Cytomegaloviral infection at pregnant women
Cytomegaloviral infection at pregnant women — clinically manifest or latentno the proceeding infectious disease caused by a cytomegalovirus which arose before conception or during a gestation. It is shown by a hyperthermia, catarrhal symptoms, cervical and submaxillary lymphadenitis, sialoadenity, the general intoxication, whitish-blue belyam, are more rare — a gepatomegaliy, splenomegaliy, generalized limfadenopatiya. It is diagnosed by means of serological and molecular laboratory methods. Treatment is carried out by specific human immunoglobulin, recombinant alpha 2 - interferon, at a heavy current — synthetic analogs of nucleosides.
Cytomegaloviral infection at pregnant women
Cytomegaloviral infection (cytomegalic inclusion disease, TsMVI) — one of the most widespread infectious diseases vnutriutrobno striking a fruit and causing various congenital anomalies. Depending on the region of an antibody to a cytomegalovirus are defined at 40-98% of patients of reproductive age. The cytomegalic inclusion disease meets in groups of the population with the low level of social and economic development more often. In Russia to TsMVI about 90% of women are seropozitivny, contamination among pregnant women is more senior than 30 years reaches 97-98%. In the European countries the congenital cytomegalic inclusion disease comes to light with a frequency of 3-5 cases at 1000 childbirth, in other states this indicator makes from 0,2 to 2,2%.
TsMVI reasons at pregnant women
The disease is caused by the large DNA-containing cytomegalovirus (TsMV) belonging to family herpes viruses. Experts allocate three strains of the activator, each of which can independently infect an organism of the same person. Infection occurs before conception or during pregnancy. Viruses for life persistirut in the woman's organism, affecting practically all types of fabrics. A part of infectiologists considers TsMV an opportunistic microorganism which clinically significant reactivation is observed only at considerable oppression of immunity.
Strengthening of pathogenicity of a cytomegalovirus in the gestational period is connected with the physiological immunosupression protecting genetically alien fruit from rejection. Under the influence of estrogen, progesterone, cortisol at the pregnant woman the absolute and relative quantity of the T-lymphocytes which are directly participating in elimination of viruses and the damaged cages decreases, their cytotoxicity decreases. As a result replication of cytomegaloviruses accelerates, they extend on an organism quicker and at the insufficient level of protective antibodies break a placentary barrier.
Feature of a Cytomegaloviral infection is plurality of ways of infection. The virus extends aerogenic, contact, fecal and oral, haemo transfusion, sexual, vertical in the ways, including transplatsentarno from the pregnant woman to a fruit. Because of rather low virulence the close contact with infected is important for infection. The TsMVI activator is defined practically in all biological environments: saliva, blood, urine, plaintive liquid, a likvor, breast milk, a tservikalny, vaginal, urethral secret, sperm, slime from a rectum, amniotic waters. After hit in an organism cytomegaloviruses are adsorbed on a surface of cages, get into them, pass a full cycle of replication of DNA then the created vireos extend to the next cages, with blood are carried on an organism. The pro-current epithelium of salivary glands, first of all parotid, other ekzokrinny glands is most sensitive to vireos.
After limfogenny and hematogenic generalization usually there comes the phase of an unproductive infection (the hidden carriage) with long preservation of a virus particle in the infected cage and transfer at division to daughter cells. At women the clinical demonstration does not happen to normal immunity, the disease gains character of a carriage at once. The cytomegalovirus can persistirovat a long time in an inactive form in sensitive cages. Penetration of TsMV into lymphocytes and mononukleara provides its protection against antiviral antibodies.
When falling immunity at pregnant women reactivation of a Cytomegaloviral infection with destruction of kernels of cages in which persistirovat a virus, a hematogenic dissemination, defeat of ferruterous bodies, development of vaskulit, induction specific tsitomegalichesky a metamorphosis of cells of different fabrics is possible. At a gestation viruses from interfleecy space get through a placenta and gematogenno infect a fruit. It is established that TsMV is capable to damage a membrane of a trofoblast.
Systematization of the main forms of a Cytomegaloviral infection at pregnant women is carried out taking into account expressiveness of a clinical picture and time of a demonstration of pathological process. Such approach is most justified from the point of view of forecasting of possible complications of a disease and the choice of optimum tactics of conducting pregnancy. Experts in the sphere of obstetrics and gynecology, infectious diseases distinguish the following options of an infection:
- Primary and manifest TsMVI. The most adverse option of a course of pathology. Results from primary infection of the pregnant woman who has no specific IgG. Differs in high probability of transplacentary transfer of a virus (to 30-75%) and pre-natal defeat of a fruit. In the period of a gestation comes to light no more than at 4% of patients. At infection with sharp symptomatology in the I trimester abortion is recommended.
