Undiagnosed & Untreated Pregnancy Infections can cause Encephalitis, Sepsis, Meningitis & Cerebral Palsy in a Newborn

Encephalitis is inflammation of the brain that occurs with a sudden onset. It is most commonly caused by a viral or bacterial infection, and it can cause a baby to have seizures, permanent brain damage and cerebral palsy. Encephalitis can be caused by maternal infections that travel to the baby at birth, such as herpes simplex virus (HSV), Group B Strep (GBS), urinary tract infections (UTI), bacterial vaginosis (BV), E coli and an intramniotic infection called chorioamnionitis. These infections can cause sepsis, septic shock and meningitis, which usually cause encephalitis. Septic shock can severely deprive a baby of oxygen and cause hypoxic ischemic encephalopathy (HIE). Encephalitis caused by meningitis is called meningoencephalitis, which is a form of neonatal encephalopathy. In fact, all insults to a baby’s brain that cause brain swelling indicative of brain injury fall under the broad category of neonatal encephalopathy.

Neonatal encephalopathy can cause the following lifelong conditions:

• Cerebral palsy
• Seizures
• Developmental delays and disorders
• Intellectual (cognitive) disabilities
• Motor disorders

The award winning birth injury attorneys at ABC Law Centers have helped hundreds of children affected by encephalitis, neonatal encephalopathy and cerebral palsy. Jesse Reiter, president of ABC Law Centers, has been focusing solely on birth injury cases for over 28 years, and most of his cases involve hypoxic ischemic encephalopathy (HIE) and cerebral palsy. The lawyers at ABC Law Centers have won numerous awards for their advocacy of children and are members of the Birth Trauma Litigation Group (BTLG) and the Michigan Association for Justice (MAJ).

Due to the risk of encephalitis and brain damage in the baby, an expecting mother must be closely monitored for signs of infection during prenatal visits. This means that the physician must take a thorough history of the mother and note any risk factors for infection. In many cases, it is the standard of care to test all mothers for infection during pregnancy. For example, mothers are screened at least once during pregnancy for a UTI, at week 12 – 16 of pregnancy.

When signs or symptoms of infection occur, the mother must be promptly diagnosed and treated. A maternal infection can be transmitted to the baby through the amniotic fluid or during vaginal delivery, when there is bacteria colonizing or infecting the mother’s lower genital tract. A viral infection, such as herpes simplex virus (HSV), usually causes infection in the baby due to the baby’s exposure to the virus in the genital tract, although in-utero exposure does sometimes occur.

Listed below are maternal infections that can infect the baby at birth and cause encephalitis, brain damage and cerebral palsy.

Group B Streptococcus is a bacterium that is part of the normal flora of the gut and genital tract. A mother has a GBS infection when she is “colonized.”  Colonization means that the bacteria has multiplied and is creating a burden on the mother. Most women with GBS show no signs or symptoms; thus, it is the standard of care for all expecting mothers to be tested between the 35th and 37th week of pregnancy. The physician performs the test by taking swab samples from the mother’s vagina and rectum. The samples are then placed in a solution to see if the bacteria grow, which is called performing a culture. If the bacteria grow, the mother is said to be colonized.

Mothers who test positively for GBS are given IV antibiotics – usually penicillin – at the onset of labor (or when their membranes rupture) to kill the bacteria. If, at the time of labor, a mother has certain risk factors for GBS or there is high suspicion that the mother has GBS, antibiotics should also be given. The antibiotics transfer to the baby to help wipe out infection and prevent sepsis, meningitis, encephalitis and cerebral palsy.

Urinary tract infections are very common during pregnancy, mainly because of changes in the urinary tract that occur during this time. E. coli is the most common cause of a UTI, but staphylococcus infections and GBS can also cause a UTI. In rare cases, a UTI may be caused by viral or fungal infections. Bacteria usually cause UTIs by entering the bladder through the urethra, but infection may occur through the blood or lymph. Bacteria can be transmitted to the urethra from the bowel.

