Maternal Lyme disease and congenital heart disease: A case-control study in an endemic area

Obstetrical and neonatal outcomes in women with gestational Lyme disease

OBJECTIVE

The incidence of Lyme disease (LD) infections has risen in recent decades. Gestational LD has been associated with adverse pregnancy outcomes; however, the results have been contradictory. The study objective was to examine the effects of gestational LD on obstetrical and neonatal outcomes.

METHODS

Using the Healthcare Cost & Utilization Project National (Nationwide) Inpatient Sample from the United States, we conducted a retrospective cohort study of pregnant patients admitted to the hospital between 2016 and 2019. The exposed group consisted of pregnant patients with gestational LD infection (International Classification of Diseases, Tenth Revision [ICD-10] code A692x), while the comparison group consisted of pregnant patients without gestational LD. Descriptive statistics and multivariate logistic regression models, adjusted for baseline maternal characteristics, were used to determine the associations between gestational LD and obstetrical and neonatal outcomes.

RESULTS

The cohort included 2 943 575 women, 226 of whom were diagnosed with LD during pregnancy. The incidence of LD was 7.67 per 100 000 pregnancy admissions. The incidence of gestational LD was stable over the study period. Pregnant patients with LD were more likely white, older, to have private health insurance, and to belong to a higher income quartile. Gestational LD was associated with an increased risk of placental abruption (adjusted odds ratio [aOR], 3.45 [95% confidence interval (CI), 1.53-7.80]) and preterm birth (aOR, 1.58 [95% CI, 1.03-2.42]).

CONCLUSION

Gestational LD is associated with a higher risk of placental abruption and preterm birth. Pregnancies complicated by LD, while associated with a higher risk of certain adverse outcomes, can be followed in most healthcare settings.

Hypertensive Disorders in Pregnancy Are Associated With Congenital Heart Defects in Offspring: A Systematic Review and Meta-Analysis

Background

Although research indicates an association between hypertensive disorders of pregnancy (HDP) and congenital heart defects (CHDs) in offspring, consistency is still lacking. Therefore, we aimed to synthesize the updated published epidemiologic evidence to estimate the association of maternal HDP with the risk of total CHDs and its phenotypes in offspring.

Methods

A systematic search of Web of Science Database, PubMed, and Embase were searched from inception through April 30, 2021 based on a preprepared protocol, and the reference lists were also manually searched. The combined risk estimates were calculated using either the fixed-effect models or random-effect models. Possible heterogeneity moderators were detected by subgroup, sensitivity analyses, and Galbraith plot.

Results

Twenty-four studies involving 477,839 CHDs cases among 40,394,699 participants were included in our meta-analysis. Mothers who had HDP exposure were significantly associated with an increased risk of total CHDs compared with non-exposure. When maternal HDP exposure was further subdivided into pre-eclampsia (OR = 1.79, 95% CI: 1.50–2.13), gestational hypertension (OR = 1.16, 95% CI: 1.02–1.31), and chronic hypertension (OR = 1.68, 95% CI: 1.49–1.89), a significantly increased risk of total CHDs were still presented. Furthermore, a statistically significant increased association was found between maternal HDP exposure and most CHD phenotypes. Besides, relevant heterogeneity moderators have been identified by subgroup and sensitivity analyses.

Conclusion

Our study suggested that maternal HDP exposure may be associated with an increase in the risk of CHDs in offspring. These findings highlight the need for greater surveillance of pregnant women with HDP exposure to allow early prevention that may be good for reducing the risk of CHDs in offspring.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [CRD42021268093].

Course and Outcome of Erythema Migrans in Pregnant Women

Information on Lyme borreliosis (LB) during pregnancy is limited. In the present study, the course and outcome of erythema migrans (EM) in 304 pregnant women, diagnosed in the period 1990–2015, was assessed and compared with that in age-matched non-pregnant women. The frequency of unfavorable outcome of pregnancies was also evaluated. The pregnant women reported constitutional symptoms less frequently than the non-pregnant women (22.4% vs. 37.2%, p < 0.001). Pregnant women diagnosed with EM later during pregnancy had a lower probability of reporting constitutional symptoms (odds ratio = 0.97 for 1-week difference in gestation week at diagnosis of EM, 95% CI: 0.94–0.99, p = 0.02). The outcome of pregnancy was unfavorable in 42/304 (13.8%) patients: preterm birth in 22/42 (52.4%), fetal/perinatal death in 10/42 (23.8%), and/or anomalies in 15/42 (35.7%). Several patients had potential explanation(s) for the unfavorable outcome. In conclusion, the course of early LB during pregnancy is milder than in age-matched non-pregnant women. The outcome of pregnancy with the treatment approach used in the present study (i.v. ceftriaxone 2 g once daily for 14 days) is favorable.

