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Our Dermatol Online.  2013; 4(4): 536-544
DOI:.  10.7241/ourd.20134.136
Date of submission:  18.07.2013 / acceptance: 04.10.2013
Conflicts of interest: None
 

SEROEPIDEMIOLOGY OF TOXOPLASMA, RUBELLA, CYTOMEGALOVIRUS AND HERPES SIMPLEX VIRUS -2 IN WOMEN WITH BAD OBSTETRIC HISTORY. PART II. CYTOMEGALOVIRUS AND HERPES SIMPLEX VIRUS INFECTIONS

Abdulghani Mohamed Alsamarai1, Zainab Khalil Mohamed Aljumaili2

1Departments of Medicine, Tikrit University College of Medicine, Tikrit, Iraq
2Departments of Microbiology, Tikrit University College of Medicine, Tikrit, Iraq
 

Corresponding author:  Prof. Abdulghani Mohamed Alsamarai    e-mail: galsamarrai@yahoo.com

How to cite an article: Alsamarai AM, Aljumaili ZKM. Seroepidemiology of Toxoplasma, Rubella, Cytomegalovirus and Herpes Simplex Virus -2 in Women with Bad Obstetric History. PART II. Cytomegalovirus and Herpes Simplex Virus Infections. Our Dermatol Online. 2013; 4(4): 536-544.

 

Abstract
Bad obstetric history (BOH) is reported worldwide and is associated with social and psychological impacts. Cytomegalovirus and herpes simplex virus play an important role in the induction of adverse outcomes of pregnancy. Highest CMV IgG prevalence rate was reported for India (91.05%), while the lowest rate was reported for Iran (14.28%). Unfortunately, six studies in Iraq reported a high prevalence of CMV IgM in non-married, pregnant and women with BOH. The range of recent CMV infection in pregnant women with BOH was from 1.4% in Jordan to 60.2% in Iraq. In women with BOH, the highest HSV 2 prevalence (16.8%) was noted in India, while the lowest rate (1.69%) was reported in India also. In Arab countries, among women with BOH, HSV 2 IgG and IgM seroprevalence higher rates were reported for Iraq. This literature review highlights the high bacterial and viral maternal infection rate in the developing world. Urgent, concerted action is required to reduce the burden of these infections. In addition to raising awareness about the severity of the problem of maternal infections in the developing world, data from this review will be beneficial in guiding public health policy, research interests and donor funding towards achieving improvement in health care delivery.
 
Key words:  TORCH; Toxoplasma; Rubella; CMV; Cytomegalovirus; HSV

 

Cytomegalovirus:
Primary Cytomegalovirus (CMV) infection during pregnancy is a frequent and serious threat to the fetuses of pregnant women [222]. The rate of susceptibility to CMV during pregnancy is also well established in many global countries [223,224]. Eight European countries (France, Belgium, Spain, Italy, Germany, Austria, Portugal, and the Netherlands) routinely screen the majority of pregnant women serologically for CMV [225,226]. This routine serologic screening occurs without the recommendations or guidelines of any governmental agency, authority, or a professional medical society. In Iraq, such screening program is not followed routinely and pregnant women screening order depends on personal interest of the clinicians. Routine serologic screening for CMV of pregnant women in Europe has yielded very important advances in our understanding of CMV infections among pregnant women [227-230]. The major risk factor for maternal acquisition of CMV during pregnancy is frequent and prolonged contact with a child less than three years of age [231-235]. This occurs among women with a child in the home or among women employed in child care centers or schools [236-241]. Another group of high-risk women are those who are seronegative, young, and poor. Even for this group, contact with a young child is an independent predictor of delivering a CMV congenitally infected infant, as is a history of frequent sexual activity [235]. A recent study suggested that C MV is likely transmitted not only via the oral mucosal route, but also via the vaginal mucosal route [231].
 
