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cardiomyopathy. C. psittaci is a tropical disease and is discussed later in the chapter with other tropical infections.
C. trachomatis is the most commonly reported sexually transmitted disease in the United States. It causes
infection of the maternal birth canal and can ascend to cause neonatal conjunctivitis and blindness,
naso-pharyngitis, otitis media, and pneumonitis. C. trachomatis infection is associated with premature delivery,
spontaneous abortion, stillbirth, and ectopic pregnancy. The organism is common among pregnant women
with an estimated prevalence of 5“22%. Therefore, it is recommended that all women under the age of 25, and
those at increased risk of infection (e.g. multiple sexual partners) be screened and treated.11 The vertical
transmission rate of C. trachomatis is estimated to be 55%.12 Untreated infection of the neonate may lead to
pneumonia and prolonged apneic spells. Eyrthromycin is the treatment of choice. Azithromycin is an
alternative therapy and has been shown to be safe in pregnancy and more efficacious than erythromycin.13,14
Eradication of C. trachomatis should include treatment of the mother and her sexual partner. Vaccines against
Chlamydia are being researched currently.
15
Listeria monocytogenes Mother: usually a mild flu-like (abdominal pain) illness, CNS symptoms (if meningitis occurs). Infant: sepsis,
pneumonia. Macroabscesses in the placenta.
Treponema pallidum Clinical manifestations depend on chronologic state of the disease, the second phase associated with splenomegaly,
lymphadenopathy, and widespread mucocutaneous lesions; tertiary phase characterized by cardiovascular and
central and peripheral nervous systems lesions; linked to low socioeconomic standards; perinatal mortality ¼ 60/
1000 deliveries of newborns > 1000 g.16 Recent increase in incidence has occurred in homosexual men.17
Streptococcus species (Group A Group A: symptomatology varies from mild influenza-like illness to tachypnea/cyanosis with poor peripheral
beta-hemolytic; Group B circulation. Cases of puerperal sepsis; postpartum meningitis and maternal death have been reported following
streptococci) epidural anesthesia.
Group B: postpartum meningitis; bimanual examination of the parturient prior to rupture of membranes may
lead to invasion of blood stream by unsuspected vaginal Group B streptococci, leading to meningitis before
onset of labor. NSAIDs may induce progression of streptococcal (A and B) infections to toxic shock syndrome.5
Association between bacteriuria and pyelonephritis in pregnancy, hypertension, preeclampsia, anemia;18
Escherichia coli
predisposition to ulcerative colitis? (elevated urinary antibodies to E. coli).
Staphylococcus species Vertical transmission, extradural abscess formation may be related to extradural analgesia; sepsis with multiorgan
(S. aureus, S. hemolyticus, system involvement; if associated with ARDS in pregnancy, extracorporeal carbon dioxide removal may be life
S. epidermidis) saving. Relationship between the use of NSAIDs and the progression of staphylococcal infections to toxic shock
syndrome?,19
Campylobacter species Bacteremia, Guillain-Barr´ syndrome, and reactive arthritis are the most serious of the long-term consequences of
e
C. jejuni infection.
Diarrhea leading to maternal dehydration and electrolyte disturbances; 90% prematurity, 80% neonatal
mortality rate.20
Actinomycosis israeli Right flank pain, infection may be clinically confused with appendicitis.
Pertussis species The incidence has risen in recent years; highly contagious respiratory disease, infected adolescents and adults with
mild illness are source of potentially life-threatening illness in infants and young children. Acellular pertussis
vaccines are recommended for entire primary vaccination series.21
Clostridium botulinum Anerobe producing potent food-related toxin; maternal GI upset, dehydration, lethargy, slurred speech, muscle
weakness, # FRC; preterm labor, abruption; toxin does not cross placenta.