Overview on the treatment of Lyme disease in pregnancy

Lyme disease is a tick-borne illness, which is typically caused by Borrelia Burgdoferi. Over time, a typical Borreliosis skin reaction takes shape, i.e. the formation of an annular erythema that tends to expand centrifugally with erythematous edges whose diameter can reach up to 20 cm. The symptoms of Lyme disease are not only cutaneous but there may be a systemic involvement. Obviously, this disease can also affect pregnant women and for this reason this review aims to summarize the main ways of treatment to avoid worsening of the clinical condition in the mother and an eventual, albeit rare, involvement of the fetus.

A systematic review on the impact of gestational Lyme disease in humans on the fetus and newborn

Lyme disease (LD), caused by bacteria of the Borrelia burgdorferi sensu lato species complex, is the most common vector-borne disease in North America and Europe. A systematic review (SR) was conducted to summarize the global literature on adverse birth outcomes associated with gestational LD in humans. The SR followed an a priori protocol of pretested screening, risk of bias, and data extraction forms. Data were summarized descriptively and random effects meta-analysis (MA) was used where appropriate. The SR identified 45 relevant studies, 29 describing 59 cases reported as gestational LD in the United States, Europe, and Asia (1969–2017). Adverse birth outcomes included spontaneous miscarriage or fetal death (n = 12), newborn death (n = 8), and newborns with an abnormal outcome (e.g. hyperbilirubinemia, respiratory distress and syndactyly) at birth (n = 16). Only one report provided a full case description (clinical manifestations in the mother, negative outcome for the child, and laboratory detection of B. burgdorferi in the child) that provides some evidence for vertical transmission of B. burgdorferi that has negative consequences for the fetus. The results of 17 epidemiological studies are included in this SR. Prevalence of adverse birth outcomes in an exposed population (defined by the authors as: gestational LD, history of LD, tick bites or residence in an endemic area) was compared to that in an unexposed population in eight studies and no difference was reported. A meta-analysis of nine studies showed significantly fewer adverse birth outcomes in women reported to have been treated for gestational LD (11%, 95%CI 7–16) compared to those who were not treated during pregnancy (50%, 95%CI 30–70) providing indirect evidence of an association between gestational LD and adverse birth outcomes. Other risk factors investigated; trimester of exposure, length of LD during pregnancy, acute vs. disseminated LD at diagnosis, and symptomatic LD vs. seropositive women with no LD symptoms during pregnancy were not significantly associated with adverse birth outcomes. This SR summarizes evidence from case studies that provide some limited evidence for transplacental transmission of B. burgdorferi. There was inconsistent evidence for adverse birth outcomes of gestational LD in the epidemiological research, and uncommon adverse outcomes for the fetus may occur as a consequence of gestational LD. The global evidence does not fully characterize the potential impact of gestational LD, and future research that addresses the knowledge gaps may change the findings in this SR. Given the current evidence; prompt diagnosis and treatment of LD during pregnancy is recommended.

Infectious Diseases in Pregnancy

Many infectious diseases have the potential to complicate pregnancy. Some illnesses may only impact maternal health, but others can infect the fetus with possible devastating or long-term sequelae. In this chapter we aim to review common infectious diseases such as urinary tract infections and influenza as well as those that can cause major neonatal morbidity and mortality including TORCH infections. We will also discuss the challenges that pregnancy creates for the management of these infectious diseases as some antibiotics that would typically be used may not be safe for the developing fetus depending on the stage of pregnancy.

Skin infections in pregnancy

A wide array of infectious diseases can occur in pregnancy. Their acquisition, clinical presentation, and course during gestation may be altered due to an impairment of the maternal cellular immunity. Some infectious diseases can lead to serious consequences for the mother or the offspring, including congenital malformations. This review describes in detail the clinical presentation, course, management, and associated maternal and fetal risks of selected viral (varicella-zoster virus infections, condylomata acuminata), fungal (candida vulvovaginitis), bacterial (Lyme borreliosis), and parasitic (scabies) infections. The treatment options are critically reviewed. First-line therapies include acyclovir and varicella-zoster virus immunoglobulin for varicella-zoster virus infections, surgical modalities for genital warts, topical clotrimazole and oral fluconazole for Candida vulvovaginitis, amoxicillin and cefuroxime for Lyme borreliosis, and permethrin for scabies. A synopsis of maternal and fetal risks of other important infections is also included.