Characteristics and results of studies reporting prevalence of maternal
CMV infection
Forty studies [1,3,36,86,89-93,95,96,167,170,171,182,204, 208,210,242-263] on maternal cytomegalovirus infection prevalence were identified (Tabl. V). The median prevalence of maternal IgG to CMV (calculated from 28 studies that reported this) was 92%, indicating a high proportion of mothers with previous exposure to CMV. Two hospital-based study in India (29.5%) [36] and Iran (28.58%) [262] identified a statistically significant higher prevalence of CMV IgM (indicating active or recent infection) in mothers with Bad Obstetric History (BOH), highlighting a role for maternal CMV infection in adverse pregnancy outcome in this setting. The highest prevalence of IgG in pregnant women was in Turkey [95] (98.9%, 1103 childbearing age women), while the lowest prevalence reported for Ireland [253] (30.4%, 1047 pregnant women). However, in women with BOH, the highest IgG prevalence rate was reported for India [3] (91.05%, 380 BOH), while the lowest rate was reported for Iran [262] (14.28%, 42 Aborted women). Active or recent infection high prevalence rate in pregnant women was reported for Poland [252] (13%, 1332 Pregnant women), while the lowest rate was reported for Turkey [204] (0%, 249 Pregnant women). In women with BOH the highest prevalence rate of IgM was reported for India [36] and the lowest one was reported for India [91]. In Arab countries, twenty- two studies [35,99-101,108,117- 119,129-131,139,147,216,221,264-269] on maternal CMV infection prevalence were identified (Tabl. VI). The median prevalence of maternal IgG to CMV was 77.8% indicating lower proportion of mothers with previous exposure to CMV as compared to global studies. Unfortunately, six studies in Iraq [100,101,117,129,264,266] reported a high prevalence of CMV IgM in non-married, pregnant and women with BOH. The range of active or recent CMV infection in pregnant women was from 2.3% in Jordan [269] to 57.2% in Iraq [129], while the range in women with BOH was from 1.4% in Jordan [269] to 60.2% in Iraq [100]. In pregnant women, maternal IgG to CMV prevalence higher rate was reported in Jordan [269] (88%, 260 pregnant women), while the lowest one was reported for Iraq [129] (77.8%, 180 pregnant women). In addition, in women with BOH, maternal IgG to CMV prevalence higher rate was reported for Jordan [269] (95%, 898 Aborted women), and the lowest one was reported in Iraq [99] (4.8%, 119 Aborted women).
 
