Infections and Pregnancy: Effects on Maternal and Child Health

1Pregnancy is a critical “formative period” that has a significant impact on an individual’s health trajectory from fetal life to adulthood. Pregnancy is governed by a series of interconnected physiological and cellular mechanisms that promote maternal homeostasis and maintain optimal maternal-fetal interface while boosting fetal growth. These mechanisms enable the woman’s body to undergo, physiological and immunologic adaptations to host fetal antigens. From the mother’s immune system perspective, the fetus is an allograft that contains foreign antigens from the father. To protect the fetus from immune rejection, the maternal immune must strike a delicate balance between maintaining tolerance to the fetal allograft by inducing anti-inflammatory properties at the maternal-fetal interface and maintaining an elevated inflammatory response with rising levels of pro-inflammatory cytokines at mucosal surfaces such as the gut to protect against microbial challenges. Concurrently, the transition of the maternal immune system during pregnancy from more inflammatory states at the start of pregnancy to lower levels of inflammation in mid-pregnancy makes pregnant women more vulnerable to infections and pregnancy complications. Although the exact etiology of pregnancy complications remains elusive, the complex interaction of microbial or other factors with host immune system is thought to be the underlying pathogenesis of pregnancy complications.

2The emerging findings from the various pregnancy cohorts, as well as many animal studies, demonstrated that pregnancy complications are heterogeneous and depend on a variety of factors, including intra- or extra-uterine infection, microbial dysbiosis, and aberrant immune system. During pregnancy, multiple immune signaling pathways and cytokines normally act as mediators to promote a healthy and successful pregnancy and to arbitrate defense against pathogens. However, the complexity of interaction between multiple host factors, including maternal infection or aberrant activation of the immune response during pregnancy, could lead to severe pregnancy complications and have a negative impact on pregnancy health or the developing fetus. Indeed, the emerging evidence indicates that these pregnancy complications may pose significant challenges to fetal growth and development during pregnancy, as well as susceptibility to a variety of diseases later in life.

3In this article, we review the complexity of the interaction between various host factors associated with different maternal infections and dynamic fluctuation of the maternal immune system in both inducing pregnancy complications and eliciting detrimental effects on the developing fetus.

4Complications from various bacterial, viral, parasitic or fungal maternal infections can occur at any stage of pregnancy. Indeed, several studies suggest that pregnant women are more vulnerable to certain infections as a result of compensatory physiological and immunologic adaptations. The “TORCH” pathogens including Toxoplasma gondii, Other agents (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes simplex virus, are known to cause various pregnancy complications such as congenital infections, abortion, and intrauterine fetal growth restrictions. In addition to these most common infections linked to congenital defects, ZIKA infection, one of the newest TORCH pathogens, has recently sparked public concern, resulting in severe pregnancy complications ranging from fetal growth restriction to miscarriages in 2015-2017. Most TORCH pathogens cause mild to moderate morbidity, but infections during pregnancy can have serious fetal consequences due to stimulation of systemic or local factors ( Table 1 ). Emerging studies indicate that various microbial pathogens and neurotropic viruses can cross the placenta barrier, and an aberrant immune response to pathogens can cause various pregnancy complications, such as:

5Acute maternal infection during pregnancy: may cause maternal morbidity and/or mortality or a wide range of obstetric complications, including low birth weight, stillbirth, miscarriage, and preterm labor.

6Vertical transmission during pregnancy: which can result in congenital infection, intrauterine death, or permanent disability.

7Perinatal transmission during delivery: which can lead to severe neonatal diseases.

8To better understand the pathophysiology and consequences of TORCH pathogens and other maternal infections during pregnancy, as well as their impact on pregnancy outcomes, we classified these pathogens into the following categories:

9Acute bacterial infections during pregnancy can increase pregnancy complications and even have a negative pregnancy outcome ( Table 1 ). Bacterial infections, such as listeriosis, bacterial vaginosis, and sexually transmitted infections (STIs), can be caused by a single bacterial pathogen or by a microbial dysbiosis and can result in inflammasome signaling at the maternal-fetal interface and/or severe congenital anomalies in the developing fetus.