Erythema migrans

Erythema migrans (EM) is the most common objective manifestation of Borrelia burgdorferi infection. Systemic symptoms are usually present. Most patients do not recall a preceding tick bite. Despite a characteristic appearance, EM is not pathognomonic for Lyme disease and must be distinguished from other similar appearing skin lesions. EM is a clinical diagnosis; serologic and PCR assays are unnecessary. Leukopenia and thrombocytopenia are indicative of either an alternative diagnosis, or coinfection with another tick-borne pathogen. When EM is promptly treated with appropriate antimicrobial agents, the prognosis is excellent. Persons in endemic areas should take measures to prevent tick bites.

Lyme disease in children

The diagnosis and management of Lyme disease in children is similar to that in adults with a few clinically relevant exceptions. The use of doxycycline as an initial empiric choice is to be avoided for children 8 years old and younger. Children may present with insidious onset of elevated intracranial pressure during acute disseminated Lyme disease; prompt diagnosis and treatment of this condition is important to prevent loss of vision. Children who acquire Lyme disease have an excellent prognosis even when they present with the late disseminated manifestation of Lyme arthritis. Guidance on the judicious use of serologic tests is provided. Pediatricians and family practitioners should be familiar with the prevention and management of tick bites, which are common in children.

Arthropod-borne bacterial diseases in pregnancy

Arthropod-borne bacterial diseases affect more than 25,000 Americans every year and thousands more around the world. These infections present a diagnostic dilemma for clinicians because they mimic many other pathologic conditions and are often low on or absent from the differential diagnosis list. Diagnosis is particularly challenging during pregnancy, as these infections may mimic common pregnancy-specific conditions, such as typical and atypical preeclampsia, or symptoms of pregnancy itself. Concerns regarding the safety in pregnancy of some indicated antibiotics add a therapeutic challenge for the prescriber, requiring knowledge of alternative therapeutic options for many arthropod-borne bacterial diseases. Physicians, especially those in endemic areas, must keep this class of infections in mind, particularly when the presentation does not appear classic for more commonly seen conditions. This article discusses presentation, diagnosis, and treatment of the most common of these arthropod-borne bacterial diseases, including Lyme disease, Rocky Mountain spotted fever, tick-borne relapsing fever, typhus, plague, cat-scratch disease, and Carrión disease.

[Skin infections in pregnancy]

The article outlines examples of a viral (varicella-zoster virus, VZV), a bacterial (Lyme borreliosis) and a parasitic (scabies) infection in pregnancy with their risk for the mother and/or child as well as their management. VZV infections cause various clinical scenarios depending on the maternal immune status and the time of infection. Herpes zoster usually poses no risk to the pregnant woman and there is no need for antiviral therapy. VZV infection of a seronegative mother, however, may lead to severe varicella in the pregnant woman and to congenital malformations (congenital varicella syndrome) in case of early infection or neonatal varicella in case of perinatal infection. Prompt therapy with acyclovir or administration of VZV immunoglobulin for prophylaxis is mandatory in those patients. In case of Lyme borreliosis of the mother, adequate antibiotic therapy with amoxicillin prevents harm to the fetus. Doxycycline is contraindicated during pregnancy. Scabies represents an important differential diagnosis of pruritic dermatoses in pregnancy and should be treated with permethrin 5% cream.

Skin manifestations of lyme borreliosis: diagnosis and management

Lyme borreliosis is a multisystem infectious disease caused by tick-transmitted spirochetes of the Borrelia burgdorferi sensu lato complex. The three characteristic cutaneous manifestations are erythema migrans, borrelial lymphocytoma, and acrodermatitis chronica atrophicans. Erythema migrans occurs in acute Lyme borreliosis, lymphocytoma is a subacute lesion, and acrodermatitis is the typical manifestation of late Lyme borreliosis. Clinical appearances of erythema migrans and lymphocytoma (when located on the ear or breast) are characteristic, whereas acrodermatitis is often confused with vascular conditions. The diagnosis of erythema migrans is made clinically. Serologic analyses often yield false-negative results and are not required for the diagnosis. However, serologic proof of the diagnosis in lymphocytoma (approximately 90% positive) and acrodermatitis (100% positive) is mandatory. Histopathologic examination often adds substantial information in patients with skin manifestations of Lyme borreliosis and is recommended in clinically (and serologically) undecided cases of erythema migrans or lymphocytoma and is obligatory in acrodermatitis. Polymerase chain reaction for Borrelia-specific DNA (rather than culture of the spirochete) and immunohistochemical investigations (lymphocytoma) are sometimes necessary adjuncts for the diagnosis. Antibacterial treatment is necessary in all patients to eliminate the spirochete, cure current disease, and prevent late sequelae. Oral doxycycline, also effective against coinfection with Anaplasma phagocytophilum, is the mainstay of therapy of cutaneous manifestations of Lyme borreliosis. Other first-line antibacterials are amoxicillin and cefuroxime axetil. Erythema migrans is treated for 2 weeks, lymphocytoma for 3-4 weeks, and acrodermatitis for at least 4 weeks.

