Intrauterine infection of the fetus. Intrauterine infections during pregnancy

How happy parents are when childbirth goes smoothly, without any complications, and the little man is born healthy. And it seems that nothing else can overshadow the joy of birth. But a couple of days pass and the health of the newborn deteriorates sharply. The kid often spits up food, he is lethargic, his appetite disappears, and there is no increase in weight. All this may be a consequence of the so-called intrauterine infections in newborns. What is it?

As medical practice shows, in the human body there are always microorganisms that are the causative agents of all kinds of diseases. And if a man, having become infected with them, is responsible only for himself, then it is more difficult with the fair sex. In addition, if she is in an interesting position at the time of infection. In this case, there is a real risk of infecting your child while still in the womb. Possible ways of infection are: the general blood flow of the mother with the child, accidental ingestion of amniotic fluid by the fetus. Often, infection occurs during the birth process.

From what pathogen will cause infection of the mother's body, this will be the disease of the baby. According to doctors, the disease is caused by:

• Herpes, rubella, influenza viruses, cytomegaly;
• Bacteria - streptococci, Escherichia coli, pale treponema, chlamydia;
• Protozoa (toxoplasma);
• Mushrooms.

The presence of the following factors in the expectant mother will increase the risk of infection of the newborn:

1. The woman's health is undermined by various ailments of a chronic nature;
2. The female body is affected by many negative factors such as smoking and alcohol busting and employment in hazardous industries;
3. Constant stress throughout pregnancy;
4. Mom suffers from chronic ailments of the genitourinary system.

In the medical environment, the diseases of the newborn received by him while in the womb of the parent were reduced to one group and gave them a common name - TORCH. This was due to the fact that, despite the fact that the pathogens are different, the manifestation of diseases have the same characteristics. This abracadabra stands for quite simply:

T - toxoplasmosis;

Oh - others. This refers to almost all ailments of an infectious nature;

R is for rubella. In Latin rubella;

C - cytomegalovirus infection of the newborn;

From the period at which the infection occurred, the degree of influence of the infection on the further development of the baby will be manifested;

• Up to twelve weeks - infection at such an early stage often leads to the fact that spontaneous interruption occurs or, in the future, the development of a small one will pass with large defects;
• Infection occurred between 12 and 28 weeks - usually at this time, infection will lead to developmental delay. The consequence of this will be that the newborn will be born underweight;
• Infection after 28 weeks is dangerous because it has a negative effect on the well-formed organs of the child. The brain, heart, liver and lungs are primarily affected. That is, all vital organs.

Most common intrauterine infections

Statistics show that this list includes the following infections in descending order:

• Toxoplasmosis;
• Cytomegalovirus;

Cytomegalovirus in newborns

Let's consider them in more detail:

Staphylococcal infections, in turn, are divided into two types:

• Purulent-inflammatory processes with a local character;
• The infection is generalized or.

The most dangerous for a child is Staphylococcus aureus. The fact that its pathogen is present in the child's body can be recognized by the pustules on the skin. This also includes purulent inflammation of the umbilical wound. The consequences of a staphylococcal infection are quite severe, up to toxicological shock. Therefore, as soon as the first signs appear, you should immediately contact a medical facility.

Who is at risk

Children's doctors have long compiled a list of those who are included in the so-called risk group. In the same list, in addition to living persons, doctors also included subjective reasons. Here is the list:

• Mothers with previously born children. Pupils of schools and pupils of preschool institutions;
• Workers of kindergartens and schools;
• Health workers working directly with children;
• Pregnant women who have inflammatory diseases with a chronic course of the disease;
• Those women who have had repeated abortions for medical reasons;
• Women who have already had infected children;
• Those women who in the past had children or pregnancies with fetal malformation and fetal death in utero;
• The amniotic fluid broke long before the birth.

A pregnant woman should seek medical attention as soon as she feels the following symptoms:

1. A sharp rise in temperature;
2. Lymph nodes enlarged and became painful to the touch;
3. The skin is suddenly covered with a rash;
4. Appeared cough, shortness of breath;
5. Drowsiness, lacrimation;
6. The joints are swollen and hurt when moving.

It is not necessary that all these signs are dangerous for the little one. But they are mandatory for contacting doctors. It is better to be safe than to be treated for a long and difficult time.

Preventive measures

It has long been known that any disease is best prevented than treated later. TORCH infections are no exception. Preventive measures are divided into two types: before conception and pregnancy.

Measures up to

First of all, this is the delivery of all tests for the presence of immunity to diseases included in the list of prenatal. If the tests show that there is such an indicator as IqG in the credits, then this will indicate that the woman's body has the necessary antibodies. If this is not available, then this means only one thing - the woman's body is open to infection. Therefore, if pregnancy is planned, then she must first be vaccinated against rubella. In order to avoid toxoplasmosis, you can temporarily remove all animals from the house before delivery and be examined together with a partner for infection with herpes and cytomegalovirus. If the IqG is very high, then this indicates that there is an acute infection in the female body. And before you plan the birth of a baby, you need to be completely treated.

Prevention during

But if the IgG titer turns out to be in the analyzes of the pregnant woman, then here it already clearly indicates infection of the female body. In theory, this means that the unborn baby is also in danger. And in order to exclude this, the expectant mother needs to pass some additional tests, by which you can determine the condition of the fetus and work out your actions further.

And keep track of your contacts.

Treatment process

If infection is detected during pregnancy, this is not a reason to give up. The disease is well treated with antibiotics. Representatives of the penicillin group excel here. After all, despite their venerable "age" among antibiotics, they are still one of the most effective drugs in the treatment of viral infections. Moreover, they are practically safe for the health of the baby.

At the same time, antimicrobial drugs are actively used. Their use often saves the life of a child, and also reduces the negative consequences.

With a viral infection, treatment is a rather difficult process, but if you start it in a timely manner, the consequences can be prevented. But if they have already formed, then antiviral drugs are useless. In this case, surgical methods often come to the rescue. In cases of cataracts or CHD, the child will have a chance to live the rest of his life on his own, with a minimum of outside help. It is not uncommon for such children to need hearing aids many years later.

Already mentioned above, acute herpes with rashes on the labia of the mother is clearly an indication for caesarean section. In other cases, nothing interferes with natural childbirth.

Carrying a child, a woman tries to protect him from adverse external influences. The health of a developing baby is the most important thing during this period, all protective mechanisms are aimed at preserving it. But there are situations when the body cannot cope, and the fetus is affected in utero - most often it is an infection. Why it develops, how it manifests itself and what risks it carries for the child - these are the main questions that concern expectant mothers.

Causes

In order for an infection to appear, including intrauterine, the presence of several points is necessary: ​​the pathogen, the route of transmission and the susceptible organism. Microbes are considered the direct cause of the disease. The list of possible pathogens is very wide and includes various representatives - bacteria, viruses, fungi and protozoa. It should be noted that intrauterine infection is mainly due to microbial associations, that is, it has a mixed character, but monoinfections are not uncommon. Among the common pathogens, it is worth noting the following:

1. Bacteria: staphylo-, strepto- and enterococci, E. coli, Klebsiella, Proteus.
2. Viruses: herpes, rubella, hepatitis B, HIV.
3. Intracellular agents: chlamydia, mycoplasma, ureaplasma.
4. Fungi: candida.
5. The simplest: toxoplasma.

Separately, a group of infections was identified that, despite all the differences in morphology and biological properties, cause similar symptoms and are associated with persistent developmental defects in the fetus. They are known by the abbreviation TORCH: toxoplasma, rubella, cytomegalovirus, herpes and others. It should also be said that in recent years there have been certain changes in the structure of intrauterine infections, which is associated with the improvement of diagnostic methods and the identification of new pathogens (for example, listeria).

The infection can enter the child in several ways: through the blood (hematogenous or transplacental), amniotic fluid (amniotic), the mother's genital tract (ascending), from the uterine wall (transmural), through the fallopian tubes (descending) and with direct contact. Accordingly, there are certain risk factors for infection that a woman and a doctor should be aware of:

• Inflammatory pathology of the gynecological sphere (colpitis, cervicitis, bacterial vaginosis, adnexitis, endometritis).
• Invasive interventions during pregnancy and childbirth (amnio- or cordocentesis, chorionic biopsy, caesarean section).
• Abortions and complications in the postpartum period (earlier transferred).
• Insufficiency of the cervix.
• Polyhydramnios.
• Fetoplacental insufficiency.
• General infectious diseases.
• Foci of chronic inflammation.
• Early onset of sexual activity and promiscuity in sexual relations.