Article Location, setting of study Type, duration of study Population Results
Tabatabaee et al, [242] Iran, hospital Cross-sectional, 7 months 1472 pregnant women 97.68% seropositive,
prevalence of active
infection 4.35%.
Das et al, 2007 [170] India, hospital Cross sectional study 1115 BOH 11% prevalence in BOH,
4% prevalence in normal
pregnant women
Ocak et al, [171] Turkey, hospital Retrospective observational study,
2 years		 1652 pregnant women 94.9%seropositivity for
anti-CMV IgG, 0.4%positive
for anti-CMV IgM
Picone et al, [243] France, Hospital Cross sectional study prospective,
2 years		 4287 pregnant women 46.8% IgG
Tamer et al, [167] Turkey, antenatal Clinics Cross sectional study, 1972 Pregnant women 97.1% IgG, 2.6% IgM
Surpam et al [86] India, Antenatal clinic Case control, 150 BOH 5.33% IgM
Uyar Y et al [182] Turkey, Hospital Case control, 1 year 600 Pregnant women 97.3% IgG, 1% IgM
Karabulut A et al [89] Turkey, Antenatal clinic Case control, 1 year 1000 Pregnant women 98.7% IgG, 1.2% IgM
Kumari N et al [1] Nepal, Hospital Case control, 4 months 12 BOH 8.3% seropositive
Nabi SN et al [90] Bangladesh, Hospital Case control, 10 months 111 Pregnant women 95.49% IgG, 0.9% IgM
Baschale MD [244] Italy, Hospital Cross sectional, 2 years 2385 Pregnant women 92% IgG, 0.4% IgM
Sadik MS et al [91] India, Hospital Case control, 2 years 86 BOH 23.25% IgG, 0% IgM
Chopra S et al [36] India, Antenatal clinic Case control, 1 year 200 BOH 29.5% IgM
Koksaldi-Motor et al [95] Turkey, Hospital Cross sectional, 1 year 1103 women childbearing
age		 98.9% IgG
Ozdemir M et al [204] Turkey, Hospital Cross sectional, 6 months 249 Pregnant women 98.7% IgG, 0% IgM
Frischknecht F et al [92] Switzerland, Hospital Cross sectional, 1 yr 723 Pregnant women in labor 4.7% seropositive
Vilibik-Cavlek T, et al
[96]		 Croatia, Hospital Cross sectional, 5 years Pregnant & non pregnant
women		 75.3% IgG, 0.09% IgM
Sarawathy TS, et al [245] Malaysia, Antenatal clinic Cross sectional, 2 years 125 Pregnant women 84% IgG, 7.2% IgM
Akinbami AA, et al [246] Nigeria, Hospital Cross sectional, 2 months 179 Pregnant women 97.2% IgG,
Bagheri L, et al [247] Iran, Hospital Cross sectional, 3 months 240 Pregnant women 69.6% IgG, 2.5% IgM
Arabpour M, et al [248] Iran, Hospital Cross sectional, 5 years 844 childbearing age women 93% IgG, 5.4% IgM
Canon MJ, et al [249]
 Global, Review
 Review
   45 – 100% seroprevalence
Ahmad RM, et al [250]
 Nigeria, Hospital
 Cross sectional,
 90 Pregnant women
 97.8% IgG
Seo S, et al [251]
 Korea, Hospital
 Cross sectional, 2 months
 744 Pregnant women
 98.1% IgG, 1.7% IgM
Gaj Z, et al , [252]
 Poland, Hospital
 Cross sectional, 11 years
 1332 Pregnant women
 76.7% IgG, 13% IgM
Knowles SJ, et al [253]
 Ireland, Hospital
 Cross sectional, 1 year
 1047 Pregnant women
IgG 30.4% in Irish & 89.7%
in non- Irish women [Africa, Asia,
E. Europe]
Yamamoto AY, et al [254]
 Brazil, Hospital
 Cross sectional
 985 Pregnant women
 97% seroprevalence
Odland JO, et al [208]
 Russia, Hospital
 Case control, 4 months
 182 Pregnant & 127 Aborted
women
 78% versus 81.1%
seroprevalence
Chen MH, et al [255]
 Taiwan, Hospital
 Cross sectional, 10 months
 483 Pregnant mother
 91.1% IgG, 3.5% IgM
Gumber S et al [256]
 India, Hospital
 Cross sectional, 17 months
 150 BOH
 4.67% IgM
Dollard SC, et al [257]
 USA, Hospital
 Cross sectional,
 6067 Women 12-49 yrs
 58% IgG, 3% IgM
Enders G, et al [258]
 Germany, Hospital
 Retrospective, 15 years
 40 324 Pregnant women
 42.3% IgG
Correa CB, et al [259]
 Cuba, Hospital
 Cross sectional, 1 year
 1131 Pregnant women
 92.6% seropositive, 2.4%
active infection
Rajaii & Pourhasan [260]
 Azerbaijan, University
Lab.
 Cross sectional, 4 years
 2049 Women 20-35 yrs [of
them 75 Pregnant]
 88.53% IgG, 8.29% IgM, In
Pregnant 66.7%seropositive
Turbadkar D, et al [3]
 India, Antenatal clinic
 Case control, 1 year
 380 BOH
 91.05% IgG, 8.42% IgM
Ashrafunnessa et al [261]
 Bangladesh, Hospital
 Case control, 11 months
 420 Pregnant women
 68.6% IgG, 5% IgM
Inagaki ADM, et al [93]
 Brazil, Antenatal clinic
 Cross sectional, 1 year
 9559 Pregnant women
 76.6% IgG, 0.2% IgM
Falahi S, et al [262]
 Iran, Hospital
 Case control
 42 BOH
 14.28% IgG, 28.58% IgM
Ebadi p, et al [210]
 Iran, Hospital
 Case control, 3 years
 120 BOH
 78.33% seropositive
Oruc AS, et al [263]
 Turkey, Hospital
 Cross sectional,5 years
 11 360 Pregnant women
 98.5% IgG, 0.3% IgM

                  Table V. Characteristics and results of studies reporting prevalence of maternal CMV infection.

