Maternal Conditions

Affecting the Newborn

Dr. Md. Masudur Rahman
Medical Officer
SCANU
Case Scenario 1:

B/O: Parvin, term, LBW female baby admitted to this hospital at SCANU
dept. at D6 on 29th oct’22 with the complaints of severe jaundice and reluctant
to feeding for 2 days. Her mother’s blood group is A(-ve).

1. What questions should we ask for?

2. What is the MX plan?
3. What precautions should take in subsequent pregnancies.
Case Scenario 2:

B/O: Puja Roy, term, macrosomic( 4.1 kg) inborn male baby
delievered by LUCS half an hour back brought to SCANU dept on 23rd Oct’22
with the complaints of difficulty in breathing. On emergency triage
assessment the baby was found hypoglycaemic (CBG: 1.9 mmol/L). His
mother is diabetic for 4 years and is on Insulin.

1. what is the MX protocol.

2. What complications may arrise?
Case Scenario 3:

A known case of HIV positive pregnant lady came to the

obstetric dept with labour pain.

1. What would be the safest mode of delivery?

2. What precautions should be taken for PMTCT?
3. Should the baby test for HIV just after birth?
Infants of Diabetic Mother (IDM):

IDM babies are characteristically

-large (may be small)
-plethoric
-moonfaced.
-Hypertricosis and hairy-pinna is pathogonomic .
-should be looked for in all large babies.
Disorder frequently encountered in IDM:

#Metabolic disorder:
Hypoglycemia
Hypocalcemia.
Hypomagnesemia

# Cardiorespiratory disorder:
Perinatal asphyxia
Respiratory distress syndrome.
Transient tachypnea of newborn.
Hypertrophic cardiomyopathy and septal hypertrophy.
#Hematologic disorder:
Hyperbilirubinemia
Polycythemia and hyperviscocity
Renal vein thrombosis

#Congenital malformation:
-Congenital heart disease: TGA, VSD, ASD
-anencephaly or meningolcele
-Renal agenesis, situs inversus
-hemivertebra
-micropthalmos
Glucose Monitoring Schedule:

Within ½ an hour.
Then every 2 hourly – 3 sample
Then every 6 hourly – 3 sample
Then every 12 hourly – 2 sample
Then 24 hourly – 1 sample

( Total 10 sample in 72 hours - ½, 2 ,4, 6, 12,18, 24,36, 48, 72 hrs)

.
Rh iso-immunization:

The severity of rhesus iso immunization may be assessed by:

-History of previous pregnancies and their outcome

- Zygosity and blood group of the father

-Anti-D antibodies titer during pregnancy

.
. Management of Rh isoimmunization:

• First thing is to do Rh phenotype of patient husband. If it is Rh positive

then antibody (Rh anti D titre) screening should be done in following gestational
wks

o At booking
o At 20 wks1
o At 24 wks
o At 28 wks
• If anti D antibody screening does not show evidence
of allo immunization (titre<4) then…..

-anti D immunoglobulin at 28 wks of gestation

-Next dose prophylactic anti D immunoglobulin is given

within 72 hours after delivery ( if baby is Rh positive).
.
Cord sample is collected and send for…..

 Blood Grouping and Rh typing

 Hb%
 Fractionated bilirubin (Total, Direct, indirect)
 Reticulocyte count
 Coomb’s test (Direct, Indirect)
- Patients in the course of their first sensitized pregnancy should have
antibody titers every four weeks unless the following occur:

o titer is at or above the critical level (usually 1: 32) on the

initial evaluation.

o The titer reaches or exceeds the critical level any time during gestation.

o There is a significant rise in the titer (two-tube dilution) between two

consecutive examples, even if the upper dilution does not reach the critical
level (e.g. increase from 4 to 32 with a critical level of 64)
•But if any of these conditions occurs, there is no further use of antibody titers …..

-Do middle cerebral artery peak systolic velocity (MCA PSV) .

- If MCA PSV >1.5 MoM, then cordocentesis is considered for detection of fetal
hemoglobin.

- Intrauterine transfusion is indicated if hemoglobin% falls below 30%.