HIV ¼ human immunodeficiency virus; CNS ¼ central nervous system; g ¼ grams; GI ¼ gastrointestinal; FRC ¼ functional residual capacity; ARDS ¼ adult
respiratory distress syndrome; NSAIDs ¼ nonsteroidal anti-inflammatory drugs




322
Chapter 18


immunodeficiency virus (HIV), hepatitis viruses, herpes simp-
Table 18.2 Maternal sepsis lex viruses, cytomegaloviruses, papillomaviruses, parvoviruses,
and the viruses that cause chickenpox, measles, influenza, and
Risk factors Previous history of recent upper respiratory or
rubella. Maternal viral infection is associated with an increased
urinary tract infection, premature rupture of
risk for adverse perinatal outcome. The acronym TORCH is fre-
membranes;18,27 >24 hours prolonged
quently applied to agents known to cause serious congenital
fasting;18 bimanual examination of parturient
infections. Except for Toxoplasma gondii, all TORCH agents are
with asymptomatic bacteruria prior to rupture
viruses: rubella, cytomegalovirus, herpes simplex, varicella zos-
of membranes.
ter, and HIV.
a
Clinical findings Minor: increased fetal tachycardia, shivering,
Use standard precautions by wearing gloves, using eye protec-
hyperthermia, meconium-stained amniotic
tion, and taking care when handling blood and body fluids.
fluid, dystocia;18
Absolute: body temperature >38 8C or <36 8C,
a white blood cell count >12 000 cells/mm3,
Human immunodeficiency virus
<4 000 cells/mm3 or >10% immature
HIV/acquired immunodeficiency syndrome (AIDS):
(band) forms.27
epidemiology and implications for the obstetric
Metabolic acidosis, altered mental status, and
anesthesiologist
oliguria are all signs of hypoperfusion and
Human immunodeficiency virus (HIV disease or AIDS) is the
severe sepsis.
greatest health crisis of the twentieth and early twenty-first
Procedures Continuous fetal heart monitoring; fetal scalp
century. For example, HIV/AIDS-associated disease was the lead-
pH sampling. Extracorporeal carbon dioxide
ing cause of mortality at the Johannesburg Hospital, South Africa,
removal combined with low-frequency
in 2000/2001 (42.7%, increasing from 20% in 1995/1996) with
positive pressure ventilation may be life saving
pneumonia the commonest cause of death.40 AIDS is also a
for ARDS unresponsive to traditional therapy
major cause of death in the USA where, as of December 2004,
(PaO2 <50 mmHg on 100% oxygen).28
944 306 persons had a diagnosis of AIDS and 529 113 (56%) died.41
a
At least two minor clinical findings must be present in the absence AIDS is a multiorgan disease that has broad implications for
of any risk factors for 95% confidence interval to diagnose sepsis.18 anesthesiologists, requiring an increasing amount of care. Risk
factors include: homosexuality, i.v. drug use, sex with an i.v. drug
abuser, crack cocaine use, blood transfusion, sexually transmitted
and antibiotic therapy. Since sepsis is associated with a high risk
disease, multiple sexual partners, and tattoo of body surfaces.
of progression to acute lung injury or ARDS, careful evaluation
Screening women with risk factors detects about one-half of
should be made prior to extubation of the trachea. Ketamine has
those who are HIV-seropositive, but if screening is applied to all
been advocated for anesthesia in septic patients because it is a
pregnant women the rate increases to 87%.42 These data, among
cardiovascular stimulant. However, if endogenous catechola-
others, led the Centers for Disease Control (CDC) in 2006 to
mine stores are exhausted, ketamine may act as a cardiodepres-
change its recommendation to advocate routine voluntary HIV
sant. Ketamine attenuates liver injury from endotoxemia by
screening as a normal part of medical practice in the precon-
reducing cyclooxygenase-2 (COX-2) and inducible nitric oxide
synthase (iNOS).36 However, it takes supra-anesthetic doses of ception period or in early pregnancy. A second screening test
should also be recommended in the third trimester. If a high-
ketamine to inhibit endotoxin-induced pulmonary inflammation
in vivo.37 Etomidate is another potential anesthetic induction risk woman with undocumented HIV status presents for labor,
then a rapid test can be performed. Women have the option to
agent in sepsis since it maintains cardiac function, but it has the
decline testing (opt-out screening).41 The enzyme-linked immu-
potential to impact negatively corticosteroid production. Since
noabsorbant assay (ELISA) and the Western Blot remain the
severe sepsis is associated with relative adrenal insufficiency,
main tests for the initial diagnosis of HIV infection. Measures
etomidate may not be the best option. Propofol is not indicated
of CD4þ T-lymphocytes are used to guide clinical and thera-
in these women as it causes dose-dependent hypotension, parti-
peutic management of HIV-infected individuals.42
cularly with intravascular volume depletion. The use of desflur-
ane during septic shock has been reported.38 Maintenance of Primary care for HIV-infected patients includes ensuring that
eligible patients receive hepatitis B and A virus vaccinations, that
anesthesia with an infusion of i.v. ketamine (2“4 mg/kg/h) and
all women undergo appropriate screening and follow-up for cer-
O2/N2O is one option. Prophylactic treatment with nitric oxide
vical cytologic abnormalities, and screening for renal function
donors regulates systemic inflammatory response and minimizes
renal damage in experimental models.39 abnormalities.