In addition, many infections are characterized by a latent course, undergoing reactivation in violation of metabolic and hormonal processes in the female body: hypovitaminosis, anemia, heavy physical exertion, psycho-emotional stress, endocrine disorders, exacerbation of chronic diseases. Those who have identified such factors are at high risk of intrauterine infection of the fetus. He also shows regular monitoring of the condition and preventive measures aimed at minimizing the likelihood of developing pathology and its consequences.

Intrauterine infection develops when infected with microbes, which is facilitated by many factors from the maternal organism.

Mechanisms

The degree of pathological impact is determined by the characteristics of the morphological development of the fetus at a particular stage of pregnancy, its reaction to the infectious process (maturity of the immune system), and the duration of microbial aggression. The severity and nature of the lesion is not always strictly proportional to the virulence of the pathogen (the degree of its pathogenicity). Often a latent infection caused by chlamydial, viral or fungal agents leads to intrauterine death or the birth of a child with serious abnormalities. This is due to the biological tropism of microbes, i.e., the tendency to reproduce in embryonic tissues.

Infectious agents have different effects on the fetus. They can provoke an inflammatory process in various organs with the further development of a morphofunctional defect or have a direct teratogenic effect with the appearance of structural anomalies and malformations. Equally important are the intoxication of the fetus with products of microbial metabolism, disorders of metabolic processes and hemocirculation with hypoxia. As a result, the development of the fetus suffers and the differentiation of internal organs is disturbed.

Symptoms

The clinical manifestations and severity of the infection are determined by many factors: the type and characteristics of the pathogen, the mechanism of its transmission, the intensity of the immune system and the stage of the pathological process in the pregnant woman, the gestational age at which the infection occurred. In general terms, this can be represented as follows (table):

Symptoms of intrauterine infection are noticeable immediately after birth or in the first 3 days. But it should be remembered that some diseases may have a longer incubation (latent) period or, conversely, appear earlier (for example, in premature babies). Most often, the pathology is manifested by the infection syndrome of the newborn, manifested by the following symptoms:

• Decreased reflexes.
• Muscle hypotension.
• Refusal to feed.
• Frequent vomiting.
• Pale skin with periods of cyanosis.
• Change in the rhythm and frequency of breathing.
• Muffled heart sounds.

Specific manifestations of pathology include a wide range of disorders. Based on the tissue tropism of the pathogen, intrauterine infection during pregnancy can manifest itself:

1. Vesiculopustulosis: rash on the skin in the form of vesicles and pustules.
2. Conjunctivitis, otitis and rhinitis.
3. Pneumonia: shortness of breath, cyanosis of the skin, wheezing in the lungs.
4. Enterocolitis: diarrhea, bloating, sluggish sucking, regurgitation.
5. Meningitis and encephalitis: weak reflexes, vomiting, hydrocephalus.

Along with a local pathological process, the disease can be widespread - in the form of sepsis. However, its diagnosis in newborns is difficult, which is associated with the low immune reactivity of the child's body. At first, the clinic is rather poor, since there are only symptoms of general intoxication, including those already listed above. In addition, the baby has a lack of body weight, the umbilical wound does not heal well, jaundice appears, the liver and spleen increase (hepatosplenomegaly).

In children infected in the prenatal period, disturbances are detected in many vital systems, including the nervous, cardiovascular, respiratory, humoral, and immune systems. Key adaptive mechanisms are violated, which is manifested by hypoxic syndrome, malnutrition, cerebral and metabolic disorders.

The clinical picture of intrauterine infections is very diverse - it includes specific and general signs.

Cytomegalovirus

Most children infected with cytomegalovirus have no visible abnormalities at birth. But in the future, signs of neurological disorders are revealed: deafness, slowing down of neuropsychic development (mild mental retardation). Unfortunately, these disorders are irreversible. They may progress with the development of cerebral palsy or epilepsy. In addition, a congenital infection can manifest itself:

• Hepatitis.
• Pneumonia.
• hemolytic anemia.
• thrombocytopenia.

These disorders disappear over a certain period even without treatment. Chorioretinopathy may occur, which is rarely accompanied by decreased vision. Severe and life-threatening conditions are very rare.

herpetic infection

The greatest danger to the fetus is a primary genital infection in the mother or an exacerbation of a chronic disease. Then the child becomes infected by contact, passing during childbirth through the affected genital tract. Intrauterine infection is less common, it occurs before the natural end of pregnancy, when the fetal bladder bursts, or at other times - from the first to the third trimester.

Infection of the fetus in the first months of pregnancy is accompanied by heart defects, hydrocephalus, anomalies of the digestive system, intrauterine growth retardation, and spontaneous abortions. In the second and third trimesters, pathology leads to the following abnormalities:

• anemia.
• Jaundice.
• Hypotrophy.
• Meningoencephalitis.
• Hepatosplenomegaly.

And herpes infection in newborns is diagnosed by bubble (vesicular) lesions of the skin and mucous membranes, chorioretinitis and encephalitis. There are also common forms, when several systems and organs are involved in the pathological process.

Rubella

A child can become infected from the mother at any stage of pregnancy, and clinical manifestations will also depend on the time of infection. The disease is accompanied by damage to the placenta and fetus, intrauterine death of the latter, or does not give any consequences at all. Children born with an infection are characterized by rather specific anomalies:

• Cataract.
• Deafness.
• Heart defects.

But in addition to these signs, there may be other structural abnormalities, for example, microcephaly, "cleft palate", disorders of the skeleton, genitourinary system, hepatitis, pneumonia. But in many children born infected, no pathology is detected, and in the first five years of life problems begin - hearing deteriorates, psychomotor development slows down, autism and diabetes mellitus appear.

Rubella has a clear teratogenic effect on the fetus, leading to various anomalies, or provokes its death (spontaneous abortion).

Toxoplasmosis

Infection with toxoplasmosis in early pregnancy can be accompanied by severe consequences for the fetus. Intrauterine infection provokes the death of a child or the occurrence of multiple anomalies in him, including hydrocephalus, brain cysts, edematous syndrome, and destruction of internal organs. A congenital disease is often widespread, manifesting itself with the following symptoms:

• anemia.
• Hepatosplenomegaly.
• Jaundice.
• Lymphadenopathy (enlarged lymph nodes).
• Fever.
• Chorioretinitis.

When infected at a later date, the clinical manifestations are rather poor and are mainly characterized by a decrease in vision or unexpressed disorders in the nervous system, which often remain undetected.

Additional diagnostics

Prenatal diagnosis of infectious lesions of the fetus is of great importance. To determine the pathology, laboratory and instrumental methods are used to identify the pathogen and identify deviations in the development of the child at various stages of pregnancy. If intrauterine infection is suspected, perform:

1. Biochemical blood test (antibodies or microbial antigens).
2. Analysis of smears from the genital tract and amniotic fluid (microscopy, bacteriology and virology).
3. Genetic identification (PCR).
4. Ultrasound (fetometry, placentography, dopplerography).
5. Cardiotocography.

After birth, newborns are examined (skin swabs, blood tests) and the placenta (histological examination). Comprehensive diagnostics allows you to identify pathology at the preclinical stage and plan further treatment. The nature of the activities carried out will be determined by the type of infection, its spread and the clinical picture. Prenatal prevention and proper management of pregnancy also play an important role.

Intrauterine infection is the main cause of morbidity and fetal mortality.

Infection of the child occurs during pregnancy, and its source is the mother. That is why, even at the planning stage, mothers should be attentive to their own health and be examined for latent infections.

Intrauterine infection during pregnancy

Intrauterine infections (IUI) are classified into viral and bacterial. Many viral infections enter the child's body in the perinatal period, but are not accompanied by clinical manifestations, thanks to the mother's immunity and protective placenta.

Types of intrauterine infection:

• Cytomegalovirus and herpetic;
• Rubella;
• Syphilis, chlamydia, gonorrhea;
• Hepatitis A and B, etc.

The intrauterine infection carries the greatest danger in the first three months of pregnancy and causes spontaneous abortions and fetal death. From the age of 6 months, the baby develops its own immunity, which allows it to specifically respond to the introduction of the infection.

Symptoms indicating infection

Signs of infection of the embryo in the first trimester of pregnancy is placental insufficiency, which leads to fading of pregnancy and miscarriage. When infected in the second trimester, the placental circulation is disturbed, the fetus develops anomalies, mainly from the central nervous system.

