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Micrograph of cytomegalovirus (CMV) infection of the placenta (CMV placentitis), a vertically transmitted infection. The characteristic large nucleus of a CMV infected cell is seen off-centre at the bottom-right of the image. H&E stain. ICD-10 ICD-9 P35 771 [1] [3] -P39 [2]
A vertically transmitted infection is an infection caused by bacteria, viruses or, in rare cases, parasites transmitted directly from the mother to an embryo, fetus or baby during pregnancy or childbirth. It can occur when the mother gets an infection as an intercurrent disease in pregnancy. Nutritional deficiencies may exacerbate the risks of perinatal infection.
Classification
The transmission can also be called mother-to-child transmission. A vertically transmitted infection can be called a perinatal infection if it is transmitted in the perinatal period, which is the period starting at a gestational age of 22[4] to 28[5] weeks (with regional variations in the definition) and ending 7 completed days after birth. The term congenital infection can be used if the vertically transmitted infection persists after childbirth.
Examples
Several vertically transmitted infections are included in the TORCH complex, which stands for: 1. 2. 3. 4. 5. T Toxoplasmosis / Toxoplasma gondii O Other infections (see below) R Rubella C Cytomegalovirus H Herpes simplex virus-2 or neonatal herpes simplex
The "other agents" under O include: Coxsackievirus Chickenpox (caused by varicella zoster virus) Parvovirus B19 Chlamydia
Vertically transmitted infection HIV Human T-lymphotropic virus Syphilis Hepatitis B may also be classified as a vertically transmitted infection, but the hepatitis B virus is a large virus and does not cross the placenta, hence it cannot infect the fetus unless there have been breaks in the maternal-fetal barrier, such as can occur in bleeding during childbirth or amniocentesis.[6] The TORCH complex was originally considered to consist of the four conditions mentioned above, with the "TO" referring to "Toxoplasma". The four-term form is still used in many modern references, and the capitalization "ToRCH" is sometimes used in these contexts. The acronym has also been listed as TORCHES, for TOxoplasmosis, Rubella, Cytomegalovirus, HErpes simplex, Syphilis. A further expansion of this acronym, CHEAPTORCHES, was proposed by Ford-Jones and Kellner in 1995: C Chickenpox and shingles H Hepatitis B, C, (D), E E Enteroviruses A AIDS (HIV infection) P Parvovirus B19 T Toxoplasmosis / Toxoplasma gondii
O Other (Group B Streptococcus, Listeria, Candida, Lyme disease) R Rubella C Cytomegalovirus H Herpes simplex E Everything else sexually transmitted (Gonorrhea, Chlamydia, Ureaplasma urealyticum, Human papillomavirus) S Syphilis
Causes
The main routes of transmission of vertically transmitted infections are across the placenta (transplacental) and across the female reproductive tract during childbirth:
Transplacental
The embryo and fetus have little or no immune function. They depend on the immune function of their mother. Several pathogens can cross the placenta and cause (perinatal) infection. Often microorganisms that produce minor illness in the mother are very dangerous for the developing embryo or fetus. This can result in spontaneous abortion or major developmental disorders. For many infections, the baby is more at risk at particular stages of pregnancy. Problems related to perinatal infection are not always directly noticeable.
During childbirth
Babies can also become infected by their mother during birth. Some infectious agents may be transmitted to the embryo or fetus in the uterus, while passing through the birth canal or even shortly after birth. The distinction is important because when transmission is primarily during or after birth, medical intervention can help prevent infections in the infant. During birth, babies are exposed to maternal blood and body fluids without the placental barrier intervening and to the maternal genital tract. Because of this, blood-borne microorganisms (Hepatitis B, HIV), organisms associated with sexually transmitted disease (e.g., Gonorrhoea and Chlamydia), and normal fauna of the genito-urinary tract (e.g., Candida) are among those commonly seen in infection of newborns.
Pathophysiology
Virulence versus symbiosis
In the spectrum of optimal virulence, vertical transmission tends to evolve benign symbiosis. It is therefore a critical concept for evolutionary medicine. Because a pathogen's ability to pass from parent to child depends significantly on the hosts' ability to reproduce, pathogens' transmissibility tends to be inversely related with their virulence. In other words, as pathogens become more harmful to and thus decrease the reproduction rate of their host organism, they are less likely to be passed on to the hosts' offspring, since there will be fewer offspring. Although AIDS is sometimes transmitted through perinatal transmission, its virulence can be accounted for by the fact that its primary mode of transmission is not vertical. Moreover, medicine has further decreased the frequency of vertical transmission of AIDS. The incidence of perinatal AIDS cases in the United States has declined as a result of the implementation of recommendations on HIV counselling and voluntary testing practices and the use of zidovudine therapy by providers to reduce perinatal HIV transmission. The price paid in the evolution of symbiosis is, however, great: for many generations, almost all cases of vertical transmission will continue to be pathologicalin particular if there are any other routes of transmission. It takes many generations of random mutation and selection to evolve symbiosis. During this time, the vast majority of vertical transmission cases will exhibit the initial virulence.[citation needed] In Dual Inheritance Theory, vertical transmission refers to the passing of cultural traits from parents to children.
Diagnosis
When physical examination of the newborn shows signs of a vertically transmitted infection, the examiner may test blood, urine, and spinal fluid for evidence of the infections listed above. Diagnosis can be confirmed by culture of one of the specific pathogens or by increased levels of IgM against the pathogen.
Micrograph of a pap test showing changes (upper-right of image) associated with herpes simplex virus, a vertically transmitted infection.
Prognosis
Each type of vertically transmitted infection has a different prognosis. The stage of the pregnancy at the time of infection also can change the effect on the newborn.
Additional images
CMV placentitis.
CMV placentitis.
References
[1] [2] [3] [4] http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ P35 http:/ / apps. who. int/ classifications/ icd10/ browse/ 2010/ en#/ P39 http:/ / www. icd9data. com/ getICD9Code. ashx?icd9=771 Definitions and Indicators in Family Planning. Maternal & Child Health and Reproductive Health. (http:/ / test. cp. euro. who. int/ document/ e68459. pdf) By European Regional Office, World Health Organization. Revised March 1999 & January 2001. In turn citing: WHO Geneva, WHA20.19, WHA43.27, Article 23 [5] Singh, Meharban (2010). Care of the Newborn. p. 7. Edition 7. ISBN 9788170820536 [6] Hepatitis B (http:/ / www. who. int/ csr/ disease/ hepatitis/ whocdscsrlyo20022/ en/ index1. html) by World Health Organization (WHO), retrieved November, 2011 [7] Syal K* and Karande AA. IgG2 Subclass Isotype Antibody and Intrauterine Infections. Current Science Vol. 102, No. 11, 10 June 2012.
License
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