10Listeriosis is a foodborne bacterial infection caused by Listeria monocytogenes. Although this infection is uncommon in healthy people, pregnant women are particularly vulnerable to L. monocytogenes infection, possibly due to their altered immune status. Once transmitted through contaminated food, L. monocytogenes can cross the intestinal barrier to reach the placenta causing pregnancy complications such as preterm birth, stillbirth, congenital diseases, and sepsis. A recent listeriosis outbreak in South Africa reported exceptionally high mortality rates among infected infants (>28%) and pregnant women. Although the pathophysiology of L. monocytogenes placental transmission is still largely unknown, emerging studies show that the bacterium binds to E-cadherin on primary trophoblasts via the internalis protein InIA and InIB or InIP, to survive in a hostile environment, suggesting that the bacterium uses trophoblast-specific virulence factors for placental colonization and fetal tissues infection. Concurrently, bacterial colonization in placental tissues leads to abscess development, innate immune cells recruitment, and aberrant IFN-γ secretion at the maternal-fetal interface and subsequently stimulates inflammasome signaling and increases severity of neonatal outcomes. A.

11Bacterial vaginosis (BV) is characterized by the loss of healthy vaginal microbiome composition and an increase in the abundance of pathogenic microbes. BV is the most common gynecological infection among women during reproductive age and pregnancy, resulting in serious pregnancy complications such as miscarriage and preterm birth ( Table 1 ). Vaginal infections caused by group B Streptococcus (GBS), Escherichia coli, Bacteroides species, C. trachomatis, and N. gonorrhoeae can ascend to the genital tract and intraamniotic fluid causing chorioamnionitis. Infections caused by ascending genito-urinary tract pathogens are typically polymicrobial and often associated with microbial biofilm and antimicrobial cervical mucous plug to reach the intra-amniotic fluid or maternal-fetal interface and induce inflammation locally, which then endangers the fetus due to aberrant inflammation at the fetal membrane. There is no clear evidence of how dysbiotic flora crosses the maternal barriers to reach the fetus, but GBS and E. coli are the most common pathogens found in the placenta and late-onset sepsis in neonates. GBS and E. coli can both adhere to the fetal membrane via various virulence factors and stimulate neutrophils and macrophages to produce inflammatory cytokines and potentially develop extracellular traps to cause premature fetal membrane rupture.

12Changing the vaginal microenvironment during pregnancy may increase vaginal susceptibility to opportunistic STIs, which are frequently asymptomatic, but can cause severe pregnancy complications if left untreated. Ascending transmission of Chlamydia trachomatis and Neisseria gonorrhoeae can lead to pelvic inflammatory disease and endocarditis, as well as serious pregnancy complications like ectopic pregnancy, preterm birth, and low birth weight. Syphilis is another common STI (caused by Treponema pallidum). Although the pathophysiology of T. pallidum ascending transmission is unknown, it may be dependent on both the gestational age of the fetus and the maternal stage of infection. Vertical transmission of this bacterium can cause excessive inflammation at the maternal-fetal interface resulting in mild to severe pregnancy complications such as low birth weight, preterm birth, congenital anomalies, and sometimes fetal loss.

13The maternal microbiome undergoes significant changes during the course of pregnancy and has been suggested to play an influencing role in the health of pregnant women and their neonates during pregnancy and beyond. The maternal microbiome consists of distinct microbial communities dominated by different bacterial taxa. For example, a vaginal microbial community dominated with Lactobacillus species are suggested to be associated with a healthy pregnancy, whereas the abundance of a complex vaginal microbial community of CST-IV including Gardnerella, Prevotella, Chlamydia and bacterial vaginosis (BV)-associated bacterium-I (BVAB-I) are associated with increased risk for adverse pregnancy outcomes and fetal infection. The gut and oral microbial communities, like the vaginal microbiome, undergo significant changes during pregnancy, including a significant decrease in alpha diversity and a significant enrichment in Actinobacteria and Proteobacteria species in the gut and oral environment ( Figure 1A ).

