Infections in Pregnant Women - Role of Diagnostic Microbiology

Pregnancy is a dynamic state of health and disease, shared by the pregnant woman and a growing fetus, a concern to the treating physician for timely diagnosis and necessary interventions. Infections with Viral, Bacterial, Parasitic and Fungi do occur in any pregnant woman like other non pregnant woman of similar age.

Most infections are not serious. But some infections are more important in pregnant woman than in non pregnant woman because of the potential for vertical transmission to foetus or infant. There is a growing awareness on HIV, HBV, CMV, Rubella and Toxoplasmosis, on rare occasions Varicella and Listeriosis can do harm to the growing foetus. With advances in medical treatments and laboratory technologies we are more concerned with transmission of HIV, and HBV as we can still interfere with appropriate treatments. Now it is certain, every pregnant woman needs a successful screening for Rubella IgG, HBV surface antigen, and HIV antibodies apart from existing protocol for screening for Syphilis in all pregnant women with VDRL / RPR testing.

WHY GOOD CLINICAL MICROBIOLOGY SERVICES ARE IMPORTANT

No laboratory test for diagnosing a specific disease should be undertaken on a casual testing basis without knowing the implication of a positive value of test. Women are more willing to accept routinely offered testing as in screening for syphilis with. The situations to screen for antibodies to HIV turn to be entirely different and needs an informed consent, as every woman has a right to refuse any medical investigation or treatments.

UNDERSTANDING MICROBIOLOGY REPORTS WITH IMPLICATIONS ON FETAL HEALTH

There is an unlimited gap of understanding between the laboratory reports and the treating physician, which should be always brought down for improving our quality of services.

1. All requests for any particular serological or molecular testing should be based on clinical symptoms (May not necessary as in HIV, HBV, CMV and Syphilis which are symptom free in early stages.)

2. Writing a good clinical history will certainly guide the testing clinical microbiologist to use the right protocol in the laboratory methods.eg. Toxoplasmosis, CMV, Rubella to determine the active infection.
INTERPRETATION OF RESULTS RUBELLA, CMV, TOXOPLASMOSIS, VARICELLA Infections.

1. Clinicians should request for IgG in all cases apart from IgM which is only positive in recent infections.

2. Best serological evidence of recent infections is IgG seroconversion (a change from a negative test to positive test) to understand all serological tests which turn out to be negative on first testing, do not exclude recent infections. Testing should be repeated upto three weeks after suspected contact, which may be extended up to 6 months in cases of diagnosis of HIV Infection for appearance of antibodies.

3. When a specific IgM is positive without IgG being positive results should be interpretated with caution. If Ig G seroconversion do not occur the IgM result is likely to be a false positive

4. The question comes how recent is infection: can be clarified with newer generation of serological testing in accredited laboratories. The clinicians should ask for IgG avidity assays which will help confirm or exclude recent infection. ( Eg , Toxoplasmosis, Rubella and CMV ) As high avidity indicates that infection occurred several months previously. Interpretation depends on laboratory protocols and should be discussed with clinical microbiologists.

HIV SCREENING OR TESTING

The problems of screening all pregnant women for HIV antibody is a complex issue. It should be discussed and issue can be still be resolved if offered as testing with motive of offering antiretroviral therapy to both mother and new born if infected.

SCREENING FOR SYPHILIS (WITH VDRL/RPR)

A routine test done in every pregnant woman irrespective of consent is associated with biological false positives. Every positive test should be reconfirmed testing with TPHA, a specific test to detect active infection. Testing with FTAbs IgG remains the best option before diagnosis of syphilis is ruled out.

BACTERIAL INFECTIONS IN PREGNANT WOMEN

Many bacterial infections have Major effect on women’s health with implications on the New born.

URINARY TRACT INFECTIONS

Urinary tract infections remain the most common infections at any stage of pregnancy. Many present with asymptomatic infections, Asymptomatic bactenuria which can only be identified on culturing the urine. It is ideal to order culturing in early pregnancy to be followed upto the last trimester of pregnancy. Most neglected part of urine culturing remains with proper collection of specimen and often left to an inexperienced nursing staff. The treating physicians should instruct the staff how to collect a mid stream and a clean catch sample.

Less experienced Microbiologists give confusing reports but should not forget to specify the validity of report. A cut off point of ? 100,000 bacteria/ml is the minimal criteria in healthy pregnant women with isolation of a single species e.g. E.coli, Klebsiella species will strengthen the diagnosis of urinary tract infections. Missing of asymptomatic bacteriuria can cause premature labor and pylonephritis in pregnant women.

GROUP-B STREPTOCOCCAL INFECTION

There is a growing awareness on infections with Group B Streptococci. CDC advices culturing for Streptococcus B group at 35-37 weeks of pregnancy is important which can help to prevent early neonatal infection particularly premature labor. Appropriate collection of specimen from cervix remains the minimal requirement
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GONOCOCCAL AND CHLAMYDIAL INFECTION

They need specific or specialized techniques for precise diagnosis but only ordered in high risk group of women as they can lead to pelvic inflammatory diseases. The physician should discuss with clinical microbiologist as routine testing is not possible in less equipped laboratories and will not serve the purpose

BACTERIAL VAGINOSIS AND CANDIDIAL INFECTIONS

There is a growing incidence of Gardnernella vaginalis and Candidial infection. Few laboratories have adequate facilities for characterization of etiological agents. The clinical requests should specify what they are looking for.Today we have an ever growing list of microbes including Varicella, Herpes simplex, Parvovirus B19, Listeriosis and many others encroaching on pregnant women. An appropriate investigation and management can reduce adverse outcome, unnecessary interventions and anxiety. The need of the hour in up gradation of our Microbiology laboratories to cope, with changing trends in infection as there is ever-increasing list of Microbes harming a pregnant women and the growing fetus.
CAUTION ON MOLECULAR METHODS

All molecular methods for diagnosis of infectious diseases ordered with caution. It is ideal to try all time tested laboratory methods and to consider the using of molecular methods which on many occasions are research or academic tools with good number of false positive reactions.


In spite of several advances in Laboratory Technologies in Developing countries, we in India must depend on the wisdom of our Physicians, as our patients do not afford many investigations on random basis or for Academic interest. However, antenatal screening that is not based on accepted criteria or well defined plan of action can cause unnecessary anxiety and potentially dangerous intervention. Still we know little how a Fetus protects and survives itself in spite of several challenges apart from Infections.

Email; tvraodoctor2000@yahoo.co.in


Dr.T.V.Rao MD working as Professor in an Indian Medical College, writes on articles of Public health interest to bring in more awareness to bring in better health care