- Termination of pregnancy is done preferably after completion of 34 wks and antenatal

corticosteroid therapy.
.
If the antibody titer remains under critical level up to 36 wks, patient should be
delivered by elective induction of labor between 38-40wks in presence of
neonatologist.
Maternal HIV

Mother to Child Transmission Mood:

-During Pregnancy (even in first trimester)

-Perinatal period (most commonly)
-Breast feeding
• In the absence of any intervention the risk of perinatal transmission is
15–30% in nonbreastfeeding populations.

• Breastfeeding by an infected mother increases the risk by 5–20%

increasing the risk to a total of 20-45%.
Risk factors for Perinatal HIV transmission

Maternal factors:
• High viral load
• Advanced disease (low CD4 count, symptoms of AIDS)
• HIV acquired during pregnancy or breastfeeding

Obstetric:
• Vaginal delivery
• Rupture of membrane for more than four hrs
• Intrpartum haemorrhage

Infant factors:
• Breast feeding
• Prematurity
Prevention of HIV Transmission :
• (ARV) prophylaxis during pregnancy and labour .

•Elective caesarean delivery (prior to the onset of labour and rupture of

membranes) and thoroughly wash the baby to remove maternal blood and
secretion
• Avoid procedures increasing risk of exposure of child to maternal blood and
secretions

• Avoid rupture of membranes unless medically indicated

• Breastfeeding is encouraged but not mixed feeding.

Maternal ART and Infant prophylaxis:

Mother:
Maternal antepartum daily ART, starting as soon as possible irrespective of
gestational age, and continued during pregnancy, delivery, during breastfeeding.

1. AZT + 3TC + NVP or

2. AZT + 3TC +EFV* or
3. TDF + 3TC (or FTC) + NVP or
4. TDF + 3TC (or FTC) +EFV*

(AZT:Azathioprine, NVP: Nevirapine, TDF: Tenofovir, 3TC: Lamivudin, EVF: Efavira)

*Note: Avoid use of EFV in the first trimester and use NVP instead
Infant:
NVP or AZT from birth (within 6 hours) or as soon as feasible thereafter until 4 to 6
weeks of age (irrespective of the mode of infant feeding)

Doses of NVP and AZT according to birth weight for infants are given below:

Birth weight Nevirapine* AZT

<2000 g 2 mg/kg body weight one times a day 2 mg/kg body weight two times a day

2000g – 2499
. g 10 mg per day 10 mg two times a day

2500 g and above 15 mg per day 15 mg two times day

Postnatal Diagnosis of HIV:
.

Test may also need to be repeated in infants who develop symptoms or signs suggestive
of HIV infection.
Co-trimoxazole prophylaxis for prevention of opportunistic infection:

 Co-trimoxazole prophylaxis is recommended for all HIV-exposed infants under

age 18 months starting at 4–6 weeks of age or when first seen and continued
until HIV infection can be excluded
Pregnancy associated Hypertensive disorders:

-Chronic hypertension
-precedes pregnancy or occurs within 20 weeks of
gestation

-does not resolve by the 6-week postpartum check-up.

-Essential hypertension.

-long standing duration may adversely effect the fetal

growth because of placental vasculopathy.
Pregnancy-induced Hypertension:

Pre-eclampsia:
hypertension after 20th week of gestation
+ proteinurea +/- edema.

Eclampsia
Pre-eclampsia + seizures/fit.
Complications:
Maternal accidental haemorrhage leads to ……

-acute fetal hypoxia,

-birth asphyxia
-respiratory distress due to meconium aspiration.
Abnormal Quantity of Liquor:

Polyhydramnios: .amniotic fluid (>2 liter) .(AFI) in USG is > 24 cm.

Maternal condition:
-Multiple pregnancy -syphilis -DM
-chronic renal or cardiac disease. -Pre-eclamptic toxaemia .

Fetal Condition:
-Anencephaly and spina bifida, -high intestinal obstruction,
-omphalocele, - gastroschisis
-ectopia vesicae. -Hydrops fetalis .
Complications:

Maternal:
-Pre-eclampsia -malpresentation -PROM
-preterm labour -cord prolapse -uterine inertia
-retained placenta -PPH .