14To ensure healthy pregnancy outcomes, this delicate balance between microbial communities and immune tolerance or immune response must be maintained ( Figure 1B ). Numerous studies have suggested that microbial dysbiosis is linked to a variety of pregnancy complications and fetal development. For example, abnormal changes in the oral microbiota during pregnancy, such as a decrease in Lactobacillus species or an increase in the abundance of Porphyromonas gingivalis, may lead to further infections and the production of pro-inflammatory cytokines, which is thought to be a contributory factor to various pregnancy complications such as early labor, pregnancy loss, and low birth weight, among others. While the link between microbial dysbiosis and pregnancy complications is clear, the exact nature of these interactions is unknown. It is unclear whether dysbiosis impairs the maternal immune system or influences other mechanisms to promote pregnancy complications and fetal development. These findings suggest that intra- or extra-uterine infection or vaginal dysbiosis induces an abnormal immune response in pregnant women and may be an important predictor marker for adverse outcomes of congenital infections.

15The human microbiome has a significant virome component, which includes a diverse collection of endogenous retroviruses, eukaryotic viruses, and bacteriophages, and is increasingly recognized as an orchestrator of bacterial diversity and functionality. Although the majority of viruses are harmless, some pathogenic viruses can cross the maternal-fetal interface and influence placental functions, potentially causing fetal disease ( Table 1 ).

16Cytomegalovirus (CMV) is a DNA virus that belongs to the Herpesviridae family. CMV is the most common viral infection transmitted vertically in utero, causing a wide range of congenital disorders such as hearing and vision loss, intracranial calcifications, microcephaly, organ dysfunction, and intellectual disability. CMV is typically transmitted from person to person via infected bodily fluids such as blood, saliva, urine, and breast milk. Once infected, the virus can live in bone marrow hematopoietic cells for the rest of one’s life. However, it is a primary infection during pregnancy, rather than a reactivation of a persistent infection, that causes adverse pregnancy outcomes. Although the exact pathophysiology of CMV is unknown, the severity of the infection and fetal consequences are dependent on gestational age at the time of maternal infection, implying that changes in maternal immune status and the maternal-fetal interface play an important role in CMV vertical transmission. According to new research, CMV may first infect placental pericytes before infecting the fetus. Additionally, CMV infected pregnant women have elevated level of cytokines including TNF-α, IL-1β, IL-10, IL-12, IL-15, IL-17, and CXCL10 which may cause various pregnancy complications or serious health problems to the baby, such as preterm birth or low birth weight, or hearing loss at birth or later in life, depending on the pregnancy.

17Herpes simplex virus (HSV) infections are often asymptomatic or cause mild symptoms in adults; however, the changing maternal immune system from higher inflammatory status at the beginning of pregnancy to a lower level of inflammation in mid-pregnancy may predispose the pregnant women to different viral infections, including HSVs. Although the mechanism of its transplacental transmission is unknown, vertical transmission via direct contact with viral lesions in the genital tract during delivery is a more common route of neonatal infection. As a result, maternal HSV infection near the time of delivery increases the risk of vertical transmission, which can result in herpes simplex encephalitis, chorioretinitis, and intracranial calcification in neonates, with a 50-80% mortality rate in untreated cases.

18Rubella virus is a contagious virus in the Togaviridae family. Rubella virus is primarily transmitted via respiratory droplets, and in healthy adults, the infection causes mild illness with a low-grade fever; however, pregnant women who acquire rubella infection are 85 percent more likely to have a miscarriage or stillbirth, and the virus can induce necrosis in the syncytiotrophoblasts allowing it to cross the placental barrier. The neonatal infection can cause severe birth defects with devastating, lifelong consequences such as ocular disorder, auditory problems, cardiovascular defects, speech disorder, and autism.