HIV impact on pregnancy and the fetus
Viral infections (see Appendix to Chapter 18
Ninety percent of children infected with HIV contract the virus
for viral classification)
from their mother while in utero, during delivery, or postpartum.
Worldwide, mother-to-child transmission of HIV-1 is estimated
Viral infections in pregnancy are of concern to the obstetric
to be responsible for 1800 new infections in children daily.
anesthesiologist. Viruses of clinical interest include human



323
5 Other disorders


Regional versus general anesthesia:
Antiretroviral therapy significantly reduces the risk of transmis-
anesthetic considerations
sion. When highly active antiretroviral therapy (HAART) is used,
mother-to-child transmission rates are reduced to < 2%, in the Human immunodeficiency virus infection should not contrain-
absence of breastfeeding.43 In the USA the number of children dicate regional anesthesia, as there is no direct evidence that
with AIDS from perinatal HIV transmission peaked at 945 in 1992 lumbar puncture facilitates central nervous system (CNS) disease
but declined by 95% in 2004.41 Asymptomatic HIV positive by introducing virus from blood into the cerebrospinal fluid
women with a CD4þ count below 500/mm3 or p24 antigenemia (CSF). In addition, HIV has low infectivity. General anesthesia
were found to be ten times more likely to transmit the virus to (GA) is safe, but drug interactions and their impact on various
their offspring.44 The presence of a low CD4þ lymphocyte count organ systems should be considered. Regional anesthesia is often
early in pregnancy may help women decide whether to discon- the technique of choice. Nevertheless, one must take into con-
tinue the pregnancy. sideration the presence of neuropathies, local infection, or blood
Breastfeeding significantly increases the risk of HIV transmis- clotting abnormalities. Sensory neuropathy, manifest by painful
sion. Breastfeeding adds a 12“26% risk of vertical infection over dysesthesias, especially in the feet, is common, occuring in 10% to
30% of AIDS patients.54 This poses a challenge for the anesthe-
and above the risk of transmission at delivery or in utero. In one
study, up to 35% of all HIV-infected children had been infected siologist presented with an AIDS patient without a central or
through breastfeeding.45 Risk factors for HIV transmission by peripheral neuropathy.55 The appearance of neurologic symp-
breastfeeding include acquiring HIV postpartum while breast- toms shortly after delivery could represent natural evolution of
feeding (29% risk of transmission vs. 10% risk if infected before the disease or an anesthetic complication. Among asymptomatic
pregnancy); degree of maternal plasma and breast milk viral HIV-positive individuals, 40“60% have positive CSF markers for
load; and the presence of mastitis.45 As a result, HIV-infected viral infection, indicating early involvement of the CNS.55,56 Some
women are advised against breastfeeding. Possible solutions to suggest avoiding GA in AIDS patients if a regional technique is
possible because of depressed immunity.57 If GA is used, HIV
allow breastfeeding include use of antiretroviral therapy and
treatment of the infected milk.46 It is uncertain if maternal HIV patients with CNS disease may be more sensitive to psychoactive
infection increases adverse perinatal outcomes, such as preterm drugs such as benzodiazepines, opioids, and neuroleptics. This
labor. A neonatal evaluation at 12 months of age is required to sensitivity may be due to the interaction between interleukin-1 (a
be certain of the HIV status of a child born to a HIV positive cytokine with sedative effects released in the acute phase reaction