Fetal:
Death due to- prematurity
congenital anomali.
cord prolapse,
hydrops fetalis
Oligohydramnios:
-AFI < 5-6 cm.
Causes:
# The fetal disorders which interfere with passage of urine such as
-bilateral renal agensis,
-renal dysplasia,
-polycystic kidney disease
-obstructive uropathy
# fetal chromosomal and structural anomalies,
# IUGR,
# hypertensive disorder
# drugs: PG inhibitor, ACE inhibitors
Complications:

Maternal:
Prolong labour
increase operative interference due to malpresentation.

Fetal:
Abortion,
deformity,
pulmonary hypoplasia,
cord compression
high fetal mortality.
Antepartum hemorrhage (APH):

bleeding from genital tract after 28th weeks of pregnancy but before the
delivery of the baby.

Complication:
Fetal hypoxia and intrauterine death,
premature delivery,
severe birth asphyxia,
birth injury
congenital malformation .
Premature Rupture of membrane (PROM)

-marked delay (>18 hours) may predispose the fetus to develop bacterial
infection by swallowing or aspirating infected amniotic fluid.

-The mother may develop clinical evidences of amnionites in the form of……
fever
tachycardia
leukocytosis
uterine tenderness
foul smelling amniotic fluid
• It is preferable and safer to deliver the baby if there are
evidences of chorioamnionitis or when gestational maturity is 34 weeks
or more.

• High vaginal swab should be taken for culture and sensitivity if

there are evidences of chorioamnionitis.
Systemic Lupus Erythematosus

#Maternal SLE may lead to….

-abortion
-prematurity
-fetal death
-intrauterine growth retardation
-transient neonatal lupus erythematosus
#Common manifestations of neonatal lupus at few weeks of life include
photosensitive maculo-papular rash on the face, trunk and proximal extremities
which is precipitated by phototherapy or exposure to sunlight.

# Mild thrombocytopenia, anemia , hepatosplenomegaly and carditis may

occur.

#The clinical condition resolves in 10 to 12 weeks without any

corticosteroid therapy
Treatment:

•Supportive and depends on the specific manifestations present

• Cutaneous lesions require sun avoidance, sunscreen, and low-potency

topical corticosteroids to hasten solution

•Infants with severe hepatic and hematological involvement may require

treatment with
-systemic corticosteroids
-intravenous immunoglobulin
-and/or immunosuppressive agents.
Maternal Hypothyroidism:

-Placental transfer of thyroid –blocking immunoglobulin’s may cause

fetal hypothyroidism which can be prevented by increasing the dose of thyroxin to
mother.

-fetal and neonatal outcomes include….

preterm birth
IUGR
congenital anomalies
fetal distress
fetal and perinatal death
Maternal hyperthyroidism

-Elevated maternal thyroid stimulating antibodies (>300%) are usually

associated with neonatal thyrotoxicosis.

-High doses of antithyroid drugs during later pregnancy may cause fetal
goiter and hypothyroidism because they readily cross the placental barrier.

-Propylthiouracil (PTU) is the preferred antithyroid drug due to its

reduced passage across the placenta and limited excretion in the breast milk.
Hepatitis-A:

-Women infected with hepatitis A are encouraged to breastfeed with care.

-Make sure of……

washing hands with warm water and soap before touching the
breasts and nipples, especially after using the washroom or changing baby's diaper.
Hepatitis-B:
Mode of transmission:

# 1 During Pregnancy: Transplacental

# 2 During Delivery: Transplacental secondary to placental leak

Exposure to amniotic fluid, vaginal secretion, maternal blood

#3 Postnatal transmission: By fecal-oral spread, blood transfusion

-The risk of vertical transmission is increased in infants of HBeAg positive

mothers:
• HBsAg and HBeAg positive mothers = ~71%.
• HBsAg positive and HBeAg negative = ~10%.
Management of Infant born to HBsAg positive Mother:

• Infant should receive Hepatitis B Immunoglobulin (HBIg), 0.5ml IM and Hepatitis B

Vaccine (0.5 ml) IM within 12 hours after delivery then follows the EPI schedule.

-Hepatitis B Immunoglobulin (HBIg), & Hepatitis B Vaccine should be given

simultaneously in separate thigh on anterolateral aspect with separate syringe.