19Despite the availability of effective anti-HIV therapies, approximately 38 million people are still infected with HIV; among these 53% are women. HIV can be transmitted through the placenta, perinatally (from direct contact to maternal vaginal fluids or blood during delivery), or postnatally (from breast milk or other sources). As a result, congenital HIV transmission remains the leading cause of neonatal infections and the associated neonatal mortality or life-long devastation. Although it is unknown how HIV crosses the placental barrier, neonates born to HIV-infected women are always at a significantly high risk of vertical transmission (25 percent in the absence of antiretroviral therapy), which predispose them to serious health consequences, including developing acquired immunodeficiency syndrome (AIDS) and cardiovascular diseases. Additionally, HIV infection is often associated with opportunistic infections, further increasing the risk of adverse pregnancy outcomes or vertical transmission.

20Zika virus (ZIKV) is an emerging arbovirus that is endemic in Africa, America, Asia, and Europe. ZIKV is primarily transmitted by the bite of an infected mosquito. Though ZIKV infection in adults causes mild symptoms with low-grade fever, headache, rash, infection during pregnancy can cross the placenta and increase the risk of adverse pregnancy outcomes and postnatal developmental sequelae, such as miscarriage or stillbirth, or surviving infants show lifelong neurological defects such as enlarged ventricles, collapsing brains, and microcephaly. Emerging studies indicate that ZIKV can selectively infect decidual fibroblasts and macrophages, trophoblasts, hofbauer cells (fetal macrophages), and umbilical cord and can significantly induce cytokine levels of IL-6, IL-15, IL-17, IFN-α, CXCL10 and IFN-γ at the maternal-fetal interface and in amniotic fluid, which may result in severe fetal neurological abnormalities. Accumulating evidence shows a link between ZIKV infection and congenital microcephaly. ZIKV infection during gestation can trigger endoplasmic reticulum stress in the embryonic brain, which may perturb physiological unfolded protein response in the cerebral cortex and lead to microcephaly in the babies born from mothers infected with ZIKV.

21The most recent COVID-19 pandemic, caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), infected over 308 million subjects, and killed 5.5 million people worldwide, highlighting the importance of focusing on women’s health. SARS-CoV2 is primarily spread through close contact with an infected person, as well as through aerosols and respiratory droplets and can severely impact a variety of physiological and immunological processes, including pregnancy health and outcomes. SARS-CoV-2 binds to host cells through the angiotensin-converting enzyme 2 (ACE2) receptor, which is expressed on the surface of various trophoblasts including, cytotrophoblast and syncytiotrophoblast cells at the maternal-fetal interface. Although the virion genome has been observed in placental and vaginal samples, but the majority of recent reports show no evidence of vertical transmission, suggesting that SARS-CoV2 cannot cross the placental barriers even in severely infected women. Despite the magnitude of the pandemic, pregnant women do not appear to vertically transfer the SARS-CoV2 to the fetus, but the inflammatory storm during SARS-CoV2 infection might indirectly induce pregnancy complications and even fetal developmental obstacles. For example, increasing levels of inflammatory cytokines during infection, such as IL-1, IL-2, IL-7, IL-10, and TNF-α in the maternal blood, at the maternal-fetal interface may lead to adverse pregnancy complications, including maternal mortality, preeclampsia, and preterm birth.

22Despite the fact that emerging knowledge and practices on prevention of mosquito-borne diseases have significantly reduced parasitic infections worldwide, some parasitic infections are still common during pregnancy due to the living conditions or decreased host immunity. Due to reduced maternal immunity during pregnancy, parasitic infections are common among pregnant women living in low resource settings and therefore can influence maternal and fetal health ( Table 1 ).