During the ultrasound procedure, the following symptoms are noted:

• Fetal growth retardation;
• polyhydramnios;
• Tachycardia in the fetus;
• Enlargement of the abdomen and liver in the fetus;
• Thickening of the placenta;

Intrauterine infection can be diagnosed using laboratory tests: blood test for latent infections (TORCH), swabs from the vagina and cervix for bacterial culture.

Main reasons

Infection of the fetus in the perinatal period occurs from mother to child if: the mother becomes ill for the first time (rubella, CMVI, hepatitis), or she is already a carrier of the infection (herpes, chlamydia, gonorrhea).

If there are foci of infection in a woman's body - caries, tonsillitis, pyelonephritis, then there is a risk of bacteria (staphylococci, streptococci) entering the fetus. Therefore, it is important for the expectant mother to visit the dentist, ENT and take urine tests every trimester for early detection of the disease and timely treatment.

Infection of the mother with an infectious disease in the first months of pregnancy almost always leads to its termination, since embryo infection occurs in 90% of cases.

In the later stages, intrauterine infection leads to rupture of the membranes, isthmic-cervical insufficiency (opening of the cervix) and, as a result, to premature birth.

A child is born with numerous diseases: pneumonia, meningitis, encephalitis, otitis, vulvovaginitis. Intrauterine infection is very dangerous for the fetus and causes congenital malformations: impaired hearing, central nervous system, digestive system and liver, splitting of the lip, palate (cleft palate).

Main features

Signs of infection of the fetus with IUI can be diagnosed during the ultrasound procedure: numerous fetal malformations, placental insufficiency, polyhydramnios. A woman, being a carrier of a latent infection, as a rule, does not feel severe symptoms.

With a primary infection during pregnancy, a woman experiences symptoms characteristic of this type of disease.

Visible signs of intrauterine infection are diagnosed during the ultrasound procedure, which are expressed in pathologies of fetal development. A child infected in the womb is born with congenital diseases, which often lead to disability, in severe cases - to death.

Chronic maternal infection during pregnancy diagnosed only by laboratory methods and has no apparent symptoms. Any foci of infection in a woman's body (tonsillitis, sinusitis, caries, pyelonephritis) should be excluded at the planning stage, or be treated and monitored from the second trimester of pregnancy. The disease acquired during pregnancy is subject to treatment in a hospital setting.

Early onset of infection

With intrauterine infection in the first trimester of pregnancy, there are infectious embryopathies, which end in spontaneous miscarriage, non-developing pregnancy.

Primary infection with rubella in the first three months of pregnancy requires its surgical interruption. Viral infections (herpes) in early pregnancy lead to spontaneous abortion or congenital malformations of the fetus.

The danger of IUI in early pregnancy is due to the impossibility of treatment, the absence of a placental barrier between mother and child, and the underdevelopment of the immune system in the embryo.

The danger of ureaplasmosis It consists in its asymptomatic course in a pregnant woman, it can be detected only by laboratory diagnostic methods. However, this disease poses a threat to the fetus. In the early stages, ureaplasmosis leads to pregnancy fading and spontaneous abortion. From the second trimester - provokes rupture of the fetal bladder, isthmic-cervical insufficiency, which lead to miscarriage.

A child infected with ureaplasmosis in the womb is born with reduced immunity, and is at risk of acquiring pneumonia, neonatal meningitis and other diseases.

Treatment of ureaplasmosis is carried out with the help of antibiotic therapy from the 20-week gestation period.

Herpes simplex virus in the acute stage causes infection of the fetus in 80% of cases. If the mother is a carrier of the virus, then the risks of infection of the embryo are reduced to 0.5%. However, with its exacerbation during childbirth, newborns become infected in 40% of cases.

With the primary infection with herpes in the early stages, the question of termination of pregnancy is raised. If infection occurs from the second trimester, the pregnant woman is at risk and is under constant supervision. Antiviral therapy and the introduction of immunoglobulins are prescribed.

Infection with herpes in the third trimester leads to the birth of a child with lesions of the skin, eyes and central nervous system. The manifestation of herpetic infection in newborns in 50% leads to death, and the remaining 50% experience severe complications, expressed in mental and physical retardation.

More than 90% of the Russian population are carriers of CMVI. IN THE USA cytomegalovirus is present in the blood of 99% of the population. CMVI in the chronic stage is asymptomatic, and the risk of infection of the fetus is reduced to zero. An exacerbation can occur in 1-2% of pregnancies, the probability of infection of the fetus is 20%.

Asymptomatic carriage of the virus is detected in 90% of newborns. Infection of the fetus with CMVI during the primary infection of the mother in the early stages leads to spontaneous miscarriage and premature birth in the 2nd and 3rd trimesters. In newborns with an acute stage of the virus, malformations are noted: hearing loss, dental dystrophy, visual impairment, mental retardation.

Viral hepatitis B and C

Infection with hepatitis viruses in the perinatal period is very rare, but infection during childbirth and breastfeeding is not excluded. In infected newborns, hepatitis occurs in a latent, asymptomatic phase. The danger of hepatitis lies in the fact that newborns, being carriers of the virus, in 85% of cases can infect other children.

Chlamydia in the acute stage is diagnosed in 10% of pregnant women, in the chronic phase - in 50%. Infection with chlamydia in utero leads to growth retardation, development and fetal hypoxia.

40% of infected newborns are diagnosed with such symptoms of chlamydia as pneumonia, pharyngitis, conjunctivitis, otitis. The greatest danger of chlamydia is for premature babies, it leads to severe forms of encephalitis and meningitis.

Treatment of women is carried out from the second trimester with the help of antibiotic therapy.

Gonorrhea

This disease adversely affects the development of pregnancy and childbirth. Ultrasound is diagnosed fetal growth and developmental delay. Newborns with gonococcal infection develop jaundice and purulent conjunctivitis, which often leads to complete blindness. Premature babies are at risk of developing gonorrhea.

Treatment of the disease is carried out with antibiotics from the first trimester of pregnancy.

Toxoplasmosis poses a serious danger to a pregnant woman. The virus is transmitted through contact with infected pets. The risk of infection of the fetus from the mother through the placenta is almost 100%.

In the first months of pregnancy, infection with toxoplasmosis leads to miscarriage. Infection in the 2nd and 3rd trimesters leads to congenital malformations: underdevelopment of the eyelids, splitting of the lip and palate, and brain defects.

It is possible to diagnose intrauterine infection with toxoplasmosis during the ultrasound procedure. Treatment of infected women is carried out at any stage of pregnancy.

Syphilis

Intrauterine infection of the fetus with syphilis occurs after 20 weeks of pregnancy through the umbilical cord vein. Children are usually born healthy, but after a few days, symptoms begin to appear: rash, swollen lymph nodes, inflammation of the mucous membranes of the eyes, nose. Treatment of syphilis during pregnancy is carried out in accordance with established standards.

The organism of a pregnant woman has an increased susceptibility to pathogens of listeriosis. Infection occurs through animal products and vegetables. Infection of the fetus occurs through the placenta after its formation.

Infection in the early stages leads to fetal death and miscarriage. In the later period of pregnancy, IUI manifests itself in the fetus in the form of sepsis. In newborns, the organs of hearing, liver and central nervous system are affected, pneumonia occurs.

A blood test during pregnancy is given by women many times, while its focus can be very different. Blood is also donated for IUI during pregnancy. This is important from the point of view of possible infection of the woman and her fetus. Intrauterine infections, in turn, are dangerous for the development of a number of complications.

An infection present during fetal development refers to the presence in the female body of pathogens that in different parts of the body lead to the onset of inflammation. The problem with such an infection is that there is a risk of fetal infection. Infection most often occurs due to the fact that the infection enters the bloodstream. However, intrauterine infections can also be transmitted at the time of delivery with contaminated genital tracts or ingestion of water that surrounds the fetus, in which infection may also be present.

What infections can pregnant women detect? The type of infection is associated with the pathogen that affects the body of the expectant mother during pregnancy, which is logical, but also before her. The cause of infection can be:

• viruses;
• bacteria;
• fungi;
• protozoa.

The risk of problems from such pathogens from a negative point of view increases if a woman has chronic diseases, if she has a job or life in harmful conditions, bad habits, some infections that were not cured before pregnancy. A particular danger arises if the mother encountered the infection for the first time during the bearing of the baby.

Tests for IUI are often referred to as tests for TORCH infections. This abbreviation is associated with the name of infections, for which they donate blood or urine. We are talking about toxoplasmosis, rubella, cytomegalovirus infection, herpes and other infectious diseases, formed into one group.

