Like all adults and children, pregnant women are at risk of developing viral and bacterial infections, especially, if they are not immunized against such infections. Such infections are a particular concern to pregnant women as they could harm the fetus or the newborn baby, depending on the severity of the infection and the health status of the mother. The good news is that the mother herself can take steps to prevent or lower the risk of exposure to such potentially harmful diseases, by adhering to a few simple rules based on personal hygiene. Many women still do not realise the health risks they could pass on to their newborn, especially, if they are not immunized against them.
Consultant Neonatologist, Dr Ranmali Rodrigo, of Colombo North Teaching Hospital shares her expertise from her hands on experience on the subject and research on Prenatal Infections, with the Sunday Observer.
Excerpts…
Q. This is International Prenatal Infection Prevention month. What does prenatal infection mean?
A. Infections in the mother that are transmitted from the mother to the unborn baby during pregnancy, before birth, are called prenatal infections. Even infections acquired from the mother around the time of birth have been included by some in this definition.
Q. A baby begins the journey of life from the time of conception. Tell us how a baby progresses in the mother’s womb from conception to birth.
A. Inside the mother’s womb a baby starts off as a single cell which is visible only microscopically. In the first eight weeks, when the growing baby is known as an embryo, most of the organ systems of the body are formed. Afterwards the organs develop, mature and grow in size. During this developing stage babies are known as fetuses. If an infection occurs in the mother in the early part of pregnancy it can result in a miscarriage or cause problems in organ / limb formation of the baby. On the other hand, the presence of a potentially infective organism in the birth canal of a mother around the time of delivery can cause life-threatening infections although it will not cause any deformities.
Q. What are the first requirements for the newborn after birth?
A. Maintaining the warmth of the baby is the first priority. Next we need to ensure that the baby is able to breathe and take in air to reach the lungs. If the baby is not breathing adequately artificial breaths should be provided.
Q. It is said the first cry of the newborn expands the lungs and starts life. Please explain how this happens.
A. While a baby is inside the mother’s womb they are inside the water bag and their lungs are full of liquid. As they come through the birth canal part of the fluid in the lung is squeezed out. The remainder of the fluid in the air sacs of the lung will be pushed out into the tiny blood and lymphatic vessels in the lining of the air sacs when the baby makes the first cry. This makes it possible for the air to enter the lungs with the first cry of the baby.
Q. Is it necessary to keep the newborn warm soon after delivery? Why? And at what temperature?
A. It is essential that we prevent a newborn becoming cold. Hypothermia (cold) is known to increase breathing difficulties and chances of getting infections and death, especially, in preterm babies. The target temperature of the baby is 36.5ºC to 37.5ºC. Drying and wrapping the baby, use of warmers, maintaining room temperature between 26ºC-28ºC are some of the methods for maintaining normothermia.
Q. What is the best nourishment for a baby as soon as it is born? Explain in detail
A. Undoubtedly breast milk. This is the ideal nourishment for newborns as it is nutritionally and biochemically the best fit for the needs of a newborn. It protects newborns from many infections in childhood and chronic diseases such as, obesity, diabetes mellitus and hypertension in the long term. Brain development and IQ are better in babies who have been breastfed when compared to those who have received formula milk only. The likelihood of developing chronic diseases such as, hypertension, diabetes and also ovarian and breast cancers are less in mothers who have breastfed for six months.
Q. For how long should a newborn be exclusively breastfed?
A. A newborn should not be given anything other than breast milk (except for prescription medications,) in the first six months of life.
Q. From your experience does this happen in the case of working mothers in Sri Lanka? If not why?
A. As most working mothers have only 84 days of maternity leave it is difficult to achieve this target. However, since breast milk can be expressed and stored in the freezer and refrigerator, for up to three months in the freezer, mothers have been able to achieve this target and avoid formula milk until two years of age. If difficult to manage with only the expressed milk, complementary feeding with semi-solids can be commenced at four months of age.
Q. Myths about breast feeding - there are some mothers who still throw away the first milk colostrum because they are ignorant of its importance. Why is Colostrum important for the baby?
A. Colostrum is the first milk that a mother secretes. It has a high level of substances that protect the newborn from infections. It is important to provide babies with this first ‘natural immunisation’.
Q. During this month I understand a Charity Group B Strep Support is campaigning to raise awareness of the infection Group B Streptococcus (GBS) and the dangers it poses to unborn babies. Group B Strep is said to be the leading cause of infection in babies under three months old. Is this true?
