종 설 박채연 조현진. 주산기주요감염질환의예방및관리한국모자보건학회지제24권제3호 (2020년 7월 ) J Korean Soc Matern Child Health 2020;24(3):133-143 DOI: https://doi.org/10.21896/jksmch.2020.24.3.133 pissn 1226-4652ㆍeISSN 2384-440X 주산기주요감염질환의예방및관리 박채연 조현진 인제대학교의과대학교산부인과학교실 Prevention and Management of Perinatal Major Infectious Diseases Che Yon Park Hyunjin Cho Department of Obstetrics and Gynecology, University of Inje College of Medicine, Busan, Korea <ABSTRACT> Perinatal infection is the leading cause of fetal and neonatal mortality and is directly related to childhood morbidity. Perinatal infections cause abnormal growth, delayed development, and many other clinical problems in newborns. In particular, TORCH syndrome can cause serious fetal and neonatal health problems through vertical infection, and timely diagnosis and treatment through regular antenatal examinations are important. There are no therapeutic options or vaccines for parvovirus or cytomegalovirus. Therefore, prevention is the most important method. In the case of toxoplasmosis, prenatal education is important because it can be prevented through hygiene management, although there are therapeutic drugs. Syphilis has a high preva lence, so early diagnosis is important. Rubella and varicella zoster infections can lead to fatal results in vertical transmission to the fetus. Therefore, preconception vaccination should be performed. Women with herpes simplex, which has a high prevalence in the community, need to be mindful when choosing a childbirth method by evaluating the infection through regular prenatal care to prevent vertical infection. Seasonal flu is rarely transmitted vertically to the fetus, but the morbidity and mortality risk to the mother is higher than that of the general population. Thus, prevention through vaccination is important. Lastly, coronavirus disease 2019 (COVID-19) infection has yet to be well studied, although the mother's mor bidity and mortality are similar to those of the general population and there is no evidence of vertical in fection. Since the findings of the effects on the mother and fetus are limited, transmission should be pre vented through social distancing and personal hygiene practices. Key Words: Perinatal infectious disease, TORCH infection, Seasonal flu, Pregnancy, COVID-19 서 론 Corresponding Author: Hyun Jin Cho Department of Obstetrics and Gynecology, University of Inje College of Medicine, Haeundae Paik Hospital, Haeundae-ro 