Article
 Location, setting of study
 Type, duration of study
 Population
 Results
Hammouda et al [108]
 Egypt, Hospital
 Case control
 100 BOH
 51% Seroprevalence
Abdulmohaymen N [99]
 Iraq, Baghdad, Hospital
 Case control, 9 months
 119 Aborted women
 17.7% IgM recurrent
spontaneous abortion
14.7% IgM non recurrent
spontaneous abortion.
4.8% IgG recurrent
spontaneous abortion
0% IgG non recurrent
spontaneous abortion
Jasim et al [100]
 Iraq, Waset, Hospital
 Case control, 1 year
 162 Aborted women
 55.5% IgG, 60.2% IgM
Al- Taie et al [101]
 Iraq, Mosul, Private
laboratory
 Case control, 1 year
 100 BOH
 24% IgM
Almishhadani & Aljanabi [119]
 Iraq, Al- Anbar, Medical
Laboratory
 Case control study, 3 years
 230 Aborted women
 90.4% IgG, 6.1% IgM
Majeed AK [117]
 Iraq, Baghdad,
 Case control, 3 years
 135 Aborted women
 20.7% IgG45.9% IgM
Alsaeed et al [118]
 Iraq, Al-Hila, Hospital
 Case control, 6 months
 120 Aborted women
 79.5% IgG, 18.8% IgM
Hadi NJ [130]
 Iraq, Thi Qar, Hospital
 Case control
 190 Aborted women
 16.84% IgG, 9.47% IgM
Salman YG [131]
 Iraq, Kirkuk, Hospital
 Case control, 11 months
 84 BOH
 8.02% Seropositive, 7.89%
IgM
Al- Azzawi RHM, [264]
 Iraq, Baghdad, Hospital
 Cross sectional, 8 months
 161 Non married women
15-35 yrs
 67.1% IgG, 41% IgM
Khalf MS, et al [265]
 Iraq, Baghdad, Hospital
 Case control, 17 months
 108 BOH
 15.7% IgM
Hannachi N, et al [221]
 Tunisia, Hospital
 Cross sectional,
 404 Pregnant women
 96.3% seroprevalence
Al- Hindi A, et al [139]
 Palestine, IVF centre
 Retrospective, 6 years
 1954 Women with infertility
or abortion
 6% IgM
Al- Shimmery MN [266]
 Iraq, Diwanya, Hospital
 Case control, 5 months
 125 Aborted women
 49.6% IgG, 22.4% IgM
Al-Khafaji & Al-Zabaidi [38]
 Iraq, Thi Qar, Hospital
 Case control, 10 months
 60 aborted women
 85% IgG, 65% IgM
Kafi SK, et al [267]
 Sudan, Hospital
 Cross sectional, 2 months
 100 Pregnant women
 95% IgG
Hamdan HZ, et al [216]
 Sudan, Hospital
 Cross sectional, 2 months
 231 Pregnant women
 72.2% IgG, 2.5% IgM
Ghazi HO, et al [147]
 Saudi Arabia, Hospital
 Cross sectional
 926 Pregnant women
 92.1% IgG
Al-Marzoqi AHM, et al [129]
 Iraq, Babylon, Hospital
 Cross sectional, 6 months
 180 Pregnant women
 77.8% IgG, 57.2% IgM
Abu- Madi MA, et al [35]
 Qatar, Hospital
 Cross sectional, 3 years
 847 Women > 20 yr age
 96.8% IgG, 2.7% IgM
Barah F [268]
 Syria, University Laboratory
 Cross sectional, 15 months
 316 Female university
students
 74.5% seropositive
Daboui & Al-Zaben [269]
 Jordan, Medical centre
 Case control, 2 months
 260 Pregnant, 100 Unmarried
women, 898 Aborted women
 IgM- 2.3% pregnant, 1%
unmarried, 1.4% Abortion.
IgG- 88% pregnant, 79%
unmarried, 95% abortion

                  Table VI. Characteristics and results of studies in Arab countries reporting prevalence of maternal CMV infection.