A. It is true in certain western countries. There are no published data in Sri Lanka about the proportion of neonatal infections caused by Group B Streptococcus. Personal experience suggests that this organism causes many identifiable early infections in newborns, but is probably not the commonest cause. This organism however, is acquired from the mother around the time of birth from the birth canal and is therefore a perinatal infection rather than a prenatal infection of the baby, with the mother only being a carrier and not actually infected.
Q. According to statistics quoted by them, one in four women are carriers of the bacteria which can be passed onto the baby during childbirth. In the UK, pregnant women are not routinely tested for Group B Strep bacteria. In countries where pregnant women are routinely tested, infection in newborn babies is said to have fallen dramatically by up to 86%. What is the scenario in Sri Lanka?
A. Mothers are not routinely tested in Sri Lanka. A study by Dissanayake et al in 2015 has reported the GBS carrier state in pregnant, 35-37 weeks gestation attendees of the Peradeniya Hospital to be 30%. However, there are no published data on the association of this finding with the occurrence of this infection in newborns in the Sri Lankan population. Such a study has just commenced at the Colombo North Teaching Hospital, Ragama.
Q. Tell me about the prenatal infections and their prevention.
A. Mothers can be infected with various organisms which they can transmit to the unborn baby through the placenta. Some of those infections include rubella, cytomegalovirus, toxoplasmosis and listeria. Listeria is more of a perinatal infection. Rubella can be prevented by vaccination to ensure that females of child bearing age are all immunized. Cytomegalo virus infection of the mother can be reduced by pregnant mothers washing hands after handling stools and urine of older children and not sharing their food and utensils. Avoidance of having raw milk or milk products can prevent listeria. Contact with cat faeces should be avoided by not touching soil without gloves, and not drinking unboiled untreated water for the prevention of Toxoplasmosis.
Q. What about after delivery? What are the health impacts on a baby exposed to these infections while still in the womb?
A. Babies who have been exposed to infections in the early part of pregnancy can be of low birth weight, have enlargement of their liver, problems in the heart, brain and eyes. Babies who acquire infections like GBS around the time of birth can get sick very quickly. They will have poor feeding, reduced activity, cold hands and feet, fever and difficulty in breathing which if not attended to soon can result in death.
Q. At what stage before birth can these infections be detected?
A. If suspected, infections like rubella in the mother can be confirmed by testing the mother. But only a few of them have treatments available, making the preventive measures mentioned previously, very important.
Q. Can early detection prevent the progress of such infections?
A. Infections like GBS if detected early in the baby can be treated with antibiotics and other supportive measures to achieve complete cure.
Q. Some western countries have screening programs for detection of GBS in mothers and provide antibiotics to the mother during labour as a preventive measure. What is the situation in Sri Lanka?
A. Current guidelines of the Sri Lanka College of Obstetricians and Gynaecologists do not recommend routine screening of pregnant women or antibiotics to the mother for prevention of GBS in the baby.
Q. Are congenital defects common in babies? What causes them?
A. The World Health Organization estimates that world wide 303,000 babies die in the first four weeks of life due to congenital anomalies. There are a variety of causes for these – genetics, infections, nutritional and environmental. It is difficult to identify the exact cause and it may be a combination of reasons.
Q. When planning a pregnancy, what advice would you give an at risk mother on how to protect her fetus or her newborn baby?
A.Taking folic acid at least from three months before a pregnancy is planned can prevent some neurological anomalies. Taking steps to prevent infections while pregnant and avoiding environmental exposures like X-rays can be preventive. Medications for which the safety profile in pregnancy is not clear should be used with caution.
Adherence to the current immunisation schedule for their other children can prevent exposure to harmful infections and it is because of the current immunisation for prevention of tetanus for pregnant women that neonatal tetanus is almost an unknown entity in the country.
Q. What are the new technological advances made globally with regard to detecting birth defects while the baby is still in the womb?
A. Special scans and certain blood tests during pregnancy can identify some anomalies and screen for others, e.g. the ‘Nuchal-thickness’ scan at 11-14 weeks of gestation to screen for Downs Syndrome. Further confirmatory tests can be done as required. The anomaly scan around 20 weeks of gestation can detect some of the other structural anomalies. However, these investigations may not detect all problems.
Q. Are they available here? If so where?
A. Most of these screening methods are available in Sri Lanka, but not in all Government hospitals. However, although anomaly scanning etc. is done in Sri Lanka the legal provision for termination, even when definitely lethal conditions are identified, is not possible.
Q. Your message to all women in the reproductive age?
A. Take folic acid from the pre-conceptional stage and adhere to the preventive measures to avoid being infected with organisms that can cause congenital infections and obtain the recommended immunisations. Plan to exclusively breastfeed your baby for the first six months of life and beyond, understanding its importance and benefits.