875, Haeundae-gu, Busan, Korea Tel: +82-51-797-2020, Fax: +82-51-797-2030 E-mail: lory1202@naver.com ORCID: https://orcid.org/0000-0003-1945-7169 Received: June 12, 2020, Revised: July 3, 2020 Accepted: July 8, 2020 Copyrightc2020 by The Korean Society of Maternal and Child Health 산전혹은주산기감염은태아, 신생아사망의주된원인이자아동기전반의건강과직결되어있으며주산기감염은신생아의비정상적인성장, 발달지연및기타여러임상적문제들을유발한다 (Neu et al., 2015). 이연구는여러주산기감염질환중그중심각한후유증을남길수있는주된감염질환에대하여문헌고찰을통해예방및관리법을제시하여임상진료및모자보건향상에도움이되는것을목적으로시행되었다. 대상감염질환은현재기본산전진찰검사에포함되어 https://doi.org/10.21896/jksmch.2020.24.3.133 133
Park CY Cho HJ. Prevention and Management of Perinatal Major Infectious Diseases 있는 TORCH (toxoplasmosis, other [syphilis, parvovirus-], rubella, cytomegalovirus, herpes virus) 감염질환을포함하여지역사회유병률이높은계절성독감, 감염률이높고특히 1세미만영아발병률, 사망률이높은백일해 (Masseria et al., 2017), 최근세계적으로유행하는 COVID-19 감염을선정하였으며각감염성질병의임상적특징, 진단, 예방및관리법에대해논하고자한다. 본론 1. Toxoplasmosis ( 톡소플라스마증 ) 1) 개요 Toxoplasma gondii는조류와사람등포유류에감염을일으키는세포내기생충이다. 고양이를비롯한고양이과의동물이완전숙주로장상피내에서생식을하여충란을분변으로배출한다. 사람은감염된생고기나감염된산양의우유를섭취하거나우연히고양이분변이손이나음식에묻었을때섭취하게되어감염이될수있다. 임산부가감염이된경우태반을통해태아로감염이전달될수있다. 2) 임상적특징건강한사람은피로, 근육통, 림프선종등이발생할수있으나대부분무증상이다. 태아의선천성감염은자궁내사망, 유산, 뇌석회화, 뇌수종, 맥락망막염, 뇌수종, 신경학적손상및간비종대, 황달등을유발할수있다. 감염의위험은임신후반기로갈수록증가하지만증상은임신전반기에감염된경우더욱심각하다. (1) 모체감염임상적으로증상이의심되는경우혈청학적진단검사를시행하도록한다 (Maldonado et al., 2017). Toxoplasma gondii 감염후 1주내에특이 IgM 항체가급증하게되며수개월에걸쳐소실된다. 특이 IgG 항체는감염 2주후부터증가하기시작하며지속적으로혈청에존재하게된다. 효소면역측정법 (enzyme-linked immunosorbent assay) 으로 IgM, IgG 항체를검출할수있으며민감도는 93% 100 %, 특이도는 78% 99% 에달한다. 임신전에 IgM 음성, IgG 양성이었다면임신중태아감염의위험성은없다. IgM 항체는감염초기에양성을보이지만 1년이상지속할수있으므로해석에주의가필요하다. IgG 항체접착력검사는항원항체의결합강도를측정하는것으로감염기간동안증가하여감염 3개월이지나면가장높은결합도를보인다. 즉 IgG 접착강도가증가되어있으면급성감염을배제할수있다 (Vera et al., 2020). (2) 태아감염태아의감염을시사하는산전초음파소견은두개강내석회화, 고음영병변, 뇌실및뇌실질확장증등있으며이와같은이상소견이있을때태아감염에대한평가를하도록한다 (Maldonado et al., 2017). 양수를이용한중합효소연쇄반응검사법 (polymerase chain reaction, PCR) 으로감염이의심되는시점에서 4주후에검사로도출이가능하다. 위양성률 0%, 양성예측률 100% 로진단이된경우 100% 감염을의미하지만민감도가 64% 로낮아중합효소연쇄반응검사법 (PCR) 검사상음성이선천성감염이아님을의미하는것은아니다 (De Oliveira Azevedo et al., 2016). 산모의감염이진단적방법으로확인되었지만추적초음파검사에서이상소견이없다면태아로의감염이행여부에따라치료방법이달라질수있어매달추적검사가필요하다. 4) 예방및치료예방법은노출원으로부터의차단이일차적이다. 노출원으로는오염된식수, 동물의분변의오염의가능성이있는흙, 육류, 조개류등이있으며오염의가능성이있는채소는세척뒤섭취하여야한다. 원충의발육단계중사람에서감염전달원은빠른분열소체 (tachyzoites), 느린분열소체 (bradyzoites) 로섭씨 66 이상가열혹은섭씨영하 12 이하로 24시간이상냉각시파괴됨으로음식조리시가열혹은냉동보관후섭취하도록한다. 진단시태아의선천적감염의위험을감소시키기위해산모의증상유무와관계없이치료를시행한다. 18주이상의산모의경우 pyrimethamine-sulfadiazine과엽산을투여한다 (Mandelbrot et al., 2018). 18주미만의산모에서는태아기형을유발할수있어 spiramycin을양수검사중합효소연쇄반응검사법 (PCR) 음성이나올때까지투약한다. 18 주이상에서도감염이지속되면 toxoplasmosis에더효과적인 pyrimethamine-sulfadia zine으로바꾸어투약한다 (Montoya et al., 2008). 134 https://doi.org/10.21896/jksmch.2020.24.3.133