A urine culture to test for a UTI should be done at the first prenatal visit or at 12 – 16 weeks of gestation.  A week after the completion of treatment, the mother should be tested again to ensure the treatment worked, which is called a test of cure.  In addition, urine cultures should be repeated monthly until the baby is born due to the risk of persistent or recurrent UTI.  The antibiotic used for treatment should be tailored to the specific organism causing the UTI.

Potential treatments include nitrofurantoin and fosfomycin. Many pregnant women experience no symptoms of a UTI, which is why all are tested at the beginning of pregnancy. Of course, anytime a mother has symptoms of a UTI, she should also be tested. Symptoms of a urinary tract infection include pain or burning when urinating, a feeling of urgency during urination, and more frequent urination.

Urinary tract infections must be promptly treated because they can cause the mother to have a kidney infection, which can progress to maternal sepsis and premature delivery. Even if a UTI doesn’t cause a kidney infection, it still increases the risk of premature rupture of the membranes (PROM), premature birth and infection in the baby such as sepsis, meningitis and encephalitis. These conditions can cause cerebral palsy.

Bacterial vaginosis is the most common vaginal infection in women of childbearing age. Normally, the vagina contains many microorganisms, including Lactobacilli, which appear to help prevent other vaginal microorganisms from multiplying to a level where they cause symptoms. The microorganisms involved in bacterial vaginosis are very diverse, and a change in the normal bacterial flora, including the reduction of Lactobacilli, allows more resistant bacteria to start to predominate and multiply, which causes BV.  Antibiotics or a pH imbalance are common causes of a reduction in Lactobacilli and BV. Douching is one of the most direct causes of BV.

Unlike UTI screening, not all pregnant women are screened for BV. It is standard practice to treat all pregnant women who have symptoms of BV, and many physicians screen all mothers who have a history of preterm birth. Symptoms of bacterial vaginosis include a milky or creamy discharge, fishy or amine odor and mild itching.

For diagnosis of bacterial vaginosis, the presence of 3 of these 4 criteria are necessary:

• Homogenous, milky or creamy discharge
• Presence of true clue cells on microscopic exam
• pH of secretions above 4.5
• Fishy or amine odor with or without addition of 10% KOH

Antibiotics such as Metronidazole or Clindamycin are effective treatments for BV during pregnancy. However, there is a high rate of recurrence. Some research shows a high rate of resistance to Metronidazole, leading to recurrence of BV.  In cases of recurrent BV, Clindamycin therapy has a better clinical efficacy. A test of cure should be performed after treatment. Intravaginal clindamycin cream should be used in pregnant women only during the first 20 weeks.

Urinary tract infections and bacterial vaginosis can not only cause a baby to be born prematurely, which places the baby at risk of having cerebral palsy and other birth injuries, but these infections can travel to the baby at birth and cause sepsis, meningitis and encephalitis, which can also cause cerebral palsy.

Listed below are complications associated with untreated or poorly treated UTI and BV.

Urinary Tract Infection Complications

• Intrauterine growth restriction (IUGR) / fetal growth restriction
• Low birth weight
• PROM
• Preterm birth
• Sepsis
• Meningitis
• Cerebral palsy
• Preeclampsia and other hypertensive (high blood pressure) disorders of pregnancy
• Amnionitis

Bacterial Vaginosis Complications

• Pelvic inflammatory disease
• PROM
• Preterm birth
• Sepsis
• Meningitis
• Cerebral palsy
• Low birth weight

The membranes that surround a baby in the womb are called the chorion and the amnion. Chorioamnionitis is a condition in which these membranes and the amniotic fluid become infected, usually from bacteria in the vagina that travel to the uterine cavity. The membranes subsequently become inflamed. Chorioamnionitis is associated with membrane rupture (the mother’s water breaking) and prolonged labor, although chorioamnionitis can occur with intact membranes.  When chorioamnionitis is present, the baby can become infected, which can cause sespis, meningitis, encephalitis and cerebral palsy.

