REVISTA ROMN DE PEDIATRIE VOLUMUL LXIII, NR.

2, AN 2014 139
Coresponding author:
Doina Broscauncianu, Clinical Hospital of Obstetrics and Gynecology Polizu, Polizu 38-52 St., Bucharest
e-mail: doinabroscauncianu@yahoo.com
DRUG ADDICTION DURING PREGNANCY RISK
FACTOR FOR PERINATAL INFECTIONS
Doina Broscauncianu
1
, Silvia Maria Stoicescu
1,2
, Gabriel Banceanu
2,3
,
Anca Cabat
1
1
Neonatology Department, Institute for Mother and Child Care,
Clinical Hospital of Obstetrics and Gynecology Polizu, Bucharest
University of Medicine and Pharmacy Carol Davila, Bucharest
3
Institute for Mother and Child Care, Obstetrics and Gynecology Department,
Clinical Hospital of Obstetrics and Gynecology Polizu, Bucharest
ABSTRACT
Introduction. Neonatal infections are a major causes of neonatal morbidity and mortality. Pregnancy compli-
cated by illicit drug abuse is a risk for perinatal infection.
Objective. To assess the incidence of early-onset neonatal sepsis (the rst 7 days of life) in newborns from
high-risk pregnancies for perinatal infections: the ones affected by drug abuse, without medical assistance
versus clinical and fully investigated pregnancies.
Material and methods. Retrospective study on newborns from IOMC Emergency Clinical Hospital of Obstet-
rics and Gynaecology Gh Polizu, Bucharest, sorted in two separate groups: one of 25 newborns, from 2005 to
2012, coming from uninvestigated pregnancies in women with illicit drug dependencies and another of 50 new-
borns from properly managed pregnancies from the clinical and anamnestic point of view, but with known risk
factors for perinatal infections. The data has been statistically analysed (correlation tests: Student T, Fisher
exact, chi-square)
Results. The incidence of newborns from pregnancies affected by drug abuse was 0,09% in all 28489 new-
borns, the highest percentage of 0,2% being recorded in 2011. Statistically signicant differences between the
two groups of newborns with risk factors for perinatal infections (emerged from uninvestigated pregnancies with
drug abuse and respectively from investigated pregnancies) were: the age of the mothers lower in drug ad-
dicted mothers (p_value 0,0002), the percentage of congenital infections (p_value 0,00003; OR 0,03; 95%CI)
and respectively the mean length of hospital stay-days (p_value0,0180) higher in dug addicted mothers. On the
other hand: the delivery by cesarean section (p_value 0,0010), urogenital colonisation (p_value 0,0016) were
more frequent in newborns from investigated pregnancies. A percent of 22 of all investigated women were
positive for Group B Streptococcus and the most frequent type was I b type. The share of perinatal infections
among neonatal morbidity was 33% for the newborns from drug addicted mothers and 27% for the newborns
from investigated mothers. The incidence of neonatal infections was 52% for the newborns from drug addicted
mothers (a risk of 1 in 1,9 cases) and 18% for the newborns from investigated mothers (a risk of 1 in 5,5 cases)
Conclusions. Drug addiction during pregnancy represents a high risk factor for perinatal infections due to
sexual and blood transmitted diseases associated with lack of hygiene, precarious nutrition and low immuno-
logical status and leads to high medical and social costs. The correct medical management of pregnancies,
through early diagnosis and treatment of neonatal infections may lower the incidence and the consequences of
perinatal infections.
Keywords: risk factors, perinatal infection, fallow up of pregnancy, maternal drug abuse
CASE STUDIES
6
INTRODUCTION
Neonatal infections still are (in an era of impo-
sing medical achievements like in vitro fertilisation
assisted human reproduction technology and the
survival of foetuses of lower and lower gestational
ages and birth weights) major causes of neonatal
morbidity and mortality.
Acknowledging the risk factors for the perinatal
infections (between 22 weeks of gestation or 154
days of pregnancy and day 7 after birth W.H.O.
denition (1)) enhance the prevention of their oc-
REVISTA ROMN DE PEDIATRIE VOLUMUL LXIII, NR. 2, AN 2014 140
currence and/or augments the diagnose and ef-
cient treatment.
Both medical factors, like the mothers precari-
ous health state, often with untreated infections,
and social-cultural factors, like the lack of medical
surveillance of the pregnancies, are indirectly con-
tributing factors to the morbidity and mortality
through perinatal infections. It is a widely known
fact that medical science can improve the mother-
child health status only when supported by an ef-
fective program of social actions (2).
Drug addiction, especially for injected illicit
drugs usually related to opiates use (although in
some countries amphetamines injection represents
a major problem), affects 1,3 to 1,7 million persons
in EU and Norway (4), from which 34% are wom-
en, most of them at fertile age (5) and that consti-
tutes an important risk factor for perinatal infec-
tions.
These infections are acquired via parenteral or
sexual way before and/or during pregnancy and
they are transferred to the foetus/the newborn be-
fore or during delivery, the most frequent ones be-
ing caused by hepatitis B or C virus, human immu-
nodeciency virus or treponema pallidum(6,7,8,9).