Follow-up:
Infants born to HBsAg positive mother with appropriate immune-prophylaxis should
be tested for HBsAg and Anti HBs at 9 months of age.

.
Hepatitis C:

• The risk of passing the hepatitis C virus to unborn child has been
related to the levels of quantitative RNA levels in mothers blood, and also whether
she is also HIV positive or not.

• Mothers without hepatitis C RNA levels detected, did not transmit hepatitis C
infection to their infants.

• There is no preventive treatment at this time that can influence the

rate of transmission of the virus from mother to infant.
Hepatitis-E:

-During pregnancy, the risk of fulminant HEV disease and maternal

mortality occurs in 20% of patients when the disease presents during the third
trimester.

-Premature deliveries with high infant mortality of up to 33% are also

observed.
Tuberculosis (TB)
Transmission:
Congenital transmission-
-Vertical transmission via hematogenous and transplacental route.
(aspiration or ingestion of amniotic fluid, Maternal extra pulmonary TB such as
military TB, tuberculous endometritis.)

Postnatal transmission-
- Airborne transmission (from mother or adult with infectious pulmonary
tuberculosis.)
-Contamination of traumatized skin or mucous membrane
Clinical features:

-Symptoms of congenital tuberculosis may be present at birth but more

commonly begin by the 2nd or 3rd wk of life.

-Clinical features are non specific similar to that of sepsis or other

congenital infections whose response to antibiotic and other supportive therapy is
poor and evaluation for other infections is unrevealing.
The most common signs and symptoms are…
o Respiratory distress
o Fever
o Hepatic or splenic enlargement
o Poor feeding
o Lethargy or irritability
o Lymphadenopathy
o Abdominal distention
o Failure to thrive
o Ear drainage
o Skin lesions
o Meningitis (30-50% cases)
o Sometimes cough, wheeze, stridor, crepitation may present when obstraction of
bronchi present.
Diagnosis:
- Most important clue for rapid diagnosis is a maternal or family history of
tuberculosis.

- Positive AFB Stain from early morning gastric aspirate.

Direct acid-fast stains on middle-ear discharge, bone marrow, tracheal aspirate, or
biopsy tissue (especially liver) can be useful.

-Polimarase Chain Reaction (PCR)

-Tuberculin skin test (TST): The infant's TST result may be unreliable in infant <
3 months of age

-Chest radiograph: Most often a miliary pattern is found. .Hilar and mediastinal
lymphadenopathy and lung infiltrates are common.
Management:
Mother diagnosed with TB in the last 2 month of pregnancy (or who has no
documented sputum smear conversion) need to be carefully managed.

Asymptomatic baby:
• Give Isoniazide preventive therapy (IPT) for 6 month.
(10 mg/kg/day, single dose; dissolved in water and multivitamin syrup.)
• Withhold BCG at birth and give after completion of 6 month INH therapy.
• No separation of mother and infant is required except only if the mother is
severely ill, noncompliant, or has MDRTB.
• Mother should be encouraged to breast feed.

• BCG is contraindicated if the infant is known to be HIV infected

Symptomatic baby:

• The baby needs to be referred to hospital for evaluation to exclude TB.

• If baby has TB, should receive full course of TB treatment.
• BCG should be given after completion of treatment.

• Exclusively breastfed infants should receive pyridoxine 5 mg daily (Crush

and dissolve one 25mg tablet in 5 mL water for injection to make a 5 mg/mL
solution. Administer 1 mL (5mg) and discard remainder)
Treatment of TB:

 Pulmonary TB or TB lymphadenitis, TB pleural effusion, pericardial TB,

abdominal TB, who live in low HIV prevalence or low resistance to INH and HIV
negative: HRZ for 2 month followed by HR for next 4 month.

 Extensive Pulmonary TB who lives in low HIV prevalence or low resistance to

INH : HRZE for 2 month followed by HR for next 4 month.

 TB meningitis: (HRZ) S for 2 month and HR for next 10 months.

 Corticosteroids: if TB meningitis, pericardial TB is confirmed.
 Multidrug-resistant TB regimen . for 20 months
Recommended dose of first line anti-TB drugs:
Isoniazide (H) -10 mg/kg
Rifampicine (R) -15 mg/kg
Pyrizinamide (Z)- 35 mg/kg
Ethambutol (E)- 20 mg/kg
Streptomycine (S)- 15 mg/kg
Congenital Syphilis

-Untreated syphilis during pregnancy has a vertical transmission rate approaching

100%.