It is important to note that approximately ten percent of all pregnancies result in transmission to the baby. At the same time, half a percent of children are born immediately with the first signs of infection.

It is important to emphasize that if a test for infections during pregnancy has shown a positive result for some items, this does not mean one hundred percent guarantee that the infection will be transmitted to your child.

It is necessary to take tests for infections during pregnancy due to the fact that often the signs of IUI are blurred or absent at all, which means that treatment is not performed in a timely manner. At the same time, providing it in sufficient volume can not only reduce, but completely eliminate the risks of infection of the child.

Ways of infection

What are the ways of infection of a child? Three main methods are distinguished by doctors. It is transplacental or otherwise hematogenous. This is how viruses, protozoa, bacteria work. We are talking about the fact that the pathogen is in the maternal blood, through which it penetrates through the barrier that forms the placenta.

If this happens in the 1st trimester, then over time the child may develop deformities and various defects. If the infection enters the fetus in the third trimester, then newborns are usually born with signs of its acute course. If the hit was directly into the child's blood, then the lesion may have a generalized form.

The ascending mode of infection is characteristic of infections affecting the genital tract. Of these, she passes to the child. This is usually fixed during the period when the membranes surrounding the fetus are torn, childbirth occurs. However, this can also be encountered during the period of direct bearing of the child. The main cause of IUI is the infection of the waters that surround the fetus. The consequence of this route of transmission is skin damage, a violation in terms of the formation of the fetus's digestive tract and its respiratory system. In the case of descending infection, the infection descends to the fetus through the uterine tubes.

Features of diagnostics

To understand whether the expectant mother has an infection, they take a set of tests. These are primarily swabs from the genitals. They are sent for testing by the PCR system, which helps to detect the DNA of various pathogens. In addition, blood is donated to rule out the presence of syphilis, hepatitis or HIV.

Very often, infections are dangerous because they are hidden, which is why testing is mandatory. Sometimes you need to perform 2-3 tests to detect a particular infectious agent. So in the urine during pregnancy, infectious signs may not be recorded, but they will be found in a smear.

When it comes to testing for infections through blood donation, then the main “semaphore” in this case is antibodies of groups M and G. If the analysis reveals only antibodies related to group G, then you should not worry. Antibodies of this group indicate that you were ill with something in the past, as a result of which your body formed immunity. Accordingly, at the moment, the infection is unable to harm you, and hence the unborn child.

When a second marker is found, things are more complicated. Antibodies of the M group indicate that an acute phase of a disease is present in the body. However, it is important to emphasize that situations are different and in this case, additional research is indispensable.

Major infections

Speaking of intrauterine infections, a number of them represent an increased risk when it comes to the likelihood of infection of a child. One such example is cytomegalovirus. Such a disease appears against the background of the work of herpes viruses.

The danger of CMV lies in the fact that infection is possible not only through sexual contact, but also through close contact in everyday life and transfusion of “impure” blood. If a woman first encountered herpes during pregnancy, then the microorganism can penetrate the placenta, infecting the fetus.

In some cases, childbirth is possible without any abnormal abnormalities. However, ten percent of children have corresponding signs of infection. Possible complications of pregnancy are also a problem, among which spontaneous abortion, stillbirth, hearing loss in a child, underweight, pneumonia, abnormal development and blindness in its various manifestations stand out.

If an infectious lesion has a combination with something else, more than half of the children do not live past four months. In addition, an insufficient rate of development may be recorded against the background of the infection. If the lesion has a mild local form, then the consequences are not so sad. The problem is that so far there are no drugs that can relieve the symptoms of CMV in newborns, however, if an appropriate diagnosis is found in women, the child is still left, since there is a chance of giving birth to a healthy baby. It is enough for the expectant mother to undergo a course of treatment that will smooth out the negative effect of the virus on the body.

Speaking of herpes, the herpes simplex virus is also present. If the mother has herpes simplex type 2, then the child manifests the congenital presence of the infection of the same name. In the vast majority of cases, such a problem can be encountered during sexual intercourse, which did not involve the use of barrier contraception. A child already from the first months of life is faced with the first signs of the disease, and becomes infected mainly during the passage through the birth canal. In some cases, the virus can cross the placenta.

The presence of herpes in the body of a newborn is fraught with inflammatory processes in the lungs, vision problems, brain damage, skin rashes, high fever, poor blood clotting, and jaundice. Sometimes babies are born dead. If we are talking about severe cases, a diagnosis of oligophrenia, cerebral palsy and the state of "vegetable" is made.

Rubella is one of the most dangerous diseases for the embryo. It is transmitted by airborne droplets, which makes it easy for an epidemic. Infection is possible even at a considerable distance. A serious threat of illness is presented in the first trimester, which leads to the formation of various kinds of deformities in the child.

In addition, spontaneous abortion or death inside the womb can occur, anomalies are recorded during cardiac and muscular development, hearing, and vision. At birth, various diseases associated with the skin, pneumonia, problems with the brain and its membranes may be present.

Syphilis is also on the list of high-risk infections. If a woman is diagnosed with an appropriate diagnosis and proper treatment is not carried out, the probability of a child intercepting the disease reaches one hundred percent. At the same time, the survival rate is not very high, less than half of the infected children. At the same time, survivors have syphilis from birth.

The problem with syphilis is that infection is fixed even in the case of a latent infection. As a result of the work of an infectious agent, teeth are destroyed in children, problems with vision and hearing appear, lesions of the limbs, skin problems, and anemia are observed. In development from a mental point of view, such children often lag behind their peers. In this case, premature birth and stillbirth can be provoked.

Pet owners face the danger of contracting toxoplasmosis. The main carriers of this infection are cats and dogs. Toxoplasmosis is dangerous because in half of the cases the infection crosses the placenta and infects the fetus directly. Against the background of the work of such an infection, damage to the visual organs, various cephalias, inflammation of the brain are recorded, children have problems with development from a psychomotor point of view. During the period when pregnancy is planned, it is important that both parents take tests.

Other infections

Another infection that poses a danger to the unborn child is parvovirus B19. Its problem lies in provoking infectious erythema. Adults, when faced with such a disease, do not feel any symptoms, but for the fetus, the danger is more than high.

Often against the background of parvovirus B19, stillbirth, spontaneous abortions and infection inside the womb are recorded. At the same time, on average, ten percent of children do not survive. The infection is especially dangerous in the period from 13 to 28 weeks of pregnancy, since at these moments the fetus has no protection.

The infection brings with it brain damage, swelling, anemia, hepatitis, myocardial inflammation, peritonitis. Chicken pox, better known as chicken pox, is no less dangerous. A child encounters intrauterine infection in a quarter of cases, but symptoms are not always present. Congenital chickenpox can be diagnosed by brain lesions, pneumonia, skin rash, delayed development of the limbs and organs of vision, up to atrophy of the optic nerve.

Babies who were infected in the womb are not treated for chickenpox because there is no progression of the clinical picture. If a pregnant woman encounters an infection immediately before childbirth, then after birth the child is treated with immunoglobulin, since there are no corresponding antibodies in the mother's body.

The danger of hepatitis B cannot be ruled out. Such an infection is very popular among people who prefer unprotected sex. The causative agent of the disease is dangerous because it freely penetrates the placenta. It is very dangerous to catch such an infection in the period from the fourth to the ninth month of pregnancy.

As a result of infection, a child can acquire hepatitis B, but it is treatable. It can provoke an infection and hepatic diseases of the oncological spectrum, a sluggish form of hepatitis. In the acute form of this disease, the child may develop liver failure, which leads to his death. It is fixed in children with such a problem and a delay in the development of psychomotor functions, hypoxia. A woman may simply have a miscarriage.

Do not forget about the dangers of HIV infection. In the presence of such an infection, special lymphocytes associated with the immune system suffer. In most cases, you can get HIV through unprotected intercourse or using disposable medical items multiple times. Infection of the child occurs both during uterine development and directly during childbirth.

Children recognized as HIV-infected remain for intensive complex treatment. Otherwise, mortality up to two years shows high rates, since the weak organism is quickly affected by the infection. Often children with such a diagnosis can die even from the simplest diseases, which do not pose a danger to healthy children.

To confirm the presence of HIV in a child, it is enough to undergo a special PCR diagnosis. It is important to detect the virus in a pregnant woman, since infected mother's milk can infect a healthy child.