The determining factors of perinatal infections
are micro-organisms passed from mother to foetus
in utero (congenital infections), frequently identi-
ed as TORCH group (T = toxoplasma gondii, O =
other agents, R = rubella virus, C = cytomegalovi-
rus or CMV, H = herpes simplex virus or HSV),
TORCHES CLAP group (TORCH and E = entero-
virus, S = syphilis, C = chickenpox - varicella - zos-
ter virus or VZV, L = Lyme disease Borrelia burg-
dorferi, A = AIDS or HIV, P = parvovirus B19) or
CHEAP TORCHES (H = B and C hepatitis - hepa-
titic B (VHB) or C (VHC) virus and E = any other
sexually transmitted disease like gonorrhoea, Chla-
mydia, Ureaplasma and papillomavirus). The in-
fections passed from mother to foetus/newborn
during delivery or immediately after are produced
by micro-organisms located within the vagina and
are frequently (Grup B streptococci, Enterococcus,
Escherichia coli, Neisseria gonorrhoeae, Listeria
monocytogenes, Candida albicans, hlamydia tra-
chomatis), seldom (Staphylococcus aureus, Alfa-
haemolytic streptococci, Proteus species, Klebsiel-
la species, Pseudomonas species, Salmonella
species, Shigella species, Alkaligenes faecalis,
Neisseria meningitidis, Haemophilus inuenzae,
Vibrio fetus, Bacteroides, Clostridium species, My-
coplasma hominis, Ureaplasma urealyticum,
Trichomonas vaginalis) or extremely rare (Lacto-
bacillus, Staphylococcus epidermidis, Gardnerella
vaginalis, Corynebacterium, Bacillus subtilis, Pep-
tostreptococcus, Veillonella, Bidobacterium, Eu-
bacterium, Mycobacterium tuberculosis) associat-
ed with neonatal sepsis (10).
The correct management of the pregnancy with
infectious hazards, early diagnosis and treatment of
maternal infections can diminish the incidence and
ameliorate the outcome of perinatal infections.
In Romania, the consequences of drug abuse
during pregnancy for the newborn have been re-
ported for the rst time in a written paper in the
year 2005 (11).
MATERIAL AND METHODS
Retrospective study on newborns from IOMC
Emergency Clinical Hospital of Obstetrics and
Gynaecology Gh Polizu, Bucharest, sorted in two
separate groups: one of 25 newborns, from 2005 to
2012, coming from uninvestigated pregnancies in
women with illicit drug addictions and another of
50 newborns from properly managed pregnancies
from the clinical and anamnestic point of view, but
with known risk factors for perinatal infections.
For the group of newborns from drug addicted
mothers a clinical exam was performed (including
assessment by FINNEGAN score) and toxicologi-
cal (urine testing for 68% of the couples newborn
mother), serological, bacteriological and bio-
chemical tests were accomplished, along with ra-
diologic and echographic exams and psycho-social
inquiries made by the social workers and the psy-
chologist.
For the group of newborns with risk factors for
perinatal infections coming from investigated preg-
nancies we have selected some of the cases already
included in a prospective study realised during
2007-2008 with The National Institute for Research
and Development in Microbiology and Immunolo-
gy Cantacuzino, Bucharest. The laboratory work-
up performed to identify the risk factors for perina-
tal infections (toxoplasmosis, rubella, cytomegalovirus
infection, herpes, B or C hepatitis, parvovirus in-
fection, syphilis, listeriosis, chlamydia and B group
streptococcus) in the stage of symptomatic or as-
ymptomatic infections/healthy carrier subjected
women in various points of their pregnancies and
28% of the newborns carried by them, who present-
ed clinical signs suggestive for perinatal infections.
To detect the Group B Streptococcus (Streptococ-
cus agalactiae) vaginal samples were taken (from
the inferior third) during week 35-37 and the lochia
were tested after delivery. Bacterial culture identi-
cation was achieved with serological methods (se-
REVISTA ROMN DE PEDIATRIE VOLUMUL LXIII, NR. 2, AN 2014 141
rotyping the specic antigen of group B streptococ-
cus).
The data has been statistically analysed (correla-
tion tests: Student T, Fisher exact, chi-square). The
signicance level of the test was compared to
p = 0,05.
RESULTS AND DISCUSSIONS
Drug addiction during pregnancy was described
in 0,09% of all women (28 489) who delivered live
babies in Polizu Hospital between 2005 and 2012,
with a peak of incidence in 2011 (0,2%).
The illicit drugs were in the vast majority of in-
tra-venous type, fact that was alone a risk factor for
perinatal infections, in addition to the overlooking
of preventive measures for sexually transmitted
diseases. More than one drug was consumed in
36% of cases.
12% of the drug addicted mothers were under-
aged (< 18 years), 40% had between 21 and 29
years and 24% between 30 and 34 years. 84% of
them resided in urban environment, 12% in rural
one, 4% had no residence and for 8% we had no
available data.
Drug addicted mothers were known for or they
tested positive for Treponema pallidum (8 cases),
hepatitis C virus (5 cases), hepatitis B virus (1 case)
and human immunodeciency virus HIV (1 case),
representing altogether a total of 60% of the cases.
Medical monitoring during pregnancy was widely
absent in the group of drug addicted mothers. In
addition to medical issues many of them also had
psycho-social difculties: psychosis (2 cases), at-
tempted suicide (2 cases), penal detention (1 case),
decease (1 case) and child abandonment (6 cases).