23Toxoplasmosis is caused by Toxoplasma gondii resulting in more than 200,000 cases of congenital toxoplasmosis worldwide each year. T. gondii can be vertically transmitted during pregnancy to cause toxoplasmosis and can lead to a high risk of congenital diseases. Although, vertical transmission of toxoplasmosis can occur only in 30-40% of patients, but T. gondii infection during pregnancy could lead to an aberrant immune response in blood to control the infection. Immune response toward the T. gondii infected cells leads to aberrant production of IFN-γ, IL-12, IL-17 which can result in miscarriage and stillbirth.

24Malaria parasites, mainly Plasmodium falciparum and Plasmodium vivax, are other pathogens associated with an elevated risk of pregnancy complications, including fetal growth restriction and preterm birth. Malaria parasite-infected erythrocytes during pregnancy can adhere to placental receptors and trigger placental inflammation and subsequent damage, causing harm to both mother and her infant. Emerging evidence suggests that malaria parasite-infected women have significantly higher systemic levels of pro-inflammatory cytokines and chemokines, including TNF-α, IFN-γ, IL-10, which appear to be a key mediators of pregnancy complications. IFN-γ response during pregnancy is a double-edged sword. It plays both protective and pathological roles during malaria infection. IFN-γ response in malaria parasite-infected women is crucial for parasite clearance in both the liver and blood stages, however high levels of IFN-γ may also exacerbate the disease severity, including cerebral malaria and other pregnancy complications such as embryotoxicity or abnormal placenta as shown in Figure 3.

25The vast majority of fungi are harmless, and serious fungal infections are uncommon during pregnancy; however, they may occur with higher frequency in pregnant women, which potentially can increase maternal complications, including prematurity or, in some cases, even fetal loss.

26Candidiasis is the most common cause of infection worldwide and is caused by Candida, an opportunistic yeast. Under normal conditions, most Candida species are commensals or endosymbionts, but some species, such as Candida albicans and Candida parapsilosis, can cause candidiasis. Vaginal candidiasis is the most common gynecological infection during reproductive age and pregnancy. According to emerging studies, up to 40% of women have vaginal colonization with Candida spp. during pregnancy, which can easily transmit to the maternal-fetal barrier and progress to intra-amniotic infection which may lead to severe pregnancy complications including low birth weight or fetal candidiasis.

27Although complications caused by maternal infections or extrinsic abnormalities can occur at any stage of pregnancy, the first trimester is critical for placental development and the formation of a selective barrier between maternal and fetal tissue. The placental barrier, which is made up of multiple layers of maternal and fetal tissues, serves as a strong barrier against human pathogens reaching the fetus. Syncytiotrophoblasts (SYNs) are multinucleated cells that form a strong barrier between maternal and fetal blood within the placenta. Despite the fact that SYNs are highly resistant to bacterial or viral infections and produce type III IFNs, some pathogens can still cross these barriers and reach the fetus ( Figure 2 ). Although the mechanism(s) by which pathogens breach the strong barriers remains unknown, intrauterine infection and associated inflammation are significant contributors to pregnancy complications. Surprisingly, approximately 25% of preterm births are microbially induced, either through intrauterine infection or maternal extrauterine infection.

28According to the findings of recent pathological and advanced metagenomic studies, which have been supplemented by cellular and experimental animal studies, a significant amount of pathogens can bypass the placental barrier integrity and modulate an abnormal immune response at the maternal-fetal interface or in the amniotic fluid. Microbial pathogens commonly associated with periodontal disease or found in the lower genital tract can cross the placental barrier and react to amniotic fluid in women who had preterm labor, possibly via hematogenous dissemination via the transplacental passage or ascending microbial invasion into the amniotic fluid (chorioamnionitis) from the urinary tract. Normally, microbial-induced pregnancy complications are mediated by an aberrant inflammatory process. Many studies have revealed an elevated level of proinflammatory cytokines such as IL-1, IL-6, IL-8, and TNF-α in cervicovaginal lavage or amniotic fluid of women experiencing pregnancy complications. Interestingly, emerging evidence suggests that microbial infection or injection of microbial products such as PAMPs or recombinant inflammatory cytokines in pregnancy mice could lead to adverse pregnancy complications, including preterm birth or even fetal demise. Microorganisms or their ligands such as LPS, CpG, Poly (I:C) are recognized by toll-like receptors (TLRs), to induce the production of chemokines (e.g., IL-8, and C-C motif legend 2 (CCL2), cytokines (e.g., IL-1β, and TNF-α), which act on the prostaglandins and proteases to induce the common pathway of parturition (Figure 3, Table 2). Indeed, murine models revealed that microbial ligands or recombinant cytokines are likely to elicit miscarriage and preterm labor, and can be used as a predictive biomarker of the onset of preterm labor, emphasizing the role of microbial induced inflammation in pregnancy complications. These studies, when taken together, highlighted the role of microbial-induced inflammation in pregnancy complications and congenital disease.