One of the latest problems is listeriosis. The disease develops as a result of the vital activity of a special bacterium Listeria. The danger of the microorganism lies in its easy penetration through the placenta. A pregnant woman can pick it up by eating unwashed vegetables or contaminated animal products. The danger of the disease is in its latent course, although some signs of infection are still present.

The presence of infection in a child is expressed in the form of a rash and a large number of pustules. It is impossible to exclude inflammation of the brain, sepsis. With active listeriosis, spontaneous abortion or death of the child in the womb is possible. If signs are evident in the first week postpartum, 60 percent of babies do not survive.

Intrauterine infection is a potential health hazard for the unborn child. In these cases, the fetus becomes infected from a sick mother with infections that can cause multiple congenital malformations of the brain or spinal cord, heart, as well as blindness, deafness, and even death of the fetus or newborn. All pathogens of intrauterine infection by foreign researchers are united under the term TORCH (according to the first letters of the English names of toxoplasmosis, rubella, cytomegalovirus, herpes). It should be noted that most of these infections are asymptomatic. Sometimes, after a short mild illness, the pathogen continues to be in the body of a woman for many years. In a latent state, it does not pose a danger to the fetus: the mother's immunity reliably protects it. Only primary infection with toxoplasmosis, cytomegalovirus infection, chlamydia, herpes in the first 3 months of pregnancy or exacerbation of a persistent (i.e. secretly ongoing infection) due to stress or drug-induced suppression of immunity are dangerous for the fetus.

IUI prevalence: 20-30% of women of childbearing age are infected with toxoplasmosis, 50-70% with cytomegaly virus, herpes simplex, etc.

Severe infections are the leading cause of neonatal deaths worldwide following preterm birth and asphyxia, accounting for up to half of all deaths in countries with very high mortality.

Causes of intrauterine infections in newborns

Etiology: viruses, mycoplasmas, chlamydia, protozoa, fungi, bacteria.

In the mother, the infectious process can proceed as acute, subclinical, latent. Of particular importance is the genitourinary infection in the mother as a source of pathogen in generalized IUI (pyelonephritis, inflammation of the appendages, vagina, etc.). Staphylococci, streptococci, intestinal flora, listeria, toxoplasma, Koch's bacilli, fungi can persist in the uterus for a long time in small quantities, causing chronic diseases of the urogenital area in a woman.

Pathways of penetration of the pathogen can be different. Antenatally, the infectious agent enters the fetus hematogenously or through infected amniotic fluid inside, on the skin, lungs, and eyes. The amniotic fluid of the mother can be infected ascending from the vagina and descending from the fallopian tubes, through the amniotic membranes with endometritis, placentitis, as well as by the fetus itself, infected hematogenously and excreting an infected agent with urine and feces.

Bacterial pathogens most often infect the fetus intranatally, causing severe bacterial infections in some children, up to sepsis (group B streptococcus, Escherichia coli, Pseudomonas aeruginosa, Citrobacter, Klebsiella, Proteus).

The pathogen, penetrating to the embryo or fetus, settles in the tissues and causes inflammation. Of great importance is the time of penetration of the infectious agent.

• Blastopathy: the penetration of the pathogen to the embryo in the first 14 days of pregnancy during blastogenesis leads to the death of the embryo, ectopic pregnancy, gross malformations with a violation of the formation of the axis of the embryo, which causes the occurrence of such gross malformations as cyclopia, rare twin malformations, gross malformations, incompatible with life, spontaneous abortions.
• When an embryo is infected during embryogenesis (from the 16th to the 75th day), embryopathies occur - malformations of individual organs and systems, teratoma, abortion. Gross malformations leading to miscarriages are especially often formed in the first 8 weeks of pregnancy. Rubella, cytomegaly, herpes, hepatitis B viruses play an important role in the formation of infectious embryopathies.
• When an infectious agent enters the fetus (from the 76th day to the 280th day of pregnancy), fetopathy occurs. The fetal period is divided into early (3 months - 7 months) and late (from 7 months to birth).

In the early fetal period, differentiation of tissues of already incorporated organs and systems occurs. If the fetus becomes infected during this period, then there is a violation of tissue differentiation with the development of sclerosis as a result of the growth of connective tissue. Examples of early fetopathy can be cirrhosis of the liver, hydrocephalus, microcephaly, hydronephrosis, fibroelastosis of the heart.

If the fetus is infected in the late fetal period, when the development of organs and systems occurs, then the birth of a child with IUGR is possible - intrauterine growth retardation, a clinic of the infectious process, premature birth, asphyxia in childbirth, impaired adaptation of the newborn.

Any microorganism that inhabits the urinary tract or lower digestive tract of the mother can cause early infections in newborns. These are gram-positive cocci - GBS, a-hemolytic streptococci (Streptococcus viridans), Staphylococcus aureus, enterococci (Enterococcus faecalis, Enterococcus faecium), rpa-negative rods (Escherichia coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Haemophilus influenza e, salmonella, shigella), gram-negative cocci (Neisseria gonorrhoeae, Neisseria meningitidis), gram-positive rods (Listeria monocytogenes), fungi (mainly Candida albicans), protozoa (Chlamydia trachomatis, Mycoplasma hominis, U. urealyticum), anaerobic bacteria. The etiological significance of microorganisms is different. Microorganisms with low virulence (such as lactobacilli, diphtheroids, and Staphylococcus epidermidis) rarely cause severe infections. Although U. urealyticum and M. hominis are sometimes isolated from the blood of fetuses weighing less than 1500 g at birth, their role in the development of early neonatal sepsis (RNS) remains unclear.

Also, the influence of some microorganisms on the development of RNS isolated from the amniotic fluid and even the blood of newborns is unknown. The role of Gardnerella vaginalis, most commonly isolated from amniotic fluid, has not been proven.

There is a statistically insignificant increase in infections of the mother and child when C. trachomatis is isolated from the amniotic fluid (in about 4% of cases, mothers of newborns are infected with C. trachomatis).

According to the National Institute of Child Health and Human Development, the most common causative agents of RNS are GBS (37.8%), E. coli (24.2%), S. viridans (17.9%), S. aureus (4.0 %) and H. influenzae (4.0-8.3%). GBS is the most common causative agent of infections in term infants, and E. coli in preterm infants. Mortality is higher in infants infected with E. coli compared with GBS (33% vs 9%; p<0,001). Также высока летальность недоношенных новорожденных при сепсисе, вызванном Н. influenzae (до 90%), который может иметь молниеносное течение, начинаясь как тяжелый РДС.

The detection of GBS in the amniotic fluid of women with intra-amniotic infection is accompanied by maternal or neonatal bacteremia in 25% of cases. When E. coli is detected, maternal or neonatal bacteremia is detected in 33% of cases.

In developing countries (Latin America, Caribbean, Asia and Africa) E. coli, Klebsiella spp. and S. aureus are more common and account for a quarter of all cases of RNS. The most common gram-positive pathogen in developing countries is Staphylococcus aureus.

anaerobic bacteria. Given that most anaerobic bacteria are part of the normal microflora of the gastrointestinal tract, genital tract and skin, they can be potential pathogens in newborns. Anaerobic infection develops mainly with a decrease in body resistance, impaired immunity, which is often observed in newborns, especially premature ones. Gram-positive anaerobic bacteria (Clostridium, Peptostreptococcus, Peptococcus) are of the greatest importance for RNS. Anaerobic infections caused by Clostridium may present as a systemic disease or localized infections such as cellulitis or omphalitis. Anaerobic bacteria were the cause of RNS for the period 1989-2003. in just 1% of cases.

Ways of infection of newborns

There are several main ways of spreading infection:

• Ascending path.
• Hematogenous (transplacental) route - as a result of bacteremia in the mother. In this case, a generalized infection usually occurs with frequent damage to the liver, lungs, kidneys, and brain.
• Contact way - contamination of the newborn when passing through the birth canal. In this case, colonization of the skin and mucous membranes of the newborn occurs first, including the nasopharynx, oropharynx, conjunctiva, umbilical cord, vulva and gastrointestinal tract (from aspiration of infected amniotic fluid or vaginal discharge). It should be noted that in most newborns, microorganisms multiply in these places without causing disease. The umbilical cord is the most common site for infection to enter. As a special case of the occurrence of RNS with a horizontal transmission mechanism, one can name an infection acquired in the absence of hygiene during childbirth, a violation of the method of processing the umbilical cord (for example, during childbirth at home), and poor hygiene skills when caring for a newborn.