Chorioamnionitis occurs when the chorioamnion and / or the umbilical cord become infected and inflamed due to the passage of bacteria from the colon, vagina or cervix to the womb. Other routes of infection include passage of infectious organisms during amniocentesis or chorionic villous sampling. When bacteria infects the cord or chorioamnion, there can be an inflammatory response by the mother and baby that can lead to the mother releasing the hormone prostaglandin, which can induce labor. This can happen long before the baby is due, resulting in the baby being born prematurely.

Indeed, chorioamnionitis is a significant cause of premature rupture of the membranes. And when membranes rupture, the baby is at a high risk of getting infected. As such, chorioamnionitis must be promptly diagnosed and treated. Chorioamnionitis may be diagnosed based on signs such as maternal fever, or the physician might test the amniotic fluid by doing an amniocentesis. However, the presence of fever and two other signs (uterine tenderness, fast heart rate in the mother or baby, and bad-smelling amniotic fluid) is typically how most physicians make a diagnosis. The presence of risk factors for chorioamnionitis, especially rupture of the membranes, further strengthens the diagnosis.

As soon as chorioamnionitis is diagnosed, treatment must be given. This includes a combination of IV antibiotics – usually ampicillin or penicillian and gentamicin. In advanced cases, a C-section may be necessary because of a failure of the fetus to progress through the birth canal. As many as 75% of women with chorioamnionitis require uterine stimulation. Thirty to forty percent of these women will eventually require a C-section.

Indeed, prompt administration of antibiotics is essential to prevent both maternal and fetal complications. C-section to expedite delivery is indicated in many cases for chorioamnionitis. If C-section is performed, clindamycin every 8 hours (or metronidazole) usually is added to the treatment. Treatment also should include administration of a single IV additional dose of antibiotics after delivery.

Failure to properly treat chorioamnionitis can cause the baby to have sepsis, meningitis, encephalitis and cerebral palsy.

When a mother has Type 1 or Type 2 vaginal herpes simplex virus, the infection can be transmitted to the baby, causing the baby to have meningitis and neonatal herpes encephalitis, which often causes brain damage and cerebral palsy. Transmission of HSV to the baby usually occurs during labor and delivery as a result of the baby coming into direct contact with the virus (virus shed) form infected sites (active infection). Infected sites typically include the vulva, vagina, cervix and perianal area. Viral shedding can occur when the mother has no symptoms or HSV lesions. This is because the virus can be in an active state without there being any lesions or symptoms. When the herpes virus is inactive (latent) there will be no shedding and the baby won’t become infected as a result of contact during a vaginal delivery.

The physician must not only be aware of the mother’s history of HSV, but a diagnosis of HSV must include accurate classification of the virus. Newly acquired HSV (primary or first episode genital nonprimary) near the time of delivery is when the risk of neonatal infection is the highest. This is because if the mother has a first infection during the last few months of pregnancy, there may not be enough time for the baby to acquire antibodies from the mother before birth. Towards the end of pregnancy, babies receive antibodies (from the mother) to infections that the mother had previously caught. These antibodies protect the baby from catching these viruses during birth and afterwards. Premature babies may not have antibodies and are thus more susceptible to becoming infected from HSV. In addition, invasive fetal monitoring, forceps and vacuum extractors can transmit HSV infection to the baby.

HSV can be diagnosed with laboratory testing: viral culture, polymerase chain reaction (PCR), direct fluorescence antibody and type-specific serologic tests. Cell culture and PCR-based testing are used for mothers who have active lesions, although PCR-based testing is the most accurate. PCR is especially useful for testing a mother for viral shedding that has no symptoms.

Experts do not recommend routine screening of pregnant women for HSV, although the American Congress of Obstetrics and Gynecologists (ACOG) acknowledge that screening may be beneficial in selected populations or couples.