- Transmission rate ranges from 70-90% in primary and secondary syphilis, 40% for early
latent syphilis and to 8% for late latent syphilis.

- The adverse pregnancy outcomes include

o stillbirths or spontaneous abortion,
o perinatal death,
o serious neonatal infection
o low birth weight.
Clinical Manifestation:
-Approximately two-third of live born neonate with syphilis is asymptomatic at birth but have
low birth weight
Early manifestation (<2 years) are:
• Snuffles
• Maculopapular or vesiculobullous rash, petichiae
• Hemolytic anemia, jaundice
• Fever, Pneumonia
• Hepatosplenomegaly
• Lymphadenopathy
• Periostitis, osteochondritis
• Pseudoparalysis

Late manifestation (>2 years):

Harison triad (blunted upper incisors, interstitial keratitis and
eight nerve deafness) and saddle nose.
Diagnosis:

• Nonspecific nontreponemal antibody (NTA) test: VDRL and RPR test:

A titer of 4 fold higher in the infant’s serum than the mother signifies probable active
infection.

• Specific treponemal antibody (STA) test:

It should be performed if NTA test results are positive. Once positive, remain positive for
life.
o FTA-ABS (Fluorescent treponemal antibody absorption test)
o MHA-TP (Microhemagglutination test for antibodies to T. pallidum)
• Direct Identification of T. pallidum :
o Microscopic Dark field Examination
o Direct Fluorescent Antibody staining .

• Radiographic Examination of long bones:

Periostitis, Ostitis, Sclerotic Metaphyseal changes, Pathological fracture.
Treatment regimen:
1. Infant with proven or highly probable disease
IV Aqueous Crystalline Penicillin G / IM Procaine penicillin G – 10 days

2. Asymptomatic infant who have normal physical examination and NTA titer ≤ 4
fold the mother titer:
a. Maternal treatment uncertain/inadequate: .
Infant should be fully evaluated and treated as before or,
Benzathine penicillin G a single IM dose
b. Maternal treatment during pregnancy is adequate :
(Benzathine penicillin a single IM dose with no evaluation
c. Maternal treatment before pregnancy is adequate, mother NTA titer low and
stable during pregnancy and delivery: No evaluation or treatment
Epilepsy:
• Untreated seizures during pregnancy can produce fetal death, brain damage due to
hypoxia and neurological sequelae in later life.

• Epileptic mothers on anticonvulsant therapy have greater risk of congenital heart disease
and a 5 to 10 times risk of giving birth to babies with cleft lip and cleft palate.

•In case anticonvulsants are inescapable, phenobarbitone and carbamazepine and

possibly hydantoin are safe as far as congenital malformation is concerned.

• Vitamin K should be routinely administered at birth to newborn babies who have been
exposed to anticonvulsants during pregnancy
Thrombocytopenic Purpura:

-Idiopathic or drug induced auto-immune thrombocytopenic purpura in the mother may

be associated with transient thrombocytopenia in the baby.

-Mother should be given prednisolone 10- 20 mg 4 times daily for 10 to 14 days before
delivery.

-High dose intravenous Ig G therapy, corticosteroids and platelet transfusions are

indicated in infants with severe thrombocytopenia
Effect of drugs on the fetus:
Effect of drugs used for the mx of CVS disorders:
o Warfarin embryopathy (15%-25%) .
fetal hemorrhage.

o propranolol IUGR
birth asphyxia
bradycardia,
hypoglycemia,
polycythemia
Hyperbilirubinemia

o Thiazide neonatal liver damage

thrombocytopenia.
Effect due to anticonvulsant drugs:

- phenobarbitone / primidone /phenytoin Neonatal haemorrhage

-phenytoin Fetal hydantoin syndrome

Effect due to antihypertensive drugs

- ACE inhibitors congenital anomalies.

-Diuretics should be used with caution if there is associated preeclampsia.

Effect of oral hypoglycemic agent:

-Oral hypoglycemic agents teratogenesis

intractable hypoglycemia