 
Herpes simplex virus
Herpes simplex virus (HSV) is an ubiquitous, enveloped, and double stranded DNA virus, belonging to the family of Herpesviridae transmitted across mucosal membranes and non-intact skin, that migrate to nerve tissues, where they persist in a latent state [270]. HSV-1 predominates in oro-facial lesions, and it is typically found in the trigeminal ganglia, whereas HSV- 2 is most commonly found in the lumbo-sacral ganglia [271]. Nevertheless these viruses can infect both oro-facial areas and the genital tract. In some developed countries type 1 has recently emerged as the prominent causative agent in genital lesions [272]. Changes in sexual behaviours of young adults may partly explain its higher incidence [273,274]. Herpes simplex virus (HSV) infections are caused by two strains, HSV-1 and HSV-2. Oro-labial infection is mainly caused by HSV-1, however, this strain is responsible for up to 53% of primary genital herpetic infection [270]. HSV-2 genital infection is much more likely to recur than genital HSV-1 infection, thus the presence of antibody to HSV-2 and a compatible clinical history would be strong presumptive evidence that the disease is recurrent genital herpes [275-277]. In addition to agent factor, genetic may play a role in susceptibility to HSV infection [278]. Primary genital HSV-1 or HSV-2 infection in pregnant women can result in abortion, premature labor and congenital and neonatal herpes [279-281]. HSV-2 infections in the newborn are particularly severe and frequently involve the CNS [282]. Recent changes in HSV-1 and HSV-2 infection epidemiology have been reported, with type incidence changes and sequential genital infections with HSV-1 and HSV-2 [272,283]. Little is known about the risk factors associated with HSV seropositivity in pregnant Iraqi women. Identification of the risk factors may help to improve the control measures of HSV infection. Although there is improve in the diagnosis and treatment of TORCH infections, it still represents a problem in developing countries. Clinical diagnosis of TORCH is difficult, since most of the maternal infections with adverse outcomes are initially asymptomatic. Routine TORCH complex screening during pregnancy is not recommended in Iraq and the extent to which it is performed is unknown. A first primary infection develops when a susceptible person (lacking of preexisting HSV-1 and HSV-2 antibodies) is exposed to HSV. Indeed, a first non-primary episode occurs when a person with preexisting HSV antibodies (against type 1 or 2) experiences a first episode with the opposite HSV type. Recurrent infection occurs in a person with preexisting antibodies against the same HSV type [271]. Infections during pregnancy may be transmitted to newborns: HSV-1 and HSV-2 may cause eye or skin lesions, meningo-encephalitis, disseminated infections, or foetal malformations. In recent years, genital herpes has become an increasing common sexually transmitted infection. From the late 1970s, HSV-2 seroprevalence has increased by 30%, resulting that one out of five adults is infected [284,285]. HSV seroprevalence in patients with STD varies from 17% to 40% (6% in the general population and 14% in pregnant women) [286,287]. Age and sex are important risk factors associated with the acquisition of genital HSV-2 infection. In fact, the prevalence of HSV infection rises with age, reaching the maximum around 40 years [284]. This infection appears related to the number of sexual partners, and regarding sex it is more frequent in women than in men [288,289]. In addition, ethnicity, poverty, cocaine abuse, earlier onset of sexual activity, sexual behavior, and bacterial vaginosis can facilitate a woman’s risk of infection before pregnancy [290,291]. Regarding pregnant population, there is a high prevalence of genital herpes, however, it is varies from country to others, depending on social and sexual behaviors and activity [289,292-294]. The risk of neonatal infection varies from 30% to 50% for HSV infections that onset in late pregnancy (last trimester), whereas early pregnancy infection carries a risk of about 1% [295-297]. Thirty-one studies [1,3,90,91,96,204,256,298-320] outlining the prevalence of maternal Herpes simplex virus 2 (HSV-2) were identified (Tabl. VII). These studies detected the presence of antibodies to HSV as a marker of maternal infection. Median prevalence of IgG HSV-2 was 18.2% which was reported for Belgium [315,357]. In pregnant women, higher seroprevalences were noted in Germany (82%), Turkey (63.1%), Zimbabwe (51.1%), and Iran (43.75%) [298,299,309,313]. However, the lowest seroprevalences were reported in two studies in Turkey [204,314], which reported a rates of 4.4% and 5%. In women with BOH, the highest prevalence (33.58%) was reported in India [3], while the lowest one (18.6%) was reported in India also [91]. Concerning IgM, the highest prevalence in pregnant women was reported in Turkey (13.8%, 130 pregnant women) [298], while the lowest rate was reported in Turkey (0%, 249 pregnant women) also [204]. In women with BOH, the highest prevalence (16.8%, 450 BOH) was noted in India [320], while the lowest rate (1.69%, 86 BOH) was reported in India also [91]. In Arab countries, nine studies [35,99-101,129,147,268,319,320] outlining the prevalence of maternal HSV-2 were identified (Table VIII). The median IgG seroprevalence was 27.1%, which was noted in Saudi Arabia [147]. A higher (27.1%, 926 pregnant women) IgG maternal seroprevalence in pregnant women was reported in Saudi Arabia [147], while the lower rate (6.5%, 459 pregnant women) was noted in Saudi Arabia also [319]. In women with BOH IgG seroprevalence was 60.6%, which was reported in Iraq [100]. Concerning IgM, the highest prevalence’s were reported in Iraq [100,129] for both pregnant women (28.9%, 180 pregnant women) and those with BOH (73.9%, 62 BOH).