Specific risk factors that increase the possibility of developing an infection have been identified:

• preterm birth is the most significant risk factor for acquiring infection in children immediately before or during childbirth;
• maternal colonization;
• rupture of the membranes of the membranes more than 18-24 hours before birth increases the likelihood of neonatal sepsis by 1%. If the baby is premature, the risk increases by 4-6%. The lower the gestational age of the newborn and the longer the anhydrous period, the higher the likelihood of developing neonatal sepsis;
• maternal intra-amniotic infection (chorioamnionitis): according to the National Institute of Child Health and Human Development (USA), from 14 to 28% of women who gave birth to premature babies at 22-28 weeks. pregnancy, have signs characteristic of chorioamnionitis. According to various data, with chorioamnionitis of the mother, sepsis is observed from 1-4% to 3-20% of newborns. If chorioamnionitis is combined with a long anhydrous period, the risk of developing RNS increases by 4 times.

Other risk factors that increase the possibility of a generalized infection:

• low socio-economic status of women (there is a high frequency of infection of amniotic fluid, bacteriuria, reduced antimicrobial activity of amniotic fluid);
• the male sex of the child;
• low Apgar score (hypoxia and acidosis can impair immune defense function);
• complicated childbirth in premature newborns;
• the presence of signs of RDS;
• maternal diabetes;
• hypothermia in newborns, usually defined as rectal temperature<35°С, связана со значительным увеличением числа случаев сепсиса, менингита, пневмонии и других тяжелых бактериальных инфекций;
• prolonged stay of the mother in the hospital;
• inadequate facilities for screening and antibiotic prophylaxis in labor;
• hereditary pathology of metabolism.

Symptoms and signs of intrauterine infections in newborns

History: miscarriage, stillbirth, miscarriage of previous pregnancies, birth of children with malformations and deaths at an early age, anomalies in the course of this pregnancy and childbirth, threatened miscarriage, polyhydramnios, short thick umbilical cord, premature discharge of amniotic fluid, their fetid odor, accretion or abruption of the placenta, diseases of the urogenital area in the mother, infections in a woman during pregnancy, including ARVI, the presence of chronic foci of infection in the urogenital area in a woman, chronic tonsillitis, chronic cholecystitis, fever in the mother during childbirth, severe infectious process in the mother before, during or immediately after childbirth, obstetric assistance in childbirth, the birth of a child in asphyxia, resuscitation of a child, deterioration in the state of intrauterine development, intrauterine malnutrition, prematurity, dysembryogenesis stigmas, malformations, hydrocephalus or microcephaly.

Common clinical manifestations of intrauterine infection: intoxication, low birth weight, poor weight gain, poor appetite, regurgitation, vomiting, restless behavior or lethargy, skin dry, pale with a cyanotic, gray or icteric tint, jaundice may be pronounced, the skin collects in folds, there may be polymorphic rashes, thinning of the subcutaneous fat layer, enlarged lymph nodes, enlarged liver and spleen, the abdomen is enlarged, swollen, hemorrhagic syndrome - bleeding, hemorrhagic rash on the skin, intestinal syndrome.

Specific symptoms and syndromes characteristic of certain infections.

Rubella: meningoencephalitis, hepatitis with jaundice, pneumonia, congenital heart disease, rotation of the legs and feet, iridocyclitis, deafness in 50%, if the mother was ill in the first month of pregnancy - Gregg's triad - eye defects, heart defects, deafness.

Cytomegalovirus infection: any organ that has epithelial cells is affected. Jaundice, hepatitis, hemorrhagic manifestations (petechiae, melena), meningoencephalitis, pneumonia, calcifications in the brain, kidney damage, nephritis, eye damage. It often appears after the neonatal period. Possible microcephaly, polycystic kidney disease, heart failure, late complications - deafness, blindness, encephalopathy, microcephaly, pneumosclerosis, liver cirrhosis.

Herpes infection: vesicular rashes on the skin of mucous membranes, keratitis, severe hepatitis, jaundice, pneumonia, DIC. Defects: limb hypoplasia, microcephaly, microphthalmia, skin scars. Complications - blindness, deafness, lag in psychomotor development.

Viral hepatitis: hepatitis, jaundice, dark urine, discolored stools. Defects - atresia of the biliary tract, complications - cirrhosis of the liver, lag in psychomotor development.

Listeriosis: meningoencephalitis, papular-roseolous rash on the back, abdomen, legs, whitish-yellowish nodules with a diameter of 1-3 mm on the back of the pharynx, conjunctivitis, complications - hydrocephalus.

Tuberculosis: enlarged peripheral and abdominal lymph nodes, ascites, lung damage, meningitis, renal failure, defects of the skeletal system.

Syphilis: specific rashes on the skin, necessarily on the palms and soles, rhinitis, sniffling, periostitis, osteochondritis of tubular bones, cracks in the corners of the mouth. At preschool age: Hutchinson's triad (keratitis, deafness, dystrophy of teeth), saddle nose, saber legs.

Toxoplasmosis Key words: meningoencephalitis with kalydificates, hydrocephalus, eye damage, microcephaly, microphthalmia, hepatitis. Constantly scratching eyes at an older age.

Chlamydia: purulent conjunctivitis, rhinitis, otitis media, pneumonia, persistent paroxysmal cough.

Newborns from high-risk groups are subject to examination for the presence of IUI.

Diagnosis of intrauterine infections in newborns

Laboratory diagnosis of infections

There is no characteristic sign only for infection. To one degree or another, all parts of the immune system respond to any stressful situation, and not just to the introduction of an infectious agent. Therefore, it is very difficult to recognize an infection only by laboratory parameters. We decided to touch upon the main markers of infections, the laboratory determination of which can currently be afforded by most medical institutions. Many putative markers (cytokines, blood cell surface antigens, granulocyte colony stimulating factor) are being investigated but not yet used for routine diagnosis. Numerous publications show that taken separately, such indicators as the concentration of leukocytes, platelets, the ratio of mature and immature neutrophils and CRP have low sensitivity and specificity. In addition, they depend on:

• postnatal and gestational age;
• from the time of the onset of the infectious process.

The information content of these indicators can be increased by:

• their sharing;
• combination with clinical symptoms;
• the dynamics of changes (with non-infectious causes, such as birth stress, there is a rapid reverse development).

It should be remembered that no laboratory data can replace ongoing medical supervision, which may be more sensitive to the onset of symptoms of infection (eg, the onset or increase in the frequency of apnea) even before changes in laboratory parameters.

Leukocyte concentration. With infections, both leukocytosis and leukopenia can develop. At the same time, uninfected children may experience pathological changes in the concentration of leukocytes due to labor stress. Of the many definitions of leukocytosis/leukopenia in the neonatal period, the following are most common:

• leukopenia - the concentration of leukocytes is less than 6000 on the first day of life, then - less than 5000 in 1 mm3;
• leukocytosis - the concentration of leukocytes is more than 30,000 on the first day, then - more than 20,000 in 1 mm3.

Neutrophil concentration. A complete neutrophil count is slightly more sensitive for detecting infection than a leukocyte count, although abnormal neutrophil counts at the onset of septic symptoms are only seen in neonates. The total number of neutrophils increases after birth and reaches its peak by 6-8 hours of life. The lower limit of normal at this time is 7500, 3500 and 1500 / mm3, respectively, for newborns> 36 weeks, 28-36 weeks. And<28 нед. гестации.

A more sensitive indicator (sensitivity 60-90%) is the neutrophil index (NI), calculated as an increase in the ratio of immature forms of neutrophils (myelocytes, metamyelocytes, stab neutrophils) with the total number of neutrophils.

The reproducibility of this indicator depends on the quality of identification of the neutrophil species by laboratory assistants.

The normal value of the neutrophilic index at birth is 0.16; later, with an increase in postpartum age, it decreases to 0.12. Most authors use NI >0.2 to diagnose sepsis, but other values ​​are also used (0.25; 0.3).

Data obtained between 6 and 12 hours after birth are more likely to be altered than those obtained immediately after birth, because a change in the number and composition of leukocytes requires an inflammatory response.

Thrombocytopenia. Different authors consider thrombocytopenia a platelet concentration of less than 100 or 150,000x109/L. The number of platelets in a healthy newborn in the first 10 days of life is rarely less than 100x109/L. Values ​​below this may occur in early-onset sepsis, although this feature is commonly seen in nosocomial infection. Thrombocytopenia is not a specific sign of sepsis due to the large number of reasons leading to its development. In general, the presence of thrombocytopenia is a non-specific, insensitive indicator and is more characteristic of late sepsis.