Most of the investigations completed in mothers
from the second group (preponderantly aged be-
tween 21 and 35 years 85% and with urban resi-
dence 70%) revealed the immunisation for
rubella (97.95%), cytomegalovirus (92.68%), toxo-
plasmosis (41.46%) and parvovirus B (31.25%).
The most frequent identied risk factors for perina-
tal infection were urogenital bacterial/Group B
Streptococcus colonisation (14%), abnormal amni-
otic uid (6%), ruptured membranes for more than
18 hours (3%), cervical cerclage (3%) and fever in
labour (2%). The Group B Streptococcus, which
may transitory, chronically or intermittently colo-
nise the maternal vagina, was found in 22% of in-
vestigated mothers, therefore representing a risk
factor for infections in newborn (vertical transmis-
sion leads to colonisation and/or early or late-onset
neonatal sepsis). Group B Streptococcus typing,
based on capsular polysaccharides identication,
has shown a prominence of Ib type (34%) followed
by type III (22%) and type IV (22%) and associa-
tions between type III and IV and respectively type
IV and V.
The newborns from this study had the following
characteristics: male sex was preponderant in new-
borns from drug addicted mothers (68%) versus
50% in the group of newborns from investigated
mothers; 72% were term babies ( 37 weeks of ges-
tation) in the group with drug addicted mothers and
70% in the second one; premature birth (gestational
age 36 weeks and 6 days) affected 28% from
newborns with drug addicted, uninvestigated moth-
ers and 30% of those with investigated mothers
during pregnancy. Low birth weight 2,500 g was
a more frequent nding (48% versus 36%) in the
group of newborns from drug addicted mothers,
whereas birth weight 2,501 g was preponderant
in the other group (64% versus 54%)
The distribution of the newborns by gestational
age and birth weight emphasised the following:
prematurity was more frequent in babies from in-
vestigated pregnancies (34% versus 28%), intra-
FIGURE 1. Illicit
drugs consumed
during pregnancy
and no. of drug
abusing mothers
REVISTA ROMN DE PEDIATRIE VOLUMUL LXIII, NR. 2, AN 2014 142
uterine growth restriction (IUGR) occurred twice
as frequent in newborns from drug addicted moth-
ers (20% versus 10%) and term babies from this
group had often weighted under 3000 g at birth
(24% versus 18% in the group with investigated
mothers). The delivery was mainly vaginal (80%)
for the drug addicted mothers and by cesarean sec-
tion (58%) for the investigated mother with infec-
tious risk factors in addition to other obstetrical risk
factors.
Neonatal morbidity was 88% for the newborns
from drug addicted mothers and 34% for the ones
from investigated pregnancies.
For the newborns from uninvestigated, drug ad-
dicted mothers the incidence of perinatal infections
was of 52% (13 cases out of 25) namely a risk for
infection of 1 in 1,9 cases; interestingly, 9 cases out
of this group had 1 type of perinatal infection
bacterial mother-to-child infection (3 cases) or con-
genital infection (6 cases: 5 with syphilis and 1
with HIV) and 4 cases counted 2 types of infection:
congenital (syphilis in 3 cases and CMV in 1 case)
associated to bacterial gram-negative neonatal sep-
sis (Escherichia coli in 3 cases and Enterobacter, 1
case). Syphilitic infection was conrmed in 2 cases
(both VDRL and TPHA positive testing) and sus-
pected in 3 cases (only TPHA positive).
In the group of newborns from investigated
pregnancies the incidence of perinatal infections
was of 18% (9 cases: 8 diagnosed with early-onset
bacterial sepsis and 1 with congenital infection)
representing an infection risk of 1 in 5,5 cases. Ma-
ternal bacterial colonisation as a risk factor for peri-
natal infection was not constantly associated to
neonatal infection. From 9 cases (22,22%) of Group
B Streptococcus maternal colonisation only 2
counted for neonatal sepsis (but the pathogen agent
was not identied in the newborn). A reasonable
explanation for this lack of identication of causal
agents might be the antibiotic treatment provided
for mothers with urogenital colonisation, other risk
factors for infections or suspected/conrmed infec-
tion before delivery (in labour) for prophylactic
reasons in order to prevent the early-onset neona-
tal sepsis. The prematurity was frequently linked to
perinatal infection. Male sex was more often relat-
80%
70%
60%
50%
40%
30%
20%
10%
0%
primiparity > parity urban rural cesarean
secton
vaginal
delivery
males females prematurity
75% 25% 62.50% 37.50% 50% 50% 63% 37.50% 66.66%
57.15% 42.85% 71.40% 26.10% 59.50% 40.47% 47.60% 52.30% 24.39%
Factors associated to early-onset mether-to-child bacterial infecton in newborns from investgated
preganancies
Infecton +
Infecton -
FIGURE 2. Associated factors to early-onset mother-to-child bacterial infection in newborns from investigated pregnancies
TABLE 1. Results
Variable
Uninvestgated. drug abusing
pregnancies
n = 25 (%)
Investgated pregnancies. with
infectous risk factors
n = 50 (%)
p_ value
Mothers age (years) 24.40 6.0553 (14-34) 29.7 5.2598 (19- 40) 0.0002 *
Male sex 17 (68%) 25 (50%) 0.138 **
Gestatonal age (weeks) 37.36 2.9704 (29-41) 36.86 3.3807 (27-42) 0.5321 *
Birth weight (g) 2510.00 639.49 (900-3850) 2772.80 861.18 (900-4200) 0.1814 *
Cesarean secton 5 (20%) 29 (58%) 0.0010 **
Birth asphyxia 2 (8%) 8 (16%) 0.2822 ***
Congenital infecton 10 (40%) 1 (2%) 0.00003***
Bacterial mother-to-child infecton 7 (28%) 8 (16%) 0.2206 **
Mean duraton of antbiotc treatment (days) 12.56 7.1 0.1191 *
Mean duraton of hospital stay (days) 22.16 11.7 0.0180 *
*Student T. **Chi-square. *** Fisher exact
REVISTA ROMN DE PEDIATRIE VOLUMUL LXIII, NR. 2, AN 2014 143
ed to the risk factors presence and to neonatal in-
fection.