박채연 조현진. 주산기주요감염질환의예방및관리 2. Syphilis ( 매독 ) 1) 개요 Treponema pallidum에의해감염되는성매개질환이다. 치료를하지않으면 1기매독 ( 세균의침범부위에발생하는무통성궤양 ), 2기매독 ( 피부발진, 점막의병적인변화 ), 잠복매독, 3기혹은후발매독 ( 다양한내부장기침범. 눈, 심장, 대혈관, 뼈, 관절 ), 신경매독 ( 뇌막자극, 뇌혈관침범 ) 으로진행한다. 2) 임상적특징산모감염인경우임신주수와상관없이모든시기의매독이태반을통한태아감염을일으킬수있다. 재태주수 9 10주경부터태반을통해수직감염이가능하며감염에대한태아의면역반응으로태아기형이나타남으로면역계가어느정도형성되는재태주수 20주후부터증상이나타나기시작한다. 사산, 태아수종, 조산, 간비대, 빈혈등의합병증이나타날수있다 (Rac et al., 2017). (1) 모체감염매독의진단을위한검사방법으로는균을직접관찰하는검사방법과혈청검사법이있다. 혈청검사는선별검사와매독균에특이적인확진검사가있다. 매독의선별검사로는비매독균검사인 VDRL (venereal disease research laboratory) 검사와 RPR (rapid plasma reagin) 검사가있다. 이검사들은결과를빨리알수있는장점이있다. 그러나실제로는매독이아니지만검사결과가양성으로나오는위양성 (false positive) 이나타나는경우가많다. 여러가지바이러스감염증이나임파종, 결핵, 결체조직질환, 임신등의경우에서위양성결과가나타날수있다. 따라서선별검사에양성이나온경우에는매독균에대한특이적검사인 FTA-ABS (fluorescent treponemal antibody absorption) 검사나 TPHA (treponema pallidum Hemagglutination assay) 검사로확인을해야한다. (2) 태아감염모체매독이진단되었으나치료받지않거나적절하게치료받지않은경우재태주수 20주이후에정기적인초음파검사를시행하여이상소견이있는경우양수혹은태아혈액을채취하여모체와동일한검사방식을사용하여진 단할수있으나태아진단의여부에따라치료방법이달라지는것이아니며검사자체의위험성이높으므로권고되지않는다 (Hollier et al., 2001). 초음파적이상소견으로는전형적인증상은없으나간비대, 태반비대, 태아빈혈로인한중뇌동맥의수축기혈류속도증가, 복수, 수종등이있다 (Rac et al., 2017 ). 4) 예방및치료임신초기및 3삼분기산전진찰시진단검사를시행하도록한다. 벤질페니실린투여로효과적으로산모의감염증및태아감염증치료를할수있으며태아로의감염을막을수있다. 2기, 초기잠복매독의경우벤질페니실린 240 만단위 1회투여하며후기잠복, 3기매독은벤질페니실린 240만단위를 1주간격으로 3회연속투여한다. 이전잠복매독의감염이의심되는무증상산모의경우후기잠복매독과동일하게치료한다. 벤질페니실린알레르기가있는경우탈감작치료를한후치료하도록한다. 매독의 2차치료제로 tetracycline, ceftriaxone, erythromycin, azithromycin이있으며 tetracycline은기형유발가능성으로사용할수없으며 ceftriazone은효용성이입증되지않았고 erythromycin, azithromycin은태반장벽을통과할수없어태아치료에효과적이지않다는한계점으로산모감염에는사용되지않는다 (Wendel et al., 2002). 3. Parvovirus ( 파르보바이러스 ) 1) 개요 Parvovirus B 19는단일나선 DNA 바이러스로호흡기비말을매개로사람에게감염을일으킨다 2) 임상적특징일반적으로증상이없거나발열, 홍반성발진, 관절통이 7 10일간지속된후에저절로호전된다. 감염이후에는면역력을획득하게되고정상성인의 50% 정도는이미면역력을가지고있다 (Koch & Adler, 1989). 항체가없는산모의 1차급성감염의 3.3% 3.8% 로알려져있다 (Rodis et al., 1990). 이러한경우유산혹은태아수종과관련이있지만무증상태아인경우장기적인후유증은없는것으로알려져있다. 그리고태아조혈세포에바이러스가부착하여심한빈혈을야기한다. 태아빈혈은태아중뇌동맥혈 https://doi.org/10.21896/jksmch.2020.24.3.133 135