29Although technological advances over the past decade have made significant advances on multiple fronts, including a better understanding of molecular mechanisms, more precise diagnostics, and significantly improved therapeutic outcomes, the increasing incidences of pregnancy-related complications continue to pose daunting challenges in understanding their underlying pathogenesis, host-pathogen interaction at the maternal-fetal interface. As the incidence of maternal infections and associated pregnancy complications rises, a better understanding of the developmental events that result in host-pathogen interaction at the maternal-fetal interface and aberrant immune response is critical for the development of rational intervention strategies. With the help of advanced molecular techniques, the TORCH pathogens and their ability to cross the maternal-fetal barrier to cause congenital fetus disease, which was first proposed decades ago, have now been expanded to include emerging maternal infections and the effects of microbial dysbiosis.

30Despite the progress made, there are still many unanswered and widely debated questions. For example, how the placental barrier remains uncompromised to multiple microbial pathogens that cause maternal systemic illness and bacteremia, such as methicillin-resistant Staphylococcus aureus, E. coli, SARS-CoV2 virus, while other pathogens have mastered a variety of evasion mechanisms leading to serious maternal and fetal complications? Another controversial question is the whether the placenta harbors its own microbiome or not?, and how/when does the priming of the fetal immune system with the maternal microbiome occur?. The intriguing question now is, what levels of proinflammatory cytokines are required systematically or locally at the maternal-fetal interface to modulate placental integrity and allow vertical transmission of pathogens? Finally, how does maternal dysbiotic microbiota influence the maternal-fetal interface or immune response to cause pregnancy complications? While emerging multi-omics have provided us with comprehensive information about the maternal microbiome, their translational impact on women’s health is still far from being achieved and requires more research.

31Future research into the mechanism of host-pathogen interaction at the maternal-fetal interface, as well as how these interactions modulate immune responses and placental integrity, will have broader implications in understanding the mechanism of adverse pregnancy complications, such as miscarriage, preterm birth, and vertical transmission of pathogens. Additionally, it may lead to future therapeutic strategies to improve maternal health and prevent vertical transmission of pathogens. Advanced, cutting-edge statistical models, as well as high-throughput molecular multi-omics techniques, can be used to integrate various datasets for assessing their role in biological processes. It should be noted that numerous specific microbial therapies, such as bacteriophage or narrow-spectrum therapies that kill the specific pathogen without affecting other health microbes, are being developed and proving to be effective. Studies are currently being conducted to determine whether these strategies will be effective for TORCH. Next-generation mRNA vaccines to control different maternal infections are being actively explored. These efforts can ultimately facilitate the design of targeted strategies to engineer the vaginal microbiota to lead to antibiotic-sparing strategies to modulate and restore a robust vaginal micro-environment, which may ultimately improve the reproductive health of women and their children.

32MK, MS and SK Conceptualization, MK and SA. Writing—original draft preparation, MK and SA. Writing—review and editing, MK, MS and SA. All authors have read and agreed to the published version of the manuscript.

33This research was funded by Sidra Medicine, Qatar, grant number SDR400161, and the APC was funded by Research Department, Sidra Medicine, Qatar.

34The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

35All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.