- Carriage. The most frequent form of a Cytomegaloviral disease at pregnant women. Bearers are women who before conception had an active form of a disease or the infection against the background of strong immunity passed into an unproductive phase at once. The immunoglobulins G circulating in the patient's blood protect a fruit from TsMV infection. At an exception of immunosupressorny influences the risk of a pathological current of a gestation is minimum.
- Reactivation of a latent infection. At considerable decrease in immunity at bearers of a cytomegalovirus the characteristic clinical picture develops. The disease in a varying degree becomes aggravated at 40-50% of seropozitivny pregnant women. The virus is transplatsentarno transmitted to 0,15-0,36% of cases to the child. The greatest risk of congenital anomalies is observed at an exacerbation of a Cytomegaloviral disease on 7-12 weeks of gestational term.
TsMVI symptoms at pregnant women
At a latent carriage the clinical symptomatology is absent. At 4-5% of pregnant women with TsMVI the typical primary sharp or reactivated latent infection with complaints to mucous allocations from a nose, temperature increase to 38-40 °C, increase and morbidity of submaxillary, cervical lymph nodes, parotid salivary glands is noted. The general intoxication — weakness, weakness, bystry fatigue, drowsiness, a headache, nausea is usually expressed. Whitish-blue vaginal allocations are possible. At essential decrease in immunity increase in a liver, spleen with the advent of weight, discomfort, a raspiraniye in the right and left podreberye, generalized increase in lymph nodes is defined. Duration of a sharp phase, as a rule, makes up to 2-3 weeks.
The complicated current of a gestation is observed mainly at the sharp or reactivated infection. Such patients have spontaneous abortions connected with heavy embrio-and fetopatiya, the premature birth caused by a uterus hyper tone, the stood pregnancies, a still birth more often. Because of damage of a membrane of a trofoblast of TsMVI can be complicated by a placenta increment, a hypertrophy and early aging of placentary fabric, fetoplatsentarny insufficiency, a pre-natal hypoxia and an arrest of development of a fruit. The premature otsloyka of a placenta, massive blood loss because of atonichesky bleeding is at the time of delivery possible. In the postnatal period latent endometritises are noted. In the subsequent the probability of development of a dismenorea increases.
At sharp primary Cytomegaloviral disease the risk of transplacentary infection of a fruit and development of abundance of water significantly increases. Children often are born premature, with low small bodies. TsMV infection in the 1st trimester which is often causing a mikrotsefaliya is especially dangerous horioretinit, neurotouch relative deafness, other anomalies of development. The congenital cytomegalic inclusion disease after pre-natal infection can proceed asymptomatically, be shown by hard proceeding manifest forms or in the form of consequences of defeat of separate bodies (a gepatomegaliya, long jaundice, violations of sucking and swallowing, permanent decrease in a muscular tone, a tremor, anemia, thrombocytopenia, lag in intellectual and motor development, pneumonia, myocarditis, pancreatitis, colitis, nephrite). The remote consequences of TsMVI at children are the blindness, deafness, speech violations which are shown on the 2-5th year of life.
At pregnant women with the TsMVI considerable immunosupression proceeds heavier, ekstragenitalny complications come to light more often. Cytomegaloviral damages of lungs (interstitsialny pneumonia), a brain (meningitis, encephalitis), peripheral nervous system (miyelit, poliradikulonevrit), heart (myocarditis, perikardit), blood formation (thrombocytopenia, hemolytic anemia) are considered as adverse forms of a disease. The direct threat for life of the pregnant woman arises at bystry generalization of an infection with development of sepsis, infectious and toxic shock, DVS-syndrome.
Complexity of timely identification of TsMVI is connected with lack of symptomatology at most of pregnant women and polymorphism of a clinical picture at a demonstration. Considering the increased risk of perinatal infection of the child with a Cytomegaloviral infection, as screening carrying out the analysis on TORCH complex is recommended. The leading methods of diagnostics are laboratory analyses, the infectious agent, to find the serological markers and to define sharpness of process allowing to verify. The plan of inspection of patients with suspicion on a cytomegalic inclusion disease includes such researches as:
- Immunofermental analysis. IFA is considered the most reliable and informative method of diagnosis of a Cytomegaloviral disease. Existence of an active infection confirms identification of IgM and more than 4-fold increase of a caption of IgG. The prescription of infection is confirmed by data on an avidnost of immunoglobulins G (at an indicator
- PTsR-diagnostics. Cytomegaloviral nucleinic acids define in biological secrets which may contain the activator. Usually for the analysis take blood, urine, a tservikalny secret, bukkalny dabs. Detection of virus DNA confirms contamination, and quantitative methods of a research allow to control the course of an infection.