The amount of congenital infections in the group
of newborns from uninvestigated, drug abusing
mothers was signicantly higher from statistical
point of view than in the group of newborns from
pregnancies with infectious risk factors but with
proper medical assistance.
CONCLUSIONS
Drug addiction during pregnancy represents a
high risk factor for perinatal infections, especially
for the congenital ones, due to sexual and blood
transmitted diseases associated with lack of hy-
giene, precarious nutrition and low immunological
status. The incidence of drug abuse during preg-
nancy might seam small but the effect is double,
both on mother and her child. Perinatal infection
was 2,88 times more frequent in newborns from
uninvestigated, drug addicted mothers than in those
born from pregnancies with infectious risk factors
but correct medical management. Proper medical
assistance during pregnancies, through early diag-
nosis and treatment of neonatal infections may
lower both the incidence and the consequences of
perinatal infections and the human and nancial
costs on short and long term.
1. http://www.who.int/maternal_child_adolescent/topics/maternal/
maternal_perinatal/en/
2. Barbara J. Stoll. Neonatal infections: A global perspective. in Jack S.
Remington & Jerome O. Klein, Christopher B. Wilson & Carol J.
Baker. Infectious diseases of fetus and newborn infant. Sixth edition.
Elselvier, Saunders.2006: 27-57
3. Raportul european privind drogurile tendine i evoluii, Observatorul
European pentru Droguri i Toxicomanie, 2013
4. European Monitoring Centre for Drugs and Drug Addiction
(EMCDDA). Annual report 2007 the state of the drugs problem in
Europe. Lisbon: EMCDDA; 2007.
5. European Monitoring Centre for Drugs and Drug Addiction
(EMCDDA). Statistical Bulletin 2008. Lisbon: EMCDDA; 2008.
Available from http://www.emcdda.europa.eu/stats08)
6. Weber A.E., Tyndall M.W., Spittal P.M., Li K., Coulter S.,
OShaughnessy M.V., et al. High pregnancy rates and reproductive
health indicators among female injection-drug users in Vancouver,
Canada. Eur J Contracept Reprod Health Care. 2003; 8(1):52-8.
7. Lejeune C.C. Simmat-Durand L., Gourarier L., Aubisson S.
Prospective multicenter observational study of 260 infants born to 259
opiate-dependent mothers on methadone or high-dose buprenophine
substitution. Drug Alcohol Depend. 2006; 82(3):250-7.
8. Prvention des risques foetaux: toxicomanie et grossesse. http://
www-ulpmed.u-strasbg.fr/medecine/cours_en_ligne/e_cours/
obstetrique/risques_foetaux_toxicomanie.pdf
9. Mirjana Vucinovic, Damir Roje, Zoran Vuinovi, Vesna Capkun,
Marija Bucat, and Ivo Banovi. Maternal and Neonatal Effects of
Substance Abuse during Pregnancy: Our Ten-year Experience. Yonsei
Med J vol. 49. Nr. 5:705 -713, 2008. DOI 10.3349/ymj.2008.49.5.705.
10. Yvonne A. Maldonado, Victor nizet, Jerome O. Klein, Jack S.
Remington, Christopher B. Wilson. Current concepts of infections of
the fetus and newborn infant in Remington & Klein, Wilson, Nizet,
Maldonado. Infectious diseases of fetus and newborn infant. Seventh
edition. Elselvier, Saunders. 2011: 2-23
11. Silvia-Maria Stoicescu, Doina Broscuncianu. Nou-nascutul cu risc
rezultat din sarcina marcata de toxicomanie. Medic.ro, februarie 2005;
p.40-44
12. Polin R.A., Elvira Parravicini, Regan J.A., Taeusch H.W. Bacterial
sepsis and meningitis in Teusch H.W., Ballard A.R., Gleason C.A.
Averys Diseases of the Newborn. 8
th
edition. Elsevier Saunders.2005:
p.551- 576
13. Morven S. Edwards, Victor Nizet. Group B streptococcal infections
in Remington $ Klein, Wilson, Nizet, Maldonado. Infectious diseases
of the fetus and newborn infant. Seventh Edition. Elsevier, Saunders.
2011: p.419-458
14. Gary L. Darmstadt, Anita K.M. Zaidi, Barbara J. Stoll. Neonatal
infections: a global perspective. in Remington $ Klein, Wilson, Nizet,
Maldonado. Infectious diseases of the fetus and newborn infant.