mother.47 to viral or bacterial infection) and the g-aminobutyric acid-A
(GABA-A) receptor.58 Thus, AIDS patients may be more sensitive
HIV-infected babies have the same frequency of congenital
abnormalities as those not infected and there is no consistent to GABAergic drugs such as barbiturates, benzodiazepines, and
pattern of defects. This suggests that viral transmission occurs propofol during the acute viral phase. If etomidate is used, early
late in pregnancy or at the time of delivery.48 Precautions to neonatal feeding is recommended in order to avoid neonatal
reduce the risk of transmission include removal of all maternal hypoglycemia. Etomidate has a transient depressant effect on
blood and fluids immediately after delivery, avoiding percuta- fetal plasma cortisol levels, especially those subjected to intra-
neous umbilical cord sampling and fetal-scalp electrodes, and uterine stress. Onset time and duration of vecuronium in AIDS
patients may be prolonged compared to noninfected controls59
avoiding vacuum or forceps delivery.
because of peripheral neuropathy60 and the effects of zidovu-
dine61 and didanosine.62 AIDS patients may suffer more frequent
Cesarean section versus normal vaginal delivery
Although C/S produces higher rates of septicemia and puerperal neuroleptic-induced extrapyramidal signs after physostigmine,
fever compared with vaginal delivery, a C/S in the HIV parturient droperidol, or carbamazepine. The latter should all be used in
has the advantage of reducing the time of contact between mater- lower doses. Halothane and isoflurane inhibit interferon-a/b
nal blood and the neonate. Indeed, a Cochrane review concluded (INF-a/b) inducible cytotoxicity related to natural killer (NK)
that elective C/S is an efficacious intervention for prevention of cells. The loss of sensitivity of NK cells to stimulation by INF-a/b
mother-to-child transmission of HIV-1 in those not taking anti- could be expected to compromise the NK cell effectiveness in
retroviral drugs or just taking zidovudine.49 However, if C/S is postanesthetic immune responses. Interestingly, NK activity
performed once labor has started then it confers no protective already enhanced by IFN-a/b before exposure to anesthetics is
not affected by anesthesia.63 Opioids may reactivate latent CNS
effect against intrapartum transmission of HIV-1. There is little
HIV infection.64 Morphine has been shown to reactivate or sti-
evidence to suggest that HIV or antiretroviral drugs increase the
mulate HIV reproduction in vitro.65 Morphine potentiates apop-
rate of pregnancy complications or that pregnancy alters the
tosis within human fetal neuronal cell cultures66 and attenuates
course of HIV infection. Isolation of HIV-1 from cervical secre-
tions of women at risk has been described previously.50 The the antiHIV activity of T cells in HIV latently infected cells.67 In
cervical mucus plug has antimicrobial properties and represents vivo animal models have shown a suppression of humoral and
a physical/chemical barrier against bacterial (and viral?) inva- cell-mediated immune responses by opioid agonists through
sion.51 Rupture of membranes for !4 hours is also another risk direct68 and indirect mechanisms.64 Some studies demonstrating
factor.52 The risk of infection in the first-born twin is 2.8-fold viral reactivation64 or opioid immune supression68 were in
greater than that of the second,53 possibly as a result of a pro- patients who required chronic opioid use. Despite these studies,
longed contact with maternal blood. short-acting opioids may be the analgesic choice in balanced GA.