Erythrocyte sedimentation rate. The use of erythrocyte sedimentation rate during the neonatal period is of little value in either diagnosing or monitoring serious bacterial infection.

Analysis of urine for the diagnosis of RNS is uninformative.

SRP is an acute-phase protein of inflammation, an increase in its level is associated with tissue damage, and it is assumed that its main function is to neutralize bacterial or intrinsic toxic substances released from tissues in response to microbial aggression. CRP is elevated in 50-90% of newborns with systemic bacterial diseases.

6-8 hours after the onset of the infectious process, the concentration of CRP gradually increases and reaches maximum values ​​after 24 hours. Therefore, often in newborns with RNS, the first determination of CRP immediately after birth may not differ from normal values. Normal CRP ranges may change during the first 48 hours of life depending on age.

Gestational age probably does not affect the reliability of the results, however, some studies have noted that preterm infants may have lower baseline CRP values, and their role in the diagnosis of neonatal sepsis is less significant. Despite some age fluctuations, the cut-off value of 10 mg/l is most commonly used, regardless of gestational age and postpartum age of the newborn, since the sensitivity of CRP values ​​above 10 mg/l to detect neonatal sepsis is 90%. Normalization of CRP may be a good indicator of successful treatment of the infection. On the dynamics of CRP indicators, the determination of the duration of antibiotic therapy can be based. After the cessation of the inflammatory reaction, due to the relatively short half-life from the blood (about 19 hours), the level of CRP decreases rapidly and returns to normal values ​​in most children within 5-10 days.

The sensitivity of CRP at the onset of sepsis is 50-90%, the specificity is 85-95%. The sensitivity of the assay increases dramatically if the first assay is done 6-12 hours after birth. Two normal CRP values ​​(<10 мг/л) - первое через 8-24 ч после рождения, а второе спустя 24 ч - позволяют на 99,7% исключить сепсис.

Many other conditions (asphyxia, RDS, maternal fever, prolonged anhydrous period, IVH, meconium aspiration, viral infection) can also cause similar changes in CRP levels. In addition, approximately 9% of healthy newborns have CRP levels >10 mg/l.

Procalcitonin is a precursor of the hormone calcitonin, which has a hypocalcemic effect. Basically, procalcitonin is produced in the neuroendocrine C-cells of the thyroid gland. In severe systemic infection, procalcitonin is probably produced by tissues outside the thyroid gland (monocytes and hepatocytes). The sensitivity of procalcitonin in bacterial infections is the same as CRP or slightly higher, but more specific. For children under the age of 48 hours, the sensitivity of an increase in procalcitonin in relation to the diagnosis of early neonatal sepsis was 92.6%, and the specificity was 97.5%. It was also noted that the level of procalcitonin increases 3 hours after the administration of the bacterial agent, while CRP appears only after 12-18 hours.

Procalcitonin is a qualitative marker for distinguishing septic shock from shock of a different nature, although sometimes there are cases of an increase in the concentration of procalcitonin in RDS, trauma, hemodynamic disorders, perinatal asphyxia, intracranial hemorrhage, gestational diabetes, and also after resuscitation.

Methods not included in routine clinical practice:

• Pro-inflammatory cytokines IL-6 and IL-8.
• Iaip (Inter-alpha Inhibitor Protein).
• Serum amyloid (SAA).
• strem-1.
• Surface antigens of blood cells.

Other methods for diagnosing infectious diseases

Serological methods. The detection of antigens and antibodies by serological methods has not become widespread in the diagnosis of infections in newborns due to the insufficient accuracy of the results obtained or the difficulty of reproduction.

Molecular Diagnostics. Polymerase chain reaction and hybridization method for the detection of bacterial genomes make it possible to quickly identify any infectious agents based on the identification of a specific region of the genome that is present in bacteria but absent in humans. The sensitivity of molecular diagnostic methods for sepsis can be higher than culture methods, ranging from 41 to 100%, with most studies showing values ​​between 90 and 100%, and specificity in the range of 78-100%.

Heart rate variability monitoring. A number of studies have shown a high dependence of heart rate variability on the degree of maladaptation of the body, which is possible under various conditions, including sepsis. A change in heart rate was the first sign in newborns, recorded 24 hours before the first clinical signs of sepsis. Continuous monitoring of the heart rate may contribute to earlier detection of infection and early initiation of antibiotic therapy.

The advantage of this method may be the possibility of continuous and non-invasive monitoring and high information content in the early stages of diagnosis.

conclusions

So far, none of the current markers of the infectious process can unequivocally diagnose cases of infection by 100%. Many serious localized infections (such as pneumonia, deep abscess, ventriculitis) may require antibiotic therapy, but blood markers may be normal. For the early diagnosis of sepsis in clinical practice, sensitivity is more important than specificity, as the consequences of inappropriately treating an uninfected newborn are less harmful than not treating an infected child.

Diagnostic tests are more effective in follow-up than in a single study.

Microbiological diagnostics

The "gold standard" is the isolation of the pathogen from the usually sterile environments of the body, for example, from CSF, blood. Isolation of microorganisms from other places can only speak of contamination.

If sepsis is suspected, at least 1 blood culture should be taken. The minimum blood volume required for culture on the medium is 1.0 ml for all newborns with suspected sepsis.

Currently (in countries where mothers are given antibiotic therapy to prevent neonatal sepsis), the number of positive blood cultures in newborns with RNS has decreased to 2.7%. Other reasons for the rare isolation of cultures from biological fluids (blood, CSF) are the inconsistency of bacteremia in a newborn, the low density of the pathogen, and the small amount of material taken for sowing. Therefore, blood cultures are currently of little help in confirming neonatal sepsis.

Tracheal aspirate culture. Tracheal aspirate samples may be important if obtained immediately after tracheal intubation. The duration of intubation reduces the value of the study, so if the endotracheal tube is in the trachea for several days, the aspirate samples lose all value.

Isolation of bacteria from superficial areas of the body, from gastric contents and urine in the diagnosis of early sepsis is of no value.

Treatment of intrauterine infections in newborns

Treatment of severe infections can be divided into replacement and antimicrobial therapy.

General stabilization of the state

• Maintain normal body temperature.
• Correction of glucose and electrolyte levels.
• Correction of anemia: the optimal values ​​of red blood for severe infections in newborns are unknown, but it is recommended to maintain a hemoglobin level of 120-140 g / l, hematocrit - 35-45% (the minimum acceptable level of hemoglobin is 100 g / l, hematocrit - 30%).
• Respiratory support depending on the severity of DN: O 2 , nCPAP, mechanical ventilation, iNO, surfactant. It is recommended to maintain the following indicators of blood gases: pH 7.3-7.45, PaO 2 = 60-80 mm Hg. (SaO 2 \u003d 90-95%), PaSO 2 \u003d 35-50 mm Hg.
• Stabilization of hemodynamics (infusion, inotropes / vasopressors, corticosteroids) should be aimed at normalizing blood pressure, the appearance / maintenance of diuresis > 2 ml / kg / h, increasing BE and reducing serum lactate levels.
• DVS therapy.
• Nutritional support/infusion therapy: The enteral route should be used as much as possible. Even minimal enteral nutrition protects the intestinal mucosa and reduces bacterial translocation.

Interventions with questionable effectiveness/understudied

• Intravenous immunoglobulins (enriched with IgM).
• Myelopoietic cytokines (granulocyte colony-stimulating factor - G-CSF and factor stimulating the activity of granulocyte-macrophages - GM-CSF).
• Transfusion of granulocytes in newborns with neutropenia.
• The use of efferent methods of detoxification.
• Pentoxifylline.

Despite the fact that a large number of works of various designs (up to RCTs) performed by domestic authors show a positive effect of drugs such as roncoleukin (recombinant interleukin-2), betaleukin (recombinant interleukin-lb), licopid (glucosaminylmuramyl dipeptide), viferon (recombinant human interferon-α2β) on survival and reduction in hospital stay of newborns of different gestational ages with sepsis and pneumonia, we believe that serious multicenter studies are needed before these drugs can be recommended for routine use.

Activities that have not shown their effectiveness

• Intravenous immunoglobulins (enriched with IgG).
• Activated protein C (Drotekogin-alpha).