Seventh Edition. Elsevier, Saunders. 2011: 24-44
15. Amy J. Gagnon, Ronald Gibbs. Obstetric factors associated with
infectios of the fetus and newborn infant. in Remington $ Klein,
Wilson, Nizet, Maldonado. Infectious diseases of the fetus and
newborn infant. Seventh Edition. Elsevier, Saunders. 2011: 51-73
REFERENCES
REVISTA ROMN DE PEDIATRIE VOLUMUL LXIII, NR. 2, AN 2014 194
Adresa de coresponden:
Dr. Doina Broscuncianu, Spitalul Clinic de Obstetric-Ginecologie Polizu, Str. Polizu nr. 38-52, Bucureti
e-mail: doinabroscauncianu@yahoo.com
TOXICOMANIA N SARCIN FACTOR DE RISC
PENTRU INFECIE PERINATAL
Doina Broscuncianu
1
, Silvia Maria Stoicescu
1,2
, Gabriel Bnceanu
2,1
,
Anca Cab
1
1
Secia neonatologie, Spitalul Clinic de Obstetric-Ginecologie Polizu, Bucureti
2
Universitatea de Medicin i Farmacie Carol Davila, Bucureti
REZUMAT
Introducere. Infeciile neonatale sunt cauze majore de morbiditate i mortalitate neonatal. Toxicomania prin
injectarea de droguri ilicite este un important factor de risc pentru infecii perinatale.
Obiectivul studiului a fost evaluarea incidenei infectiilor cu debut precoce la nou-nscui provenii din sarcini cu
risc de infecie perinatal: sarcini neinvestigate, marcate de toxicomanie i sarcini investigate clinico-paraclinic.
Material i metod. Studiu retrospectiv care a cuprins nou-nscui n Institutul pentru Ocrotirea Mamei i
Copilului, Spitalul Clinic de Obstetric-Ginecologie POLIZU, grupai n 2 loturi: un lot de 25 nou-nscui n
perioada 2005-2012 provenii din sarcini neinvestigate survenite la femei consumatoare de droguri ilicite i un
lot de 50 nou-nscui provenii din sarcini corect investigate anamnestico-clinic cu factori de risc pentru infecie
perinatal. Datele au fost analizate statistic (teste specice de corelaie: Student T, Fisher exact, Chi-square).
Rezultate. Incidena nou-nscuilor din sarcini marcate de toxicomanie a fost de 0,09% din totalul de 28.489
nateri, cu o maxim de 0,2% nregistrat n anul 2011. Diferene semnicativ statistic s-au nregistrat ntre cele
dou loturi de nou-nscui cu factori de risc infecios prezent n privina: vrstei mamelor mai mic la
toxicomane (p_value = 0,0002) a procentului de infecii congenitale (p_value = 0,00003) OR = 0,03; 95%CI
precum i a duratei medii (zile) de spitalizare (p_value = 0,0180) mai mari la nou-nscui ai mamelor cu
toxicomanie, dar i n privina modului de natere prin cezarian (p_value = 0,0010) a colonizrii bacteriene a
tractului uro-genital matern (p_value = 0,0016) mai frecvente la nou-nscui provenii din sarcini investigate.
22% din femeile nsrcinate investigate, au prezentat Streptococ grup B, cel mai frecvent tip ind serotipul Ib.
Ponderea, n cadrul morbiditii neonatale, a infeciilor perinatale a fost pentru nou-nscui din mame toxicomane
de 33%, iar pentru nou-nscui provenii din sarcini investigate de 27%. Incidena infeciei perinatale a fost de
52% la nou-nscui din mame toxicomane (risc de infecie de 1/1,9 cazuri) i de 18% la nou-nscui din sarcini
supravegheate (ceea ce reprezint un risc de 1/5,5 cazuri).
Concluzii. Toxicomania n cursul sarcinii constituie, prin boli infecioase dobndite pe cale sexual sau sanguin
asociate cu deciene de igien pe fond de nutriie precar i de imunitate sczut, un important factor de risc
pentru infecie perinatal. Asistena sanitar n cursul sarcinii, prin diagnostic i tratament precoce al infeciei
materne, poate diminua incidena i consecinele medico-sociale ale infeciei neonatale.
Cuvinte cheie: toxicomanie n sarcin, factor de risc, infecie perinatal
STUDII CAZUISTICE
6
INTRODUCERE
Infeciile neonatale sunt nc, n aceast epoc
de mari progrese medicale ca fertilizarea in vitro
tehnologie de reproducere uman asistat, supra-
vieuirea unor fei cu vrste gestaionale i greuti
din ce n ce mai mici, cauze majore de morbiditate
i mortalitate neonatal.
Cunoaterea factorilor de risc pentru infecia
produs n perioada perinatal (cuprins ntre 22
sptmni complete sau 154 zile de sarcin pn n
a 7-a zi dup natere (1) contribuie la prevenirea
apariiei i/sau la depistarea i tratarea ecient a
acestora.
Factori medicali ca starea precar a sntii
mamei, deseori cu infecii netratate, ca i factori
socio-culturali ca lipsa de asisten sanitar n cursul
sarcinii, concur indirect ca factori favorizani la
morbiditatea i mortalitatea prin infecii perinatale.