324
Chapter 18


survivors have significant residual neurologic deficits.76 Herpes
Further studies are required to predict the overall perioperative
risk for the HIV-positive patient. encephalitis is part of the differential diagnosis of seizures during
pregnancy.77 One report describes the failure of acyclovir to
Conclusions prevent neonatal infection in a parturient with herpes type 2
encephalitis.78
In the absence of intracranial hypertension and coagulopathy,
neuraxial anesthesia is recommended for surgical procedures in There is evidence of HSV-1 reactivation in patients after the use
of epidural morphine,79 epidural fentanyl,80 and intrathecal mor-
parturients with AIDS, independent of gestational age. However,
phine.81 The mechanism is unclear, but opioid activity within the
the mother should have the risks and benefits of a general versus
spinal nuclei of the trigeminal nerve may be responsible.79
regional anesthetic technique explained, and she must partici-
pate in the decision-making process. The use of neuraxial opioids
in patients with HIV has not been fully studied.
Cytomegalovirus
Cytomegalovirus (CMV) seroprevalence among women of child-
Viral hepatitis (see also Chapter 14)
bearing age ranges from 30“100%.82 Its incidence in the lower
genital tract has been reported to be from 4“12%,83 and CMV
Acute viral hepatitis is the most common cause of jaundice in
pregnancy. The course of most viral hepatitis infections (hepatitis is the major pathogen detected in cases of placental infection
associated with fetal death.84 Clinical manifestations of virus
A, B, C, and D) is unaffected by pregnancy. A more severe course
of viral hepatitis in pregnancy is seen with hepatitis E.69 For replication are seldom seen, except in immunocompromised
further details see Chapter 14. individuals. Following primary infection, the virus can be isolated
from urine for months to years, with a greater risk of neonatal
infection among mothers who continue to shed virus.
Herpes simplex viruses (HSV)
Congenital CMV infection is the leading cause of mental retar-
Herpes infection occurs in approximately 1 in 7500 births in the dation and hearing impairment. Following primary CMV infec-
United States.70 Most patients with HSV-2 antibodies have no tion, the rate of transmission to the fetus is about 40%. More than
historical, clinical, or virological evidence for HSV-2 infection. 90% of the approximately 40 000 infants with congenital CMV
infection born in the USA each year appear normal at birth.85
They are identified as HSV-2 carriers on the basis of HSV-2 anti-
body screening. Herpes simplex virus-1 has been isolated from Cytomegalovirus recurrence during pregnancy appears to be
the genitourinary tract or anal canal in 3.5% of women with mainly due to reactivation rather than reinfection. However, in
HSV-1 antibodies,71 and of these 66% were symptomatic. In low-income nonwhite women a high proportion of congenital
Europe, clinically probable genital herpes was observed in 25% CMV infection is due to recent maternal infection and not reacti-
vation of infection.86 Maternal humoral immunity may not pro-
of subjects with HSV-2 infection and in some subjects with HSV-1
infection. Coinfection with HSV-1 appeared to protect against tect the fetus, which can become infected after recurrent and
symptom expression in those infected with HSV-2.72 primary maternal infection. There is a high incidence of CMV
In primary HSV infection, dysuria is the most common com- reactivation in mothers during lactation, and a significant risk of
transmission to preterm infants through breast feeding.87
plaint (80% of patients). In one study, 70% had vulvar ulceration,
66% had tender inguinal lymph nodes, and 46% had a cervical To date, there is no effective intervention for primary CMV
ulcer. Of those with recurrent genital infection, two-thirds had during pregnancy, but in one study hyperimmune globulin ther-
vulvar ulcers.73 Serologic tests for HSV-2 are reliable for detecting apy was found to be safe and it produced a significant reduction
in congenital CMV infection.88 Controlled studies are required to
recurrent genital infections, while culture is the most effective
diagnostic technique for primary infections.73 confirm this benefit. Elective C/S is recommended for infected
Women with asymptomatic or unrecognized HSV-2 infection individuals since cervical contamination is usually responsible
for neonatal infection.85 However, since placental infection
are at risk of delivering babies who develop neonatal herpes.
occurs in 4% of women with CMV,84 C/S will not prevent all
Neonatal herpes infection is associated with significant morbidity
and mortality, despite antiviral therapy.71 Most fetal complications cases of neonatal CMV. The primary means of prevention of
result from ascending infection after rupture of membranes or CMV is avoidance of infection during pregnancy through good
passage of the neonate through an infected birth canal. If lesions personal hygiene.
are present at the time of delivery then C/S is recommended.74 There are no special anesthetic considerations for the parturi-
General, epidural, and spinal anesthesia have all been used ent with CMV infection. It should be kept in mind, however,
safely in women with active recurrent herpes simplex lesions. that immunocompromised patients with CMV may develop
Although concerns exist about introducing virus into the CNS fulminant hepatitis or significant neurologic disease including
myelitis.89
during primary infection, only one report of transient postpar-
tum neurologic deficit in association with regional anesthesia
and primary infection has been published.75 Nonetheless, some
Human papillomavirus
caution against the use of regional anesthesia during primary
infection because herpes simplex encephalitis is such a devastat- Human papillomavirus (HPV) is a very common sexually trans-
ing infection. Indeed, despite antiviral therapy, two-thirds of mitted infection in the USA and sexually active adolescents are at