Suppressive therapy is often recommended, beginning at 36 weeks of gestation and continuing until delivery. Suppressive therapy is when the mother takes an antiviral drug, such as acyclovir, every day to reduce the risk of an HSV outbreak. This treatment reduces the likelihood of clinical recurrence of HSV and asymptomatic viral shedding at the onset of labor and thus reduces the need for C-section delivery. A C-section delivery decreases (but does not eliminate) the risk of the baby becoming infected.

For mothers with primary or first episode genital nonprimary HSV (which are active), antiviral therapy with acyclovir should be given three times a day for 7 – 10 days, with the treatment being extended if the mother needs more time to heal. Anitviral therapy can decrease the duration of lesions and viral shedding and decrease the risk of HSV transmission to the baby.

As discussed, C-section delivery reduces the risk of neonatal HSV infection when a mother has had a diagnosis of genital HSV type 1 or 2. As with any procedure or medication, the physician must discuss the risks, benefits and alternatives with the mother.

When a mother with HSV experiences PROM far from term, she should be given IV acyclovir as well as steroids to help the baby’s lungs mature. She should be closely monitored in the hospital with a team ready for delivery at the first signs of fetal distress or impending distress. When PROM occurs at term, an immediate C-section delivery should take place.

During delivery, the measures to prevent transmission of HSV to the baby include the following:

• A C-section delivery should be performed on mothers with active lesions during delivery.
• Babies delivered vaginally by mothers with active genital herpes must be closely observed and treated with acyclovir.
• For all mothers with an HSV diagnosis, suppressive acyclovir should be initiated at 36 weeks of gestation and maintained up to and during delivery, regardless of delivery mode.

Babies born to mothers with active genital lesions and babies who have a suspected HSV infection should be:

• Isolated
• Managed with contact precautions to avoid direct contact with skin and mucosal lesions, excretions and body fluids
• Immediately treated with IV acyclovir without delay

Chorioamnionitis and maternal infections such as urinary tract infections, bacterial vaginosis, group B strep and herpes simplex virus can cause PROM and premature birth, which increase a baby’s risk of experiencing birth injuries, such as the following:

• Hypoxic ischemic encephalopathy (HIE). HIE usually involves damage to the basal ganglia, cerebral cortex or watershed region, but it sometimes includes periventricular leukomalacia (PVL).
• Intraventricular hemorrhages (IVH)
• Neonatal encephalopathy
• Permanent brain damage
• Hydrocephalus
• Seizure disorders
• Cerebral palsy (CP)
• Intellectual disabilities
• Developmental delays, speech delays
• Motor disorders

In addition, maternal infections can cause sepsis, septic shock, meningitis and encephalitis, which can cause brain damage and conditions such as cerebral palsy.  Due to the risk of birth injuries and brain damage, it is very important for physicians to promptly diagnose and treat infections in the mother.  At birth, the baby must be assessed for signs of infection and given appropriate medications, such as antibiotics and antiviral medications when indicated.

If you are seeking the help of a cerebral palsy lawyer, it is very important to choose a lawyer and firm that focus solely on birth injury cases. ABC Law Centers is a national birth injury law firm that has been helping children with birth injuries for almost 3 decades.

Birth injury lawyer Jesse Reiter, president of ABC Law Centers, has been focusing solely on birth injury cases for over 28 years, and most of his cases involve hypoxic ischemic encephalopathy (HIE) and cerebral palsy. The lawyers at ABC Law Centers have won numerous awards for their advocacy of children and are members of the Birth Trauma Litigation Group (BTLG) and the Michigan Association for Justice (MAJ).

If your child was diagnosed with a birth injury, such as sepsis, meningitis, cerebral palsy, a seizure disorder or hypoxic ischemic encephalopathy (HIE), the award winning birth injury lawyers at ABC Law Centers can help. We have helped children throughout the country obtain compensation for lifelong treatment, therapy and a secure future, and we give personal attention to each child and family we represent.

• What is encephalitis and what causes it?
• How do sepsis and meningitis cause cerebral palsy?
• How do pregnancy infections cause premature birth?

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