Infections Acquired in Uterus

There is a surprising similarity in the clinical features of a group of non-bacterial infections acquired by the fetus during pregnancy and those presented in the first week or so after birth. Not all affected babies show all these features. The organisms concerned are: rubella virus, cytomegalovirus, toxoplasma gondii, herpesvirus hominis, treponema pallidum.

The clinical features in common are: central nervous system abnormalities, choroidoretinitis, osteitis, hepatosplenomegaly, anemia, purpura, intrauterine growth retardation.

Congenital Rubella. In addition to the clinical features listed above infants exposed to intrauterine rubella infection in the first three months of pregnancy may have eye defects, cardiac defects and damage to the eighth cranial nerves. The involvement of the central nervous system may lead to retarded mental development.

The diagnosis of congenital rubella infection may be confirmed by the findings of specific fluorescent antibody in the baby's struma. If both mother and baby have a raised rubella antibody the baby's titre must be measured again four to six months later. If it is still raised a retrospective diagnosis of congenital rubella can be made. Affected babies may excrete the virus for up to one year after birth and can be a source of infection to others.

Congenital Cytomegalovirus Infection. The fact that this infection occurs commonly is of importance. In the newborn it is usually symptomless, sometimes it gives rise to relatively mild effects and infequently causes a severe acute syndrome. The clinical infection may result in mental retardation in babies and there is some information to suggest that a significant number of mentally retarded children may have a subclinical infection with cytomegalovirus in the neonatal period. The finding of virus-specific IgM or the isolation of the virus indicates infection, but not necessarily a clinical disease. Retrospective diagnosis is made by finding a high titre of complement fixing antibody at birth and four to six months later.

Congenital Toxoplasmosis. The toxoplasma protozoon is commonly found in animals including the domestic ones which is a potent source of infection in man. During pregnancy the organism may be transmitted to the fetus from a mother with unrecognized mild infection. Most of the exposed infants are unaffected but the effect on the eyes and the brain in those that develop symptoms may be very severe. The diagnosis is established either by finding the organism in the CSF or by appropriate serological tests in mother and infant.

Antibiotics in Neonatal Infections. It is commonly considered unnecessary or unwise to use antibiotics for prophylaxis in the newborn. However it may be necessary to use them for a sick newborn before the laboratory confirmation of the nature of infection is made. In such circumstances all material for bacteriological diagnosis must be obtained before starting treatment.

The choice of antibiotic for a baby with a presumed infection depends on the probable site of infection and the knowledge of usual colonizing organisms in the particular hospital environment. Since these considerations will probably indicate the possibility of either a Gram-negative or Gram-positive organism it is usual to choose a broad spectrum combination of antibiotics such as ampicillin and cloxacillin, kanamycin and benzyl penicillin or gentamycin and cephazolin. In any case the antibiotic therapy must be reviewed if and when the organim and its sensitives are known. In case of meningitis chloramphenicol alone is an additional choice because of its wide spectrum and high concentration in the cerebrospinal fluid. The dose should not exceed 25 mg/kg/d in the first week of life, as high doses in preterm infants have produced collapse and death (“grey syndrome”).

Ophthalmia Neonatorum. It is a preventable disease occurring in newborn children due to maternal infection acquired as a result of carelessness at the time of birth; it used to be responsible for 50 per cent of blindness in children. Previously the disease used to be very severe but nowadays it is mild in nature.

There occurs dense infiltration of the bulbar conjunctiva, and the lids are swollen and tense. Later the lids become softer and more easily everted, the conjunctiva becomes puckered and velvety, and the blood stasis gives place to intense itching and congestion, with the free discharge of pus, serum and often blood. In some cases a false membrane forms, so that the case resembles a membranous conjunctivitis.

There is a great risk of corneal ulceration in untreated gonococcal ophthalmia neonatorum, since this organism has the power of invading intact epithelium. The slightest haziness should be viewed with apprehension, hardly metastatic stomatitis and arthritis occur. The arthritic manifestations usually appear in the third or fourth week and affect the knee, wrist, ankle or sometime elbow.

In inadequate cases serious sequelae may occur. If the corneal ulceraton heals without perforation there is always much scarring of this tissue, but the nebula clears more in babies. Perforation may be followed by anterior synechial, adherent leucoma, partial or total anterior staphyloma, anterior capsular cataract or panophthalmitis. When vision is not completely destroyed but is seriously impaired by the corneal opacities, the development of macular fixation which takes place during the first six weeks of life is impaired, resulting in the development of nystagmus which persists throughout life; this may not manifest until a later date.

The inclusion conjunctivitis is caused by a virus. As the disease is preventable, so a prophylactic treatment is, therefore, of prime importance. Any suspicious vaginal discharge during the antenatal period should be treated. The newborn baby's closed lids should be thoroughly cleaned and dried. A drop of silver nitrate solution, one percent, should be instilled into each eye. The eyes must be carefully watched during the first week.