325
5 Other disorders


nonpregnant varicella pneumonia.99 In-utero infection can pro-
high risk. There are over 100 serologic types of HPV and > 99.7%
of cervical cancers contain at least one high-risk type, with duce congenital varicella syndrome, postnatal herpes zoster with-
approximately 70% containing types 16 and 18.90 Vaccines are out a history of chickenpox in an infant, or positive immunity
without clinical signs.100 Maternal viremia leads to transplacental
available for various serotypes of HPV, with the initial targets
being types 16 and 18, and types 6 and 11.91 It is hoped that infection of the fetus in 25% of cases. Congenital varicella syn-
widespread use of these vaccines will significantly reduce future drome occurs when the fetus is infected during the first half of
morbidity and mortality from carcinoma of the cervix. pregnancy. Affected newborns are likely to have intrauterine
Human papillomavirus 6 and 11 infections are responsible for growth restriction (IUGR) and skin changes, e.g. hypertrophy,
90% of genital warts and nearly all recurrent respiratory papillo- erythema, and scar formation (cicatrix). They may also have
matosis, but are considered low risk and unlikely to be involved brain malformations (e.g. cortical atrophy and dilated ventricles),
in cervical cancer. Most HPV infections become undetectable hypoplastic limbs, and an array of other defects, depending on
within one to two years, perhaps as a result of type-specific the timing of infection in relation to organogenesis. Congenital
varicella syndrome occurs in 0.4“2.0% of infected mothers.101
acquired immunity. Multiparity, oral contraceptives, and smok-
ing are risk factors for persistence and progression of the disease. Varicella-zoster immune globulin is given to exposed VZV-
This reflects an increased expression of the virus as a conse- seronegative pregnant patients. Those women with a past history
quence of hormonal depression of the immune system. of chickenpox or positive VZV serology are considered to be
Condyloma from HPV infection begin as small, verrucose immune. With the introduction of the varicella vaccine, the rate
growths, usually on the vulva or genital area. Dysplasia is usual. of varicella in pregnancy is expected to decrease dramatically.
There is a marked tendency for the lesions to become more Pregnancy should be avoided within one month of varicella
prominent during pregnancy and to coalesce into cauliflower- vaccine and the vaccine should not be given during an existing
pregnancy.102
like or raspberry-like masses. These are occasionally so extensive
as to cause obstruction of the birth canal.92 Spinal anesthesia for C/S in a woman with varicella has been
described.102 The woman was noted to have active lesions, fever,
Massive vulvar lesions may expose the parturient to lacera-
tions, sepsis, and significant bleeding during vaginal delivery so and a productive cough at 39 weeks™ gestation. She was given
elective C/S may be preferable. An association between maternal varicella immunoglobulin and surgery was deferred for nine
condyloma accuminatum and neonatal laryngeal papillomatosis days at which time she was afebrile and the lesions were dry
is controversial.93 Neonatal infection may occur transplacentally, and crusted. An uneventful spinal anesthetic was performed in
but there may be greater risk of transmission from vaginal deliv- an area of skin free of lesions. Her fetus had congenital disease
ery. Prolonged labor is associated with a two-fold greater risk of and was treated with acyclovir.
disease transmission.94 The CNS is the most common site for extracutaneous involve-
Laser treatment of HPV produces a plume that can contain ment with varicella and CNS infection can lead to acute cerebellar
infective particles,95 so surgical smoke should be evacuated and ´