Syphilis and borreliosis during pregnancy

Syphilis and lyme borreliosis have similar etiologic, clinical, and epidemiologic characteristics. Both are multisystem infectious disorders spread worldwide. Their clinical course can be divided into three stages and as to spirochetal origin, antibiotic therapy is similar too. Taxonomical relationship of Treponema and Borrelia could explain also congenital manifestations well-known in syphilis, and suggested in borreliosis. Therapy of pregnant women with syphilis and lyme borreliosis should follow the same strategy.

Erythema migrans

Erythema migrans (EM) is the most common objective manifestation of Lyme disease, accounting for about 90% of cases. Establishing the diagnosis of EM is important because appropriate treatment with oral antibiotics at an early stage of infection with Borrelia burgdorferi results in excellent outcomes. This article includes a discussion of the epidemiology of EM and its clinical, differential, and laboratory diagnosis. The treatment of EM and the prevention of Lyme disease are also discussed.

Getting to the heart of the matter: epidemiology of cyanotic heart defects

Congenital heart defects (CHDs) are the most common type of birth defect, making significant contributions to infant morbidity and mortality, but not all CHDs contribute equally to such outcomes. Although cyanotic CHDs constitute some of the most serious CHDs, its epidemiology is poorly understood. We present a comprehensive systematic review of the literature on the epidemiology of cyanotic CHD, with emphasis on the most current knowledge on identified risk/etiologic factors. Literature for this review was identified by searching the PubMed database from the National Center for Biotechnology Information at the US National Library of Medicine as well as bibliographies of identified papers. The 100 reports that contributed to this review describe risk factors such as infant sex, race, and ethnicity, environmental exposures, and maternal and paternal age. Several studies reported differences in prevalence rates by race and ethnicity and elevated sex ratios, and they identified some risk factors, including advanced maternal age. Investigators have made significant progress in the effort to describe the etiology of cyanotic CHDs, but discrepancies, such as the variation in prevalence rates by race and ethnicity and the impact of environmental exposures, still need to be addressed.

[Lyme disease: prophylaxis after tick bite]

Lyme disease is a bacterial infection caused by Borrelia burgdorferi, which is transmitted by infected ticks. The transmission depends on several factors, especially on the duration of the tick's presence in the host body (the nymph which is smaller than the adults and thus less visible, is in this case the most frequently involved) and on whether the tick is infected or not. The interpretation of results in the few available studies is made difficult by the lack of information obtained (due to difficulty to collect information and examination costs). The comparison is made even more difficult by the difference between Borrelia ticks species in various regions. Today, the best methods are preventive: protective clothing, tick repellents, checking and removal of ticks after a journey in an endemic zone, and in case of tick bite, regular examination of the bite site during the following weeks in order to initiate an early curative treatment if ECM is diagnosed. The currently available data seems to be insufficient to suggest systematic antimicrobial prophylaxis in case of tick bite.

Lyme Disease in Pregnancy: Case Report and Review of the Literature

Lyme disease is the most common vector-borne disease in the United States. A number of other spirochetal diseases, if contracted in pregnancy, have been shown to cause fetal harm and there is concern over a similar effect with gestational borreliosis. Previously published individual case reports have suggested a possible association between gestational borreliosis and adverse pregnancy outcome; however, no specific pattern of teratogenicity has been shown, and a causal relationship has never been proven. In addition, larger epidemiological and serological series have consistently failed to demonstrate an increased risk to pregnant women who develop Lyme disease if they receive appropriate antimicrobial therapy. We describe a favorable outcome in a 42-year-old woman who developed Lyme disease in the third trimester and was treated with a full course of oral amoxicillin. In addition, we offer a review of the relevant literature regarding Lyme disease and pregnancy. The appropriate investigation and management of a woman with gestational borreliosis are discussed.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that Lyme disease is not an uncommon disease during pregnancy and can occur in states outside of the Northeast, explain that the diagnosis is made clinically and may be confirmed by laboratory tests, state that treatment is recommended during pregnancy, and summarize that there is no consistent data of adverse fetal effects even though the placenta is infected.