Article Location, setting of study Type, duration of study Population Results
Kurewa et al, [299] Zimbabwe, peri-urban clinics Cross sectional, 19 months 691 Pregnant women
 51.10% IgG
Yahya-Malima et al, [300] Tanzania,antenatal clinics (6) Cross sectional, 1296 Pregnant women
 20.7% prevalence of genital herpes
Chen et al, [301] China, antenatal clinic Cross sectional, 3 months 502 pregnant women
 10.8% seroprevalence
Haddow et al, [302] Australia, antenatal clinic Cross sectional, 2 years 535 pregnant women
 30% seroprevalence
Joesoef et al, [303] Indonesia, prenatal clinic Cross sectional, 15 months 599 pregnant women
 9.9% seroprevalence
Surpam et al [86] India, Antenatal clinic Case control, 150 BOH
 8.66% IgM
Kumari N et al [1] Nepal, Hospital Case control, 4 months 12 BOH
 33.3% Seropositive
Nabi SN et al [90] Bangladesh, Hospital Case control, 10 months 111 Pregnant women
 9.91% IgG, 1.8% IgM
Sadik MS et al [91] India, Hospital Case control, 2 years 86 BOH
 18.6% IgG, 1.69% IgM
Ozdemir M et al [204] Turkey, Hospital Cross sectional, 6 months 249 Pregnant women
 4.4% IgG, 0% IgM
Xu F et al [304] USA, Hospital Cross sectional, 4 years 626 Pregnant women
 22% seroprevalence
Kucera P et al [305] Switzerland, Hospital Cross sectional, 1030 Pregnant women
 21.2% seroprevalence
Patrick MD et al [306] Canada, antenatal clinic Cross sectional, 1 year 1215 Pregnant women
 17.3 % seroprevalence
Munjoma MW et al [307] Zimbabwe, Antenatal clinic Cross sectional, 6 months 354 Pregnant women
 49.1% seroprevalence
Diawara S et al [308] Senegal, Antenatal clinic Cross sectional, 6 months 260 Pregnant women
 22% seropositivity
Sauerbri A et al [309] Germany, Hospital Cross sectional, 8 years 200 Pregnant women
 82% IgG
Ades AE et al [310] UK, Hospital Cross sectional, 2 years 3533 Pregnant women
 10.4% IgG
Rathore S et al [311] Kashmir, Antenatal clinic Cross sectional, 2 year 200 Pregnant women
 7.5% IgG
Duran N [298] Turkey, Hospital Cross sectional, 21 months 130 Pregnant women
 63.1 % IgG, 13.8% IgM
Biswas D et al [312] India, Hospital Cross sectional, 2 years 1640 Pregnant women
 8.7% HSV-2 IgG
Shahraki AD et al [313] Iran, Hospital Cross sectional, 96 Pregnant women
 43.75% HSV-2 IgG
Dolar N et al [314] Turkey, Hospital Cross sectional, 300 Pregnant women
 5% HSV-2 IgG
Bodeus M, et al [315] Belgium, Hospital Cross sectional, 1000 Pregnant women
 18.2% HSV-2 IgG
Chen XS et al [301] China, Hospital Cross sectional, 3 months 504 Pregnant women
 10.8% seroprevalence
Sasadeusz JJ et al [316] Australia, Antenatal clinic Cross sectional, 1371 Pregnant women
 13.6% seroprevalence
Vilibik-Cavlek T, et al [96] Croatia, Hospital Cross sectional, 5 years Pregnant & non pregnant
women
 6.8% IgG, 1.2% IgM
Straface G et al [317] Italy, Review Retrospective  
7.6 – 8.4% seroprevalence Italy
22% seroprevalence USA
Kim D et al [318] Korea, Hospital Retrospective, 19 months 500 Pregnant women
 17% HSV-2 seroprevalence
Gumber S et al [256] India, Hospital Cross sectional, 17 months 150 BOH
 3.33% IgM
Turbadkar D, et al [3] India, Antenatal clinic Case control, 1 year 380 BOH
 33.58% IgG, 3.6% IgM
Li et al [319] China, Hospital Cross sectional, 1740 Pregnant women
 23.56% seroprevalence
Haider M, et al [320] India, Hospital Case control 450 BOH
 16.8% IgM