Postnatal prevention and etiotropic treatment

The main therapy for infections is the correct selection and timely administration of antibacterial drugs. Antibacterial therapy is prescribed for all children with clinical and laboratory signs of sepsis. The absence of bacteriological confirmation is not a decisive factor for not prescribing antibiotic therapy, especially since bacteriological data appear at best after 48-72 hours. Therefore, the decision to prescribe antibiotics is often made more on the basis of anamnesis data (mainly maternal). A Cochrane review of 2 randomized trials performed in the 1970s does not answer the question of whether asymptomatic newborns with one or more risk factors should receive prophylactic antibiotics. Many authors, based on their own experience, prefer to carry out antibacterial prophylaxis in the presence of risk factors for infection while monitoring the child. In most countries, the protocols used have much in common, differing more in developing countries (mainly in types of antibiotics and timing of therapy). Below is one of the protocols based on the latest recommendations from the Centers for Disease Control and Prevention.

Newborns requiring antibiotic therapy

I. Newborns with clinical signs of sepsis.

Every critically ill or deteriorating neonate should be evaluated to decide whether to initiate empiric antibiotic therapy (previously by blood culture, even in the absence of obvious risk factors for sepsis).

II. A healthy-looking newborn with a high probability of RNS.

GBS is not a risk factor if the mother received adequate antibiotic prophylaxis (penicillin, ampicillin, cefazolin) at least 4 hours before delivery or had a caesarean section with intact membranes in the absence of labor.

1. Newborns with gestational age<37 нед. без клинических признаков сепсиса, но с 1 фактором риска (длительный (>18 hours) anhydrous period, or chorioamnionitis, or inadequate antibacterial prophylaxis of the mother during childbirth):
   • antibiotic treatment;
   • • if the blood culture is negative, the child's condition is good and laboratory parameters are normal, antibiotic therapy should be stopped.
2. Newborns with gestational age >37 weeks without clinical signs of sepsis, but with 1 risk factor (chorioamnionitis):
   • antibiotic treatment;
   • laboratory tests (leukocytes, CRP, blood culture at the age of 6-12 hours):
     • with a positive result of blood culture - lumbar puncture, continue antibiotic therapy;
     • with a negative result of blood culture, a good condition of the child, but pathological laboratory parameters - continue antibiotic therapy if the mother received antibiotics during childbirth;
     • with a negative result of blood culture, a good condition of the child and normal laboratory parameters - stop antibiotic therapy and observe for 48 hours.
3. Newborns with a gestational age > 37 weeks. without clinical signs of sepsis and with other risk factors (not chorioamnionitis): prolonged (>18 h) anhydrous period or inadequate maternal antibiotic prophylaxis in labor (use of antibiotics other than penicillin, ampicillin, or cefazolin, or if antibiotic administration was less than 4 h before birth):
   • antibiotic therapy is not carried out;
   • observation;
   • examination (leukocytes, CRP, blood culture at the age of 6-12 hours).

Each region should probably have its own protocol adapted to local conditions.

Etiotropic treatment of bacterial infections

Etiotropic therapy for RNS is almost always empirical. If there is no reason to assume an infectious history of the mother, the microflora is likely to be represented by the usual representatives of the urogenital tract. If the woman was in the hospital before giving birth, the presence of nosocomial flora is likely. Known data on maternal colonization should be taken into account when prescribing antibiotics.

Empiric antibiotic therapy for early infections in developed countries should target GBS, E. coli, and L. monocytogenes. Combination therapy is usually used, including the appointment of penicillins with an extended spectrum of activity (ampicillin or amoxicillin) and aminoglycosides (usually gentamicin or netromycin / tobramycin). In most cases, such treatment “covers” the entire possible spectrum of pathogenic maternal microflora and is inexpensive. At the same time, there are rare reports of the possible emergence of GBS resistance to penicillins. It should be remembered that aminoglycosides do not penetrate the blood-brain barrier well enough, therefore, in meningitis, a combination of ampicillin and third-generation cephalosporins is often preferred. III generation cephalosporins provide concentrations of drugs in most foci of infection, significantly exceeding the minimum inhibitory concentrations of susceptible pathogens (GBS, E. coli and other gram-negative intestinal bacteria) with low toxicity. However, none of the cephalosporins is active against Listeria and Enterococcus and has variable activity against Staphylococcus aureus.

III generation cephalosporins are not usually used as an alternative to aminoglycosides due to a number of features:

• rapid development of resistance to cephalosporins III and IV generations with their widespread use;
• with prolonged use, the risk of developing invasive candidiasis increases significantly;
• ceftriaxone is contraindicated in newborns due to the competitive displacement of bilirubin from protein binding, which can lead to the development of kernicterus.

Therefore, the use of cephalosporins (in the appointment of empirical therapy) is limited to the treatment of meningitis caused by gram-negative microorganisms. Cefotaxime is the safest of the cephalosporins, since it does not displace bilirubin from its association with albumin and does not pose a threat of toxic damage to the central nervous system.

In developing countries, where RNS pathogens differ from those in developed countries, the combination of penicillins and aminoglycosides may not be effective. Therefore, in such countries, empiric antibiotic therapy should be determined individually for each hospital or region.

A review of the literature on antibiotic susceptibility of community-acquired sepsis in Africa and Asia showed that the 2 most common pathogens, S. aureus and Klebsiella spp. - were highly resistant to almost all commonly used antibiotics (such as ampicillin, ceftriaxone, chloramphenicol, cotrimoxazole, macrolides and gentamicin). Good susceptibility to all these agents, except for cotrimoxazole, was demonstrated only by Str. pneumoniae.

Anaerobic microflora may require the additional appointment of metronidazole.

Once the pathogen is identified, antibiotic therapy should be narrowed down. There is considerable variation in recommendations for the duration of empiric antibiotic therapy for suspected RNS when blood cultures fail, but it is standard practice to discontinue antibiotic therapy when blood cultures are negative (usually 48–72 h) and there is no clinical or haematological evidence of infection.

Duration of treatment

The optimal duration of empiric antimicrobial therapy reduces the development of resistance, prevents unwanted changes in the flora in the NICU, and also minimizes unnecessary costs in negative blood cultures.

Bacteremia requires antibiotic therapy for 10-14 days (for GBS) or at least another 5-7 days after the clinical result is obtained.

Many authors recommend longer antibiotic therapy for negative blood cultures in newborns with suspected RNS and necrotizing enterocolitis. Limited data suggest that a 7-day course of treatment may be sufficient for uncomplicated bacteremia.

Many authors report that short courses of antibiotic therapy (5 days or less) in culture-proven sepsis (excluding meningitis and osteomyelitis) are as good as longer courses. Similar data were obtained with short (4-7 days) courses of therapy for pneumonia. The authors found that reducing the duration of antibiotic therapy did not increase the risk of recurrent infection in infants with early sepsis, while reducing the incidence of late-onset sepsis.

Long duration (>5 days) of initial empiric antibiotic therapy with broad-spectrum antibiotics is associated with an increased risk of necrotizing enterocolitis, late neonatal sepsis, and death in newborns with ELBMT. Other adverse effects of long-term empiric antibiotic therapy include an increased risk of neonatal candidiasis and altered gut microflora. The choice of cefotaxime (III generation cephalosporins) over gentamicin in the first 3 days of life is associated with higher mortality. Newborns (especially preterm infants) receiving long-term therapy with broad-spectrum antibiotics (especially cephalosporins) need fluconazole prophylaxis for candidiasis.

Control

The culture should be repeated 24-48 hours after completion of therapy to ensure that the bacteria have been killed. Persistent positive cultures suggest inadequate therapy and/or an existing site of infection (eg, infected infusion line). When determining the duration of antibiotic therapy, one should be guided by the clinical condition of the newborn and a combination of laboratory parameters: the neutrophil index, the total number of leukocytes and CRP, with successful therapy, should begin to normalize after 72 hours.

conclusions

In newborns immediately after birth, in most cases it is impossible to predict the development of infection in advance. Antibacterial therapy in the first days of life is almost always empirical. It is prescribed if there are reasonable assumptions of the development of an infectious process (this is especially true for preterm infants). The scope of "reasonableness" depends on many factors - they can narrow or expand depending on local conditions (qualifications, experience of staff, availability of resources, healthcare organization, etc.). In most cases, ampicillin and an aminoglycoside (gentamicin, netromycin) are sufficient. Subsequently, if data on a bacterial infection are not confirmed, antibiotic therapy is stopped. If the patient's condition does not improve, it is necessary to exclude other causes of a serious condition, infections of a different etiology, or resistance of the pathogen to the prescribed drugs.