infection by HCV is often silent and only discovered by serologic screening such as occurs during blood donation or routine health screening. The recent discovery of the HCV genome in 1989 by Choo et al3has led to the development of diagnostic tests and a better understanding of the natural history of this disease. Although HCV infection causes less acute disease than does hepatitis B, it accounts for twice as many deaths. Costs for treatment because of HCV infection are estimated to be $600 million per year.4Hepatitis C virus also has been shown to be vertically transmitted to infants, making this disease of particular significance to the obstetrician.5,6The economic burden of progressive disease to the mother as well as the potential for maternal-fetal transmission emphasizes the importance of preventative measures and early identification and treatment of HCV. This article will review the epidemiology, diagnosis, and treatment of hepatitis C. Emphasis will be placed on recommendations for screening and counseling pregnant women diagnosed with HCV.

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Genital herpes (Herpes simplex virus, HSV) is a common sexually transmitted disease that is increasing in frequency.1An estimated 5% of reproductive age women have clinically evident disease, whereas 25-30% have subclinical infection.1,2Approximately 85% of genital infections are caused by HSV-2, and the remainder are caused by HSV-1.3,4Although HSV of either type is not typically life threatening in immunocompetent adults, perinatal transmission to newborn infants can result in devastating disease.

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

In the United States, there are an estimated 650,000-900,000 individuals living with HIV infection.1Of these, approximately 200,000-250,000 are thought to be severely immunocompromised, with CD4+T cell counts of less than 200 cells/mm3.1-4Among this population, opportunistic infections cause a great deal of morbidity and mortality. In the past few years, the face of the epidemic concerning AIDS deaths and incidence of opportunistic illnesses has been changing. There have been significant advances in the treatment of HIV and AIDS. Combination therapy using three and four drugs including the potent protease inhibitors have played a significant role in decreasing the number of deaths due to AIDS. Because of the ability of these medications to decrease the amounts of HIV viral RNA to nearly undetectable levels, and in doing so, assisting in the reconstruction of the immune system, the occurrence of opportunistic infections has decreased.5Prophylactic medications to prevent opportunistic infections in the severely immunocompromised HIV-infected patient also have contributed greatly to decreasing the occurrence of these infections. These advances have changed the natural history of the AIDS epidemic. The number of cases of AIDS have decreased, and many of the previously commonly occurring opportunistic infections, the cause of AIDS-defining illnesses, are not as frequent. The incidence ofPneumocystis cariniipneumonia, toxoplasmic encephalitis, fungal infections, and cytomegalovirus (CMV) disease all have decreased.6Despite these advances, these devastating illnesses continue to contribute significantly to morbidity and mortality among the HIV-infected population, illustrating that more work needs to be done to further decrease the significant impact of opportunistic infections in the HIV-infected individual.Toxoplasmosis, Cytomegalovirus (CMV), Herpes Simplex Virus (HSV), and Syphilis are all important pathogens that co-infect patients with HIV infection, and all contribute significantly to the morbidity and mortality associated with HIV disease. Toxoplasmosis has been reported in 1-5% of patients with AIDS. Toxoplasmic encephalitis has been reported as the AIDS-defining illness in 45-60% of HIV-infected patients.7,8Cytomegalovirus is also a significant contributor to morbidity and mortality in the HIV-infected population. Cytomegalovirus-related disease has been reported to occur in 40% of HIV-infected patients.9The virus has been implicated in pathologic processes of the eye, gastrointestinal tract, and pulmonary system as well as involvement of almost every major organ system of the body.Herpes simplex virus also can have a serious impact on the course of HIV disease, with frequent relapses and recurrences, and is included in the Centers for Disease Control (CDC) criteria for an AIDS-defining illness.10Syphilis also has an impact on those dually infected with it and HIV. Several reports question the efficacy of routine therapy for syphilis in the HIV-infected patient. Given the relation between the spread of syphilis and HIV, the impact of co-infection with these organisms is monumental.Thus, with these disease entities exerting a profound impact on the health status of the HIV-infected individual, knowledge of the patient's serologic status concerning these pathogens perhaps could significantly affect the ability to predict the occurrence of disease. Prophylactic measures then could be instituted. This article will examine these four major causes of morbidity and mortality in the HIV-infected population and examine the role of screening for these various infections in this population.

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

摘要:

Toxoplasmosis when acquired by the immunologically naïve woman during early pregnancy, although a rare event in the United States, can infect the fetus and cause devastating consequences.1Recent advances in both immunologic and molecular biologic technologies have provided clinicians the ability to identify early pregnancy-associated maternal infection as well as the potential to reliably diagnose in utero infection.2,3Because of the potentially severe fetal effects of toxoplasmosis and because there are therapies known to modify these effects, it is desirable that pregnancy-associatedToxoplasmainfections be accurately identified. Not only is it important to avail treatment for the genuinely infected fetus identified by a "true positive" test, but it is also essential that unneccessary maternal anxiety, administration of potentially toxic antibiotics, or perhaps proceeding with interruption of pregnancy for "false positive" diagnoses be avoided.1,2Because most acuteToxoplasmainfections are relatively asymptomatic, the problem that obstetricians face is how to identify affected pregnancies. One strategy that has been discussed frequently, but never widely adopted in the United States, is that of routine population screening. Although the adoption of such a strategy intuitively seems the obvious solution to the problem of congenital toxoplasmosis, certain caveats must first be recognized and rigorously considered. These caveats include problems related to the diagnostic accuracy of available testing technologies and the attendant critical statistical considerations for such screening tests applied to large populations having variable disease prevalence.4,5The purpose of this article is to provide an understanding of the mathematical underpinnings of screening tests used in medical practice. The focus of our discussion is the problem of congenital toxoplasmosis, a rare but often silent and devastating disease, and the effort to identify cases utilizing a pregnancy maternal serum screening strategy. We also provide hypothetical examples and a concrete example from the Papanicolaou (Pap) Test, a more familiar and highly regarded screening test used in clinical obstetrics and gynecology. To begin, we outline some basic notation and formulas that may simplify our later commentary.

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID

ISSN:0009-9201    

出版商:OVID    

年代:1999

数据来源: OVID