REVISTA ROMN DE PEDIATRIE VOLUMUL LXIII, NR. 2, AN 2014 195
Se consider de altfel c tiina medical poate
ame liora starea de sntate materno-infantil, nu-
mai susinut de aciuni eciente pe plan social (2).
Toxicomania, i n mod special consumul de
dro guri ilicite prin injectare, asociat de regul cu
consumul de opiacee (dei n unele ri injectarea
amfetaminelor reprezint o problem major) (3)
afecteaz aproximativ 1,3-1,7 milioane persoane n
Uniunea European i Norvegia (4) din care 34%
sunt femei, majoritatea la vrsta fertil (5) i este
un important factor de risc pentru infecii perinatale.
Dobndite pe cale sanguin sau sexual nainte
i/sau n timpul sarcinii i transmise ftului/nou-
nscutului nainte sau n timpul naterii, cele mai
frecvente infecii sunt cele determinate de virus he-
patitic C sau B, virusul imunodecienei umane sau
de treponema pallidum (6,7,8,9).
Factori determinani ai infeciei perinatale sunt
microorganisme ce pot transmise de la mam la
ft n timpul vietii intrauterine (infecii congenitale)
i care sunt frecvent identicate prin acronime ca:
TORCH (T = toxoplasma gondii, O = alte infecii/
patogeni, R = rubeolic virus, C = citomegalic virus
sau CMV, H = herpes simplex virus sau HSV)
TORCHES CLAP (TORCH i E = enterovirus, S =
silis cauzat de treponema pallidum, C = chickenpox
cauzat de virus varicela-zoster sau VZV, L = boala
Lyme cauzata de Borrelia burgdorferi, A = AIDS
sau HIV, P = parvovirus B19) sau CHEAP
TORCHES (H = hepatita B i C cauzat de virus
hepatitic B (VHB) sau C (VHC) i E = orice altceva
care este transmis sexual ca gonoreea, Chlamydia,
Ureaplasma i papillomavirus.
Infecia transmis de la mam la ft/nou-nscut
n cursul naterii sau imediat dup natere este de-
terminat de microorganisme aate n tractul va-
ginal, asociate cu infecia neonatal n mod sem-
nicativ (Grup B streptococci, Enterococcus,
Escherichia coli, Neisseria gonorrhoeae, Listeria
monocytogenes, Candida albicans, Chlamydia
trachomatis) neobinuit (Staphylococcus aureus,
Alfa-haemolytic streptococci, Proteus species,
Klebsiella species, Pseudomonas species, Salmonella
species, Shigella species, Alkaligenes faecalis,
Neisseria meningitidis, Haemophilus inuenzae,
Vibrio fetus, Bacteroides, Clostridium species,
Mycoplasma hominis, Ureaplasma urealyticum,
Trichomonas vaginalis) sau foarte rar (Lactobacillus,
Staphylococcus epidermidis, Gardnerella vaginalis,
Corynebacterium, Bacillus subtilis, Peptostrepto-
coccus, Veillonella, Bidobacterium, Eubacterium,
Mycobacterium tuberculosis) (10).
Supravegherea corect a evoluiei sarcinii cu
risc infecios, diagnosticul i tratamentul precoce al
infeciei materne poate diminua incidena i con-
secinele infeciei perinatale.
n Romnia efectele toxicomaniei din cursul
sarcinii asupra nou-nscutului au fost semnalate n
scris prima dat n 2005 (11).
MATERIAL I METOD
Studiu retrospectiv care a cuprins nou-nscui
n Institutul pentru Ocrotirea Mamei i Copilului,
Spitalul Clinic de Obstetric Ginecologie Polizu
grupai n 2 loturi: un lot de 25 nou-nscui n
perioada 2005-2012, provenii din sarcini survenite
la femei consumatoare de droguri ilicite (sarcini
neinvestigate) i un lot de 50 nou-nscui provenii
din sarcini cu factori derisc pentru infecie perinatal
depistai prin corecta investigare anamnestico-
clinic.
Pentru lotul nou-nscuilor cu mame toxicomane
s-au efectuat: examen clinic (inclusiv evaluarea
prin scorul FINNEGAN) examen toxicologic al
urinei (recoltri efectuate la 68% din cupluri nou-
nscut-mam) analize de serologie, bacteriologie,
biochimie, radiologie i ecograe, ancheta psiho-
social realizat de asistent social i de psiholog.
Pentru lotul nou-nscuilor cu factori de risc
pentru infecie perinatal provenii din sarcini in-
ves tigate, au fost selectate cazuri incluse ntr-un
proiect de cercetare prospectiv n colaborare cu
Institutul Naional de Cercetare-Dezvoltare pentru
Microbiologie i Imunologie Cantacuzino efec-
tuat n perioada 2007-2008.
Investigaiile de laborator, realizate n vederea
depistrii de factori de risc pentru infecie perinatal
(toxoplasmoza, rubeola, citomegaloviroza, herpes,
hepatita B sau C, parvoviroza, silis, listerioza,
infecie cu Chlamydia i Streptococ grup B) ca in-
fecii simptomatice sau asimptomatice/stare de
pur ttor sntos, au inclus femeile aate n diverse
momente ale sarcinii, precum i 28% dintre nou-
nscuii lor, care au prezentat semne clinice evoca-
toare de infecie perinatal. Pentru depistarea de
Streptococul grup B (Streptococcus agalactiae) au
fost recoltate probe din vagin (1/3 inferioar) n
sptmna 35-37 de sarcin i probe din lohii, dup
natere. Identicarea de certitudine s-a realizat prin
metode serologice (serogruparea prin detectarea
anti genului specic de grup B).