Lyme borreliosis: from infection to autoimmunity

Lyme borreliosis in humans is an inflammatory disease affecting multiple organ systems, including the nervous system, cardiovascular system, joints and muscles. The causative agent, the spirochaete Borrelia burgdorferi, is transmitted to the host by a tick bite. The pathogenesis of the disease in its early stages is associated largely with the presence of viable bacteria at the site of inflammation, whereas in the later stages of disease, autoimmune features seem to contribute significantly. In addition, it has been suggested that chronic persistence of B. burgdorferi in affected tissues is of pathogenic relevance. Long-term exposure of the host immune system to spirochaetes and/or borrelial compounds may induce chronic autoimmune disease. The study of bacterium-host interactions has revealed a variety of proinflammatory and also immunomodulatory-immunosuppressive features caused by the pathogen. Therapeutic strategies using antibiotics are generally successful, but chronic disease may require immunosuppressive treatment. Effective and safe vaccines using recombinant outer surface protein A have been developed, but have not been propagated because of fears that autoimmunity might be induced. Nevertheless, new insights into the modes of transmission of B. burgdorferi to the warm-blooded host have been generated by studying the action of these vaccines.

Breast milk and infection

Three viruses (CMV, HIV, and HTLV-I) frequently cause infection or disease as a result of breast-milk transmission. Reasonable guidelines have been pro-posed for when and how to avoid breast milk in the case of maternal infection. For other viruses, prophylactic immune therapy to protect the infant against all modes of transmission are indicated (VZV, varicella-zoster immunoglobulin, HAV and immunoglobulin, HBV, and HBIg + HBV vaccine). In most maternal viral infections, breast milk is not an important mode of transmission, and continuation of breastfeeding is in the best interest of the infant and mother (see Tables 2 and 3). Maternal bacterial infections rarely are complicated by transmission of infection to their infants through breast milk. In a few situations, temporary cessation of breastfeeding or the avoidance of breast milk is appropriate for a limited time (24 hours for N gonorrheae, H infiuenzae, Group B streptococci, and staphylococci and longer for others including B burgdorferi, T pallidum, and M tuberculosis). In certain situations, prophylactic or empiric therapy may be advised for the infant (eg, T pallidum, M tuberculosis, H influenzae) (see Table 1). Antimicrobial use by the mother should not be a reason not to breastfeed. Alternative regimens that are compatible with breastfeeding can be chosen to treat the mother effectively. In most cases of suspected infection in the breastfeeding mother, the delay in seeking medical care and making the diagnosis means the infant has been ex-posed already. Stopping breastfeeding at this time only deprives the infant of the nutritional and potential immunologic benefits. Breastfeeding or the use of expressed breast milk, even if temporarily suspended, should be encouraged and supported. Decisions about breast milk and infection should balance the potential risk compared with the innumerable benefits of breast milk.

'Lyme disease': ancient engine of an unrecognized borreliosis pandemic?

Unexpectedly we have found large numbers of chronically ill Borrelia burgdorferi PCR- and seropositive patients in Houston, Texas, a zoonotically 'non-endemic' area. In order to understand this finding prior to sufficient data availability, we chose to examine critically currently accepted but troublesome 'Lyme disease' concepts. Our method was to analyze each foundation 'Lyme disease' premise within the context of available medical and veterinary literature, then to reconstruct the disease model consistent with the preponderance of that data. We find the present conceptualization of the illness seriously truncated, with a high likelihood of two distinct but connected forms of human B. burgdorferi infection. The yet-unrecognized form appears to have a broader clinical presentation, wider geographic distribution, and vastly greater prevalence. We conclude that 'Lyme disease' currently acknowledges only its zoonosis arm and is a limited conceptualization of a far more pervasive and unrecognized infection state that must be considered a global epidemic.

Teratogen update: Lyme disease

We reviewed the world literature concerning the reproductive effects of Lyme disease (LD). Borrelia burgdorferi, which is the etiology of LD, is a spirochete and, as such, may share the potential for causing fetal infection, which may occur in the setting of maternal spirochetemia. Information concerning the effects of gestational LD derives from case reports and series, epidemiologic studies, and experimental animal models. Although provocative, these studies fail to define a characteristic teratogenic effect. However, skin and cardiac involvement have predominated in some reports. Pregnancy wastage has been suggested primarily by animal studies. Gestational LD appears to be associated with a low risk of adverse pregnancy outcome, particularly with appropriated antibiotic therapy. Suggestions for management of clinical situations are presented.

Maternal issues affecting the fetus

Maternal disorders and exposures that affect fetal cardiac structure and function are reviewed, emphasizing fetal echocardiographic diagnosis and monitoring, and approaches for in utero therapy. Maternal diabetes, hyperthyroidism, lupus erythematosis, epilepsy, congenital heart disease, infections, and drug exposures are considered.