                  Table VII. Characteristics and results of studies reporting prevalence of maternal HSV-2 infection.

Article
 Location, setting of study
 Type, duration of study
 Population
 Results
Abdulmohaymen N [99]
 Iraq, Baghdad, Hospital
 Case control, 9 months
 119 Women with history of
abortion
 8.1% IgM recurrent
spontaneous abortion
17.4% IgM non recurrent
spontaneous abortion.
Jasim et al [100]
 Iraq, Waset, Hospital
 Case control, 1 year
 162 Women with
spontaneous abortion
 60..6% IgG, 73.9% IgM
Al- Taie et al [101]
 Iraq, Mosul, Private laboratory
 Case control, 1 year
 100 BOH
 11% IgM
Alzahrani et al [319]
 Saudi Arabia, Hospital
 Cross sectional,
 459 Pregnant women
 6.5% IgG, 0.5% IgM
Obeid EO [320]
 Saudi Arabia, Hospital
 Cross sectional, 2 years
 459 Pregnant women
 6.8% IgG
Barah F [317]
 Syria, University Laboratory
 Cross sectional, 15 months
 316 Female university
students
 52% seropositive
Ghazi HO, et al [192]
 Saudi Arabia, Hospital
 Cross sectional
 926 Pregnant women
 27.1% IgG
Al-Marzoqi AHM, et al [174]
 Iraq, Babylon, Hospital
 Cross sectional, 6 months
 180 Pregnant women
 22.2% IgG, 28.9% IgM
Abu- Madi MA, et al [87]
 Qatar, Hospital
 Cross sectional, 3 years
 847 Women > 20 yr age
 26.3% IgG, 7.6% IgM

                  Table VIII. Characteristics and results of studies in Arab countries reporting prevalence of maternal HSV-2 infection

 
Gaps in existing knowledge
In the process of reviewing the subject, we identified several facility-based retrospective studies reporting causes of maternal mortality. Many of these studies attributed a proportion of deaths to infection or sepsis, but were unable to provide microbiological or serological evidence of the specific underlying mortality causes. Our review confirms the suspected high prevalence of parasitic and viral maternal infections in the developing world, as demonstrated by the median prevalence rates calculated for each pathogen studied. Of particular concern are the aetiology of infection. The literature review highlights a gap in existing knowledge on the epidemiology and impact of maternal infection, especially on the aetiology of infectious agents that lead to puerperal sepsis and subsequent mortality. Increased surveillance and diagnostic capabilities in healthcare facilities and in the community is needed to identify the aetiological agents responsible for puerperal sepsis and maternal mortality. The prevalence of maternal infection reported by the studies identified in this literature review may be an underestimate of actual rates of infection as not all pregnant women in developing countries may have access to or choose to access formalized antenatal care. This could be due to financial constraints, difficulties in accessing these facilities and personal or cultural beliefs. In addition, antenatal care services may not have the capacity to routinely screen for maternal infections, especially those that are asymptomatic and those that require serological tests such as PCR and ELISA to diagnose, due to limited resources or expertise. These infrastructural problems are essential contributors to the persistence of high maternal morbidity and mortality in developing countries and need to be overcome in order to accurately characterize the burden of maternal infections in these countries.
 
Conclusion
This literature review highlights the high bacterial and viral maternal infection rates in the developing world. Urgent, concerted action is required to reduce the burden of these infections. In addition to raising awareness about the severity of the problem of maternal infections in the developing world, data from this review will be beneficial in guiding public health policy, research interests and donor funding towards achieving improvement in health care delivery.
 
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