Datele au fost analizate statistic (teste specice
de corelaie: Student T, Fisher exact, Chi-square)
Nivelul de semnicaie a testului s-a comparat cu
p = 0,05
REVISTA ROMN DE PEDIATRIE VOLUMUL LXIII, NR. 2, AN 2014 196
REZULTATE I DISCUII
Toxicomania n sarcin a fost depistat la 0,09%
din totalul femeilor (28.489) care au nscut n
Spitalul Polizu n anii 2005-2012, perioad n care
o inciden maxim de 0,2% s-a nregistrat n 2011.
Drogurile ilicite consumate erau cu administrare
intravenoas n majoritatea cazurilor, ceea ce cons-
tituia factor de risc pentru infecie perinatal, ca i
ignorarea msurilor de prolaxie a bolilor cu trans-
mitere sexual. Politoxicomania a fost prezent n
36% cazuri.
12% din mamele toxicomane erau minore (< 18
ani) 40% aveau ntre 21-29 ani i 24% ntre 30-34
ani. Domiciliul acestor mame a fost n 84% cazuri
n mediul urban, 12% n mediul rural, 4% erau fr
domiciliu i n 8% nu s-au putut obine date.
Mamele toxicomane se tiau sau au fost depistate
ca ind afectate de Treponema pallidum (8 cazuri)
de virus hepatitic C (5 cazuri), virus hepatitic B i
virusul imunodecienei umane (cte 1 caz), ceea
ce reprezint n total 60% din cazuri. Supravegherea
medical a sarcinilor mamelor toxicomane a fost n
aproape toate cazurile absent. Asociate probleme-
lor medicale, la multe mame s-au nregistrat proble-
me psiho-sociale: psihoz (2 cazuri), tentativ sui-
cid (2 cazuri), detenie n penitenciar (1 caz), deces
(1 caz), abandonarea nou-nscutului (6 cazuri).
Investigaiile efectuate mamelor nou-nscuilor
din al doilea lot, cele mai multe ind cu vrste ntre
21-35 ani (82%) i cu domiciliul n mediul urban
(70%), au evideniat faptul c n majoritatea cazu-
rilor exist imunizare pentru rubeol (97,95%),
cito megalovirus (92,68%), toxoplasmoz (41,46%)
i parvoviroz B (31,25%). Factorii de risc pentru
infecie perinatal depistai cel mai frecvent au fost
colonizarea tractului uro-genital cu bacterii/ Strep-
tococ grup B (14%), lichid amniotic anormal (6%),
membrane rupte de > 18 ore (3%), cerclaj col uterin
(3%), febr n travaliu (2%). Streptococul de grup
B care poate coloniza tractul vaginal matern tran-
zitoriu, cronic sau intermitent, reprezentnd astfel
un factor de risc infecios pentru nou-nscut (prin
transmiterea la nou-nscut se produce colonizare i
/sau infecie bacterian cu debut precoce sau tardiv)
s-a depistat la 22% din mamele investigate. Seroti-
parea Streptococilor de grup B, pe baza polizaha-
ridului capsular, a indicat predominant tip Ib
(34%), urmat de tip III (22%) i tip IV (22%) i de
asocieri ntre tip III cu IV i tip IV cu tip V.
Nou-nscuii provenii din sarcinile mamelor
studiate au avut urmtoarele caracteristici: sexul
predominant de 68% a fost cel masculin n rndul
nou-nscuilor mamelor toxicomane, fa de 50%
n rndul celor investigate n timpul sarcinii; nscui
la termen ( 37 sptmni) au fost 72% n lotul de
nou-nscui cu mame toxicomane i 70% n al
doilea lot; prematur (cu vrsta de gestaie 36 sp-
tmni + 6 zile) s-au nscut 28% din cei cu mame
toxicomane, neinvestigate, i 30% din cei cu mame
investigate n sarcin. Greutatea la natere 2.500 g
s-a nregistrat cu preponderen (48% fa de 36%)
n lotul nou-nscuilor provenii din mame toxico-
mane i greutatea 2.501 g a fost majoritar n ce-
llat lot (64% fa de 54%).
Repartiia nou-nscuilor n funcie de vrsta de
gestaie i de greutatea la natere, a evideniat urm-
toa rele: prematuritatea a fost mai frecvent la nou-
nscui din sarcini investigate (34% fa de 28%)
restricia de cretere intrauterin RCIU) a fost
mai frecvent de 2 ori la nou-nscui din sarcini
mar cate de toxicomanie (20% fa de 10%), iar
nou-nscuii la termen, provenii din aceste sarcini
au avut mai frecvent greuti mai mici de 3.000 g
(24% fa de 18% n lotul cu mame investigate).
Modul naterii a fost predominant pe cale vaginal
(80%) pentru lotul cu mame cu toxicomanie i prin
ope raie cezarian (58%) pentru lotul cu mame
inves tigate cu factori de risc infecios, dar i cu ali
factori de risc obstetrical.
Morbiditatea neonatal a fost de 88% la nou-
nscui din mame toxicomane i de 34% pentru cei
provenii din sarcini investigate.