Taking into account a possibility of reactivation of Cytomegaloviral process at any stage of a gestation planned virologic monitoring is recommended to bearers on 8-12, 23-25, 33-35 weeks of pregnancy. At suspicion on pre-natal defeat of a fruit amniocentesis with PTsR-diagnostics of the activator in amniotic liquid is carried out with definition of IgM in umbilical blood. For assessment of a condition of a fruit, detection of fetoplatsentarny insufficiency, possible anomalies according to indications ultrasonography of a fruit and a placenta, doppler sonography of a uterine and placentary blood-groove, a fetometriya, KTG, a fruit phonocardiography, a biopsy of a horion are carried out. The cytomegalic inclusion disease is differentiated with HIV infection, an infectious mononukleoz, toxoplasmosis, listeriosis, herpes, viral hepatitises, bacterial sepsis, limfogranulematozy, a sharp leukosis. If necessary the patient is advised by the infectiologist, the virologist, the immunologist, the oncologist, .
Treatment of TsMVI at pregnant women
Choosing tactics of maintaining a gestation, consider the TsMVI clinical form and term of infection. Primary demonstrating in the period of 1 trimester, performing abortion is recommended to women with a cytomegalic inclusion disease. Termination of pregnancy on medical indications is also shown to patients with clinically and laboratory confirmed primary infection at detection to 22 weeks of BONDS signs of malformations of a fruit. In other cases prolongation of a gestation is possible. To pregnant women with a carriage drug treatment is not appointed. In the absence of clinical and laboratory signs of reactivation of a Cytomegaloviral disease the correction of a way of life directed to prevention of considerable immunosupression is required. Sufficient rest and a dream, an exception of excessive physical and psychological activities, good nutrition, reception of vitamin and mineral complexes, prevention of a SARS, care at purpose of the medicines reducing immunity are necessary for patients.
To pregnant women with an active form of an infection the treatment directed to knocking over of an aggravation and the termination of an ekskretion of a cytomegalovirus is carried out. Complexity of the choice of adequate medicamentous therapy is connected with a fetotoksichnost of the majority of antiviral means. Taking into account possible indications and contraindications at a gestation are applied to treatment of TsMVI:
- Anti-Cytomegaloviral human immunoglobulin. Hyperimmune medicines allow to restore a caption of specific IgG, to block replication of the activator and to limit its dissemination. Use of immunoglobulin of the person significantly reduces risk of pre-natal infection with a cytomegalovirus.
- Recombinant α-2-interferon. Medicine stimulates T-helpery and T-killers, increasing the level of T-cellular immunity. Increases activity of phagocytes and speed of a differentiation of V-lymphocytes. Oppresses replication of cytomegaloviruses and promotes their inactivation various immune agents. It is recommended in the form of rectal candles.
- Synthetic analogs of nucleosides. Are appointed only at severe generalized forms of a Cytomegaloviral infection when the risk of toxic effects of medicines is justified by rescue of life of the pregnant woman. Antiviral medicines inhibit a DNA polymerase of virus particles and at the expense of it slow down synthesis of Cytomegaloviral DNA.
Inductors of an interferonogenez, immunomodulators apply extremely seldom because of possible premature interruption of a gestation. As non-drug methods carrying out endovascular laser radiation of blood and a plasma exchange is admissible. A preferable method of a rodorazresheniye is natural childbirth. Cesarean section is carried out in the presence of absolute obstetric or ekstragenitalny indications or at a combination relative (pre-natal infection with a cytomegalovirus, a chronic hypoxia of a fruit, the II-III degrees of a delay of its development, primary and secondary infertility in the anamnesis).
Forecast and prevention
Timely identification of latent TsMVI and prevention of its activation significantly improve the result of pregnancy both for the woman, and for a fruit. The forecast is adverse at generalization of primary Cytomegaloviral infection. At the established diagnosis of a cytomegalic inclusion disease planning of conception taking into account recommendations of the obstetrician-gynecologist, knocking over of active process, pregravidarny immunocorrection with use of peptide immunostimulators and recombinant interferon is shown. Antiviral therapy of women from manifest TsMVI reduces risk of reactivation of an infection by 75% in the most dangerous on emergence of complications 1 trimester. The general prevention of infection assumes observance of rules of personal hygiene with frequent washing of hands, refusal of close direct contacts with other people.