The Impact of Maternal Illness on the Newborn

Julniar M. Tasli Herman Bermawi Afifa Ramadanti

Background

Improvements in obstetric care can directly influence neonatal survival Prevention of neonatal asphyxia, sepsis, preterm birth and low birth weight can be achieved through improved care during pregnancy and during delivery In the new model of integrated perinatal care pediatric and obstetric care occur collaboratively towards the common goal of a safe delivery and improved neonatal survival

Learning Objectives

Identify maternal conditions during pregnancy and labor that can influence neonatal outcomes. Understand the association between specific conditions and neonatal outcomes. Suspect and recognize neonatal clinical presentations related to such conditions. Decide on management plan of the newborn based on maternal presentation

Maternal Well-being in Pregnancy:

Spacing of pregnancy Adequacy of prenatal care including immunizations (4 visits or more) Avoiding pregnancy at extremes of maternal age Avoidance of extremes of maternal prepregnancy weight (under-weight and morbid obesity) Appropriate weight gain and physical activity

Balanced nutrition (micronutrient intake; iron, zinc, folic acid, iodine, calcium) Avoidance of environmental exposures (nicotine, other drugs, medications, pesticides) Mental health including stress and depression

Lack of compliance can be directly and indirectly associated with :

Prematurity and low birth weight and complications associated with these important contributors to infant mortality and morbidity Higher incidence of specific neonatal complications e.g. congenital anomalies (neural tube defects) and in-utero growth retardation

Prenatal care and its role:

Prenatal care is designed to identify maternal complications early and give pregnant mothers guidance to healthy behaviors during pregnancy. Prenatal care should educate mothers and their community on the identification of early danger signs during pregnancy Prenatal care should also help mothers prepare for the arrival of the newborn, and give them basic education on the early care of the neonate.

1. Early Identification of Pregnancy:

Accurate gestational age determination

Promotes the early adoption of healthy behaviors and avoidance of unhealthy behaviors and exposures

Early screening for infections and other risks

Enhances the ability for early diagnosis and treatment of maternal diseases affecting pregnancy: Anemia Maternal malnutrition Pre-existing medical conditions (hypertension, diabetes, TB, malaria, STI & urinary tract infections) Uterine conditions e.g. fibroids, and anatomic abnormalities (bicornuate uterus) Maternal cardiac disease Thyroid disorders

A. Maternal Nutrition

Evaluating nutritional status Low pre-pregnancy weight (less than 50Kg?) Adequate weight gain (10-15 Kg) Maternal anemia (Hgb =<10gm) Maternal obesity (screen for hypertension & diabetes) Endemic iodine deficiency ( goiter) Diet evaluation especially vitamins

Recommendations

Balanced dietary intake Vit. D supplementation (severe deficiency may be associated with neonatal hypocalcemia). Adequate folic acid intake (starting before pregnancy) reduces the risk for neural tube defects. Adequate iron supplementation especially in cases with anemia. Avoiding Vit. A in high doses (teratogenic effects)

B. Perinatal Infections

Viral Infections:

Cytomegalovirus Transmitted trans-placentally, breast milk Associated with IUGR, hepatosplenomegaly, microcephaly, retinopathy, and hydrops
May present in the neonate also with: Jaundice, LBW, thrombocytopenia with skin petechiae, and hearing loss

Rubella:

Transplacentally transmitted Dangerous effects on the fetus in the first trimester Effects on the fetus include congenital heart disease, IUGR, retinopathy, auditory nerve hearing loss, cataract, purpura, and hepatosplenomegaly

Herpes simplex (HSV)

Ascending infection (intrapartum) Effects on the fetus/neonate include: IUGR, Encephalitis/meningitis, seizures, retinitis, mental retardation

Varicella Zoster

Transmitted transplacentally (<20 weeks, and also by contact after birth) Congenital varicella; Microcephaly, retinitis, scars on the skin Neonatal varicella

HIV

Transmitted transplacentally, during labor and in breast milk Neonatal HIV/AIDS mostly asymptomatic in the immediate neonatal period although some manifest IUGR

Hepatitis B

Transmitted mainly as an ascending infection, and through breast feeding, rarely transplacentally. Associated with post-natal chronic hepatitis, cirrhosis and hepatocellular carcinoma.

Non-viral infections:

Neisseria Gonorrhoea Ascending infection intrapartum Ophthalmia neonatorum (early)

Treponema pallidum (syphilis) Transmitted transplacentally, anytime during pregnancy (worst effects with early infection) Associated with fetal loss and still birth, and congenital syphilis (skin and mucous membrane lesions, hepato-splenomegaly, anemia and thrombocytopenia, bone lesions)

Toxoplasma gondii Transplacentally transmitted with the worst effects in early transmission Associates with Hydrocephalus/microcephaly, brain calcifications, hepatosplenomegaly, retintis/blindness hearing loss and mental retardation.

C. Thyroid Diseases

Hypothyroidism

Suspected after thyroid surgery, and in cases with goiter (thyroid swelling) Associated with Hashimoto thyroiditis May cause still birth, IUGR, placental abruption, and preeclampsia. Thyroxine replacement is indicated

Hyperthyroidism

Much more common than hypothyroidism Should be suspected in cases with goiter Most commonly due to Graves disease If untreated can be dangerous to mother and fetus. Maternal complications include severe preeclampsia and heart failure, and cardiac arrythmias Fetal complications include preterm birth and neonatal thyrotoxicosis

2. Identifications of Illnesses Complicating of Pregnancy:

Identification and early treatment of hypertension in pregnancy as a continuum of Pre/eclampsia

Identification and treatment of Gestational Diabetes Identification and treatment of infections complicating pregnancy (UTI, systemic, malaria, TB, HIV)

A. Impact of maternal hypertension

IUGR Asphyxia Prematurity and LBW/ SGA Congenital anomaly Multiple gestation Polycytemia + Hypebilirubinemia

B. Impact of maternal diabetes

Maternal diabetes type A C : + LGA + Birth injuries + Hyalin membran disease + Polycythemia + Hyperbilirubinemia + Hypoglycemia + Congenital anomaly

Maternal diabetes type D F&R : + LBW / SGA + Conenital anomaly + Hypoglcemia + Polycythemia + Hyperbilirubinemia