ataxia, encephalitis, meningitis, or Guillain-Barre syndrome.
all personnel attending laser therapy should wear special face Brown and colleagues speculated that a pencil-point spinal nee-
masks and eye protection. dle would be less likely than an epidural needle to core tissue and
introduce infected cells into the neuraxis.102 They recommended
that GA be used when active lesions are present. Before antiviral
Varicella-zoster virus (chickenpox)
therapy, 65% of pregnant women with varicella developed vari-
Varicella-zoster virus (VZV) is highly contagious with secondary cella pneumonia “ the current rate is <10%. High death rates have
attack rates of 80“90% and seroprevalence rates > 90%.96 been observed with varicella pneumonia during pregnancy,99 but
Approximately 7000 pregnancies annually are complicated by a recent series of 18 women with varicella pneumonia reported no
varicella,97 while about 6000 pregnant women annually have maternal deaths.103 This suggests that antiviral therapy is effec-
herpes zoster.98 The average incubation period is 14 days. It tive (e.g. acyclovir 7“10 mg/kg i.v. three times a day for seven
days).103 Although prior VZV infection is thought to confer immu-
occurs more frequently during late winter and early spring. A
day after onset of fever, a nonsynchronous maculopapular rash nity, exposure of medical personnel (and others) to infectious
appears on the skin and mucosa. The lesions undergo vesicula- patients should be avoided or minimized since secondary infec-
tions are more common than previously thought.102
tion and appear as pruritic, superficial thin-walled vesicles, aris-
ing in crops.
The incidence of VZV is no higher in pregnant than in non-
Rubeola (measles)
pregnant women. Varicella-zoster virus primary infection, or
chickenpox, during pregnancy appears to be associated with Measles is a highly contagious exanthematous viral illness cau-
increased maternal morbidity and mortality. Pregnant women sed by a paramyxovirus (Morbillivirus). Its incidence worldwide
are more likely to develop hypoglycemia, pneumonia, encepha- has decreased dramatically since the introduction of effective
litis, hepatitis, pancreatitis, and nephritis after chickenpox infec- vaccines, nevertheless, outbreaks still occur among clusters of
tion. Most cases of varicella pneumonia in pregnancy occur in the individuals, especially young adults that vaccination programs
third trimester. In one report of 17 cases of varicella pneumonia have failed to reach. In 1997, it was estimated that 50 million
cases occur annually worldwide with 1 million deaths.104
during pregnancy, the mortality rate was 41% compared to 17% in



326
Chapter 18


Although substantial progress has been made worldwide in vac- population is susceptible to the virus, while 20% will become
infected after exposure.111 Approximately 1“5% of pregnant
cination programs, measles still remains the fifth leading cause of
mortality among children under five years of age.105 Susceptible women will be affected, with most having a normal outcome.112
young women are at unique risk because measles in pregnancy The risk of fetal death from placental transmission of parvovirus
ranges from 1% to 15%,113 with an increase in adverse outcomes
follows a more complicated course than in nonpregnant women.
Measles in pregnancy is defined as an illness in a pregnant when maternal infection occurs in the first two trimesters.
woman meeting the definition for ˜˜probable measles™™ by the Maternal symptoms include malaise, low-grade fever, maculo-
CDC. This clinical definition includes generalized rash, which papular rash (˜˜slapped cheeks™™), and a symmetric polyarthralgia
occurs simultaneously with the onset of the effector phase of involving the hands, wrists, and knees that resolves sponta-

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