FIGURA 1. Droguri
ilicite consumate n
timpul sarcinii
REVISTA ROMN DE PEDIATRIE VOLUMUL LXIII, NR. 2, AN 2014 197
Pentru nou-nscuii provenii din mame toxico-
mane neinvestigate n sarcin, incidena infeciilor
perinatale a fost de 52% (13 cazuri din 25) riscul
de infecie ind de 1/1,9 cazuri; de remarcat c n
acest lot, 9 cazuri au avut cte 1 tip de infecie peri-
natal, bacterian materno-fetal (3 cazuri) sau
con genital (6 cazuri, dintre care 5 cu silis i 1 cu
HIV), iar 4 cazuri au evoluat cu cte 2 tipuri de
infecii, infecie congenital (silis 3 cazuri i CMV1
caz) asociat cu infecie bacterian materno-fetal
cu germeni Gram-negativi (Escherichia coli n 3
ca zuri i enterobacter 1 caz). Silisul congenital a
fost conrmat (VDRL i TPHA pozitive) n 2 cazuri
i suspectat (TPHA pozitiv) n 3 cazuri.
n lotul nscuilor din sarcini investigate inci-
dena infeciilor perinatale a fost de 18% (9 cazuri
care au prezentat infecii: infecie bacterian pre-
coce materno-fetal 8 cazuri i infecie congenital
1 caz), ceea ce reprezint un risc de infecie de
1/5,5 cazuri. Colonizarea matern ca i factor de
risc pen tru infecia neonatal nu a fost asociat
constant cu infecia neonatal. Din 9 cazuri
(22,22%) de colonizare matern cu Streptococ grup
B, doar n 2 cazuri s-a produs sepsis neonatal pre-
coce (cu ger mene neidenticat ns). Ad ministrarea
de anti bi otic nainte de natere (n travaliu) la mam
colo nizat sau cu ali factori de risc infecios, cu
infecie suspicionat sau conrmat, pentru pro -
laxia in fec iei neonatale precoce, poate o ex-
plicaie a lipsei de identicare a germenilor la nou-
nscut. Prematuritatea a fost frecvent asociat cu
infecia perinatal. Sexul masculin a fost mai frec-
vent aso ciat cu prezena factorilor de risc infecios
i cu in fecia neonatal.
Procentul de infecii congenitale din lotul nou-
nscuilor provenii din sarcini marcate de toxico-
manie, neinvestigate, a fost semnicativ statistic
mai mare dect cel existent n lotul nou-nscuilor
din sarcini cu risc infecios, dar cu asisten corect
medical.
80%
70%
60%
50%
40%
30%
20%
10%
0%
paritate > paritate urban rural cezarian vaginal masculin feminin prematuritate
75% 25% 62,50% 37,50% 50% 50% 63% 37,50% 66,66%
57,15% 42,85% 71,40% 26,10% 59,50% 40,47% 47,60% 52,30% 24,39%
IMF +
IMF -
FIGURA 2. Factori asociai cu infecie precoce bacterian materno-fetal (IMF) la nou-nscui provenii din sarcini investigate
TABELUL 1. Rezultate
Variabil Sarcini neinvestgate,
cu toxicomanie
n = 25 (%)
Sarcini investgate,
cu factori de risc infecios
n = 50 (%)
p_ value
Vrsta mam (ani) 24,40 6,0553
(14-34)
29,7 5,2598
(19-40)
0,0002 *
Sex masculin 17 (68%) 25 (50%) 0,138 **
Vrsta gestaie (sptmni) 37,36 2,9704
(29-41)
36,86 3,3807
(27-42)
0,5321 *
Greutate la natere (g) 2510,00 639,49
(900-3850)
2772,80 861,18
(900-4200)
0,1814 *
Cezarian 5 (20%) 29 (58%) 0,0010 **
Asxia la natere 2 (8%) 8 (16%) 0,2822 ***
Infecie congenital 10 (40%) 1 (2%) 0.00003***
Infecie materno-fetal bacterian 7 (28%) 8 (16%) 0,2206 **
Antbiotcoterapie durat medie (zile) 12,56 7,1 0,1191 *
Spitalizare durat medie (zile) 22,16 11,7 0,0180 *
*Student T, **Chi-square, *** Fisher exact
REVISTA ROMN DE PEDIATRIE VOLUMUL LXIII, NR. 2, AN 2014 198
CONCLUZII
Toxicomania n cursul sarcinii constituie, prin
boli infecioase dobndite pe cale sexual sau san-
guine, asociate cu deciene de igien pe fond de
nutriie precar i de imunitate sczut, un important
factor de risc pentru infecie perinatal, preponderent
infecie congenital. Incidena consumului de dro-
guri n sarcin, aparent mic, are impact dublu asu-
pra mamei i copilului nou-nscut. Infecia peri-
natal a fost de 2,88 mai frecvent la nou-nscui
din mame toxicomane neinvestigate, dect la nou-
nscui din sarcini cu factori de risc infecios inves-
tigate corect. Asistena sanitar n cursul sarcinii,
prin diagnostic i tratament precoce al infeciei ma-
terne, poate diminua incidena i consecinele in-
feciei perinatale, dar i costurile umane i nanciare
pe ter men scurt i lung.