If the disease is established and there is any purulent discharge, the eyes must be irrigated with warm saline and intensive therapy with penicillin started, using drops in a concentration of 5,000 units per ml every minute, for half an hour. Repeated irrigations are unnecessary since, in the first place, penicillin remains effective in the presence of pus and, in the second, the discharge rapidly disappears. Any pus that does accumulates is wiped away with moist pledgets of cotton-wool, Penicillin drops continued at five minute interval for a further half-hour, and the treatment is consolidated by half hourly and then hourly instillations for two days or so. Astringent lotions are then employed.

An alternative is a systemic administration of full course of sulphonamides as sulphadiazine.

In default of treatment by antibiotics, or when dealing with insensitive organisms, reliance must perforce be placed on the old-fashioned treatment of repeated application of silver nitrate together with repeated irrigations with antiseptic solution. Such treatment, however, is most unsatisfactory: corneal complications frequently supervene and recovery is often slow.

Atropine should be used in all cases in which the cornea is involved since this is always accompanied by some iritis; corneal complications require very active treatment.

Birth Injuries. Birth injuries are those injuries which occur during the birth of the child. These injuries were described in special chapter.

Care of the Neonate. The care of the neonate should provide conditions favouring its development. The main principle underlying the care of the neonate is its protection from unfavourable effects of the environment, especially from possible infection.

Specially trained nurses are admitted to take care of the neonate. An obstetrician takes care of the neonate at small hospitals. Auxiliary personnel are not admitted to contact the neonate.

At the beginning of the shift, the medical personnel should obligatory wash their hands (to the elbows) using soap and a brush and then disinfect them (alcohol, lysoform, chloramine solutions, etc.). The nurse should wash her hands and disinfect them each time before swaddling the infant.

When the infant is brought into the neonate room from the delivery room, it is wrapped in warmed-up cloths, placed in bed and its condition is observed thoroughly. It should be remembered that a neonate may vomit or develop cyanosis; the umbilical stump may bleed.

Two times a day (before the first feeding and in the evening) the neonate should be given a hygienic treatment. During this procedure the infant is given a general outer examination, all skin folds are inspected, the bandage on the umbilical stump is checked, and the prescribed procedures are done. The weight and temperature of the infant are also measured.

Proper care of the infant's skin is very important since abrasion and intertrigo may become the site of entrance of infection. Purulent diseases of the skin may become the cause of sepsis.

The body of the infant is inspected during the morning and evening toilet; special attention should be paid to the skin folds where intertrigo would most likely occur (behind the ears, on the neck, in the armpits and groins, etc.).

The infant should not take bath before the umbilical cord falls off since infection is likely to enter through the non-healed umbilical wound. The washing therefore consists only in wiping the face with a piece of cotton wool soaked in warm boiled water or a 2 per cent solution of boric acid. The ears, the skin behind the ears, the skin folds on the neck, the palms and soles should be wiped with a wet cotton wool pad. The body should then be dried up.

If any reddening appears on the skin, the affected sites should be coated with sterile vaseline or sunflower oil.

The neonate should be swaddled anew after each urination or defecation (in the intervals between nursing). Soiled swaddles are replaced by clean ones, while the lower part of the infant's body should be washed in a jet of warm water. In doing so it is necessary to protect the umbilical region from wetting with water. The skin should then be dried up by touching (not rubbing!) it with a clean cloth readily absorbing moisture. For prophylactic purposes the skin of the buttocks and the groins should be coated with sterile oil.

Intertrigo would normally be the result of inadequate care of the neonate. Treatment of intertrigo includes improved care, prevention of the skin from soiling with faeces or urine. If intertrigo is insignificant (skin is only reddened), application of sterile oil would usually be enough. If the reddened skin is macerated, a 3 per cent solution of potassium permanganate should be used to treat the affected skin with subsequent powdering with the preparation of the following composition: boric acid 1.0 g, bismuth subnitrate, zinc oxide 5.0 g of each, talcum and starch (amylum), 50.0 g of each.

Prophylaxis of pyodermitis is especially important. If any purulent foci appear on the skin, the infant should be isolated from other neonates. Each pustule should be treated with an alcoholic solution of gramicidin (0.04 per cent), or potassium permanganate (3 per cent). Penicillin is often prescribed intramuscularly. The neonate should be under constant medical observation.

Care of the sense organs. The eyes of the neonate should be treated with cotton wool soaked in a 2 per cent solution of boric acid. Each eye is treated with a separate ball of cotton wool, moving it from the outer canthus of the eye to the inner one.

Wiping the ears with wet cotton during the morning toilet will normally be enough; it is unnecessary to clean the meatus.

The nostrils should only be treated if the respiration is difficult and much mucus or crusts are accumulated in them. The openings are then wiped carefully with a piece of cotton wool twisted into a cord and soaked in vaseline oil.

It is prohibited to wipe the mouth mucosa since it can easily be damaged. Even in case of thrush (the result of inadequate care and feeding) the mucosa should not be wiped but only coated carefully with a 10 per cent solution of borax and glycerol.