Park CY Cho HJ. Prevention and Management of Perinatal Major Infectious Diseases 류검사로진단할수있다. 혹은태아심근세포을공격하여심비대및간손상을일으켜태아수종을초래한다. 대규모전향적연구를통해 1삼분기에감염된경우유산율은 13 %, 13 20주사이감염시 9%, 20주이후감염은 0% 로보고되고있다 (Enders et al., 2004). 진증후군, congenital rubella syndrome [CRS]). 세계적으로매년 100,000건의 CRS이발생하지만예방접종으로감염이많이감소하고있다. 2004년미국 Centers for Disease Control and Prevention (CDC) 는공식적으로 rubella 감염종식을선언하였다 (Reef, 2006 ). (1) 모체감염감염환자와의접촉이있었다면다른바이러스감염과마찬가지로특이항체 IgM, IgG로면역력여부를확인할수있다. 특이항체 IgM 음성, IgG 양성이면이전감염으로부터면역력이획득되었음을의미한다. 특이항체 IgM, IgG이모두음성이라면산모는감염의위험이있으므로 3 4주후에재검사를시행하여여전히모두음성이라면감염되지않은것으로판단한다. 예방을위한백신이나바이러스박멸을위한약물치료는존재하지않는다. 임신전정기적선별검사도권고되지않는다. 증상이있거나감염이의심되는경우에검사를시행한다. IgM, IgG 모두양성이라면추적초음파검사를시행한다. 산모감염인경우 33% 에서태아가감염된다. (2) 태아감염양수를이용한중합효소연쇄반응검사법 (PCR) 과태아혈액내특이항체 IgM 양성여부로진단이가능하다. 태아혈액채취는검사법자체의위험도가 1% 의유산율을갖고있어권장되지않는다 (Török et al., 1992). 산전초음파검사에서태아수종혹은빈혈이의심된다면 parvovirus 에대한즉각적인검사가필요하다. 태아의잠복기는 8 10 주까지보고되고있으므로산모감염이의심되는시점부터적어도 10주까지매주초음파검사를시행하여태아수종및빈혈에대한추적평가가필요하다. 4) 예방및치료예방백신및현재가능한약물치료방법은없으며역시감염원으로부터의차단이일차적이다. 4. Rubella (german measles, three day measles, 풍진 ) 1) 개요 Rubella는단일나선 RNA virus으로공기감염으로전파되며태반을통과하여태아감염을야기한다 ( 선천성풍 2) 임상적특징 25% 50% 는무증상이고증상이있더라도미열, 결막충혈, 콧물, 기침, 발진등경미한증상으로그친다 (Best et al., 2009). 임신초기에산모가감염된경우 80% 에서태아의감염을야기하고임신 2삼분기에감염된경우에는 10% 20%, 임신 3 삼분기에감염되면다시 60% 까지태아감염이증가한다. 임산부가감염되면유산, 사산, 혹은 CRS 를야기한다. 임신초기에감염될경우증상도가장심하다. CRS의증상은다음과같다. 감각신경성난청, 백내장, 심기형, 동맥관개존증, 폐혈관협착, 대동맥축착, 기타안구기형등이있다 (Miller et al., 1982). (1) 모체감염 ACOG (American College of Obstetricians and Gynecologists) 에서는첫산전진찰방문시 rubella IgG - 혈청선별검사를시행할것을권고한다. IgM Ab가최근감염을의미하지만간혹일년이상 IgM Ab가지속되는경우도있어해석에주의를요한다. 임산부가 rubella 환자와접촉한경우 12일이내에 IgG가양성이면이미면역력이있음을의미한다. IgG가음성이라면 IgG, IgM을 3주간격으로재검하여무증상감염을배제해야한다. 3주후에 IgG 와 IgM이음성이라면감염이없음을의미하고, IgG가양성이라면최근수주이내감염의가능성이있으므로 IgG 항체접착검사등으로확진검사를시행한다. IgM 양성, IgG 음성이라면최근감염의가능성이있다. Toxoplasmosis와마찬가지로 IgG 항체접착검사로감염의시기를예측할수있다. 낮은접착력을보이는경우 1 3개월이내의최근감염을의미하고높은접착력를보인다면 3개월이내의최근감염을배제할수있다 (Best et al., 2009). (2) 태아감염임산부감염이확인된경우태아의 CRS 감염을진단평가하도록한다. 태아혈액에서 IgM을검출하거나양수, 태아혈액에서중합효소연쇄반응검사법 (PCR) 을시행하여 136 https://doi.org/10.21896/jksmch.2020.24.3.133
박채연 조현진. 주산기주요감염질환의예방및관리 확인할수있다. 특히검체채취가감염 6주이후에시행되었고임신 21주이후인경우검체의이송, 보관방법이적절하다면검사의민감도는 90% 이상이고정확도는 100% 이다 (Bosma et al., 1995). 태아감염의산전초음파소견은심기형, 안기형, 소뇌증, 간비대, 비장비대, 태아성장지연등이있다. 4) 예방및치료임신계획시 IgG 항체가없다면 MMR (measles, mumps, rubella) 을접종하고 28일이후에임신할것을권고한다. 산모의감염시감염증상은대증치료로대부분소실되지만태아에대한영향을막을수있는치료는없으며특히 16주이전의감염은임신종결을권유한다 (Watson et al., 1998). 5. Cytomegalovirus (CMV, 거대세포바이러스 ) 1) 개요이중나선 DNA 바이러스로성접촉, 감염된혈액, 소변, 타액을통해전염된다. 성인의 50% 정도는이미면역이있는상태이다. 면역이없는상태의일차감염의경우태반을통한태아감염률은 30% 40% 이며면역이있는산모의재발성감염의경우태반을통한태아감염률은 1% 미만이다 (Gaytant et al., 2003). 미국에서출생아의 0.6% 0.7% 가선천성 CMV 감염으로가장흔한선천성감염성질환이다. CMV 감염된성인의 50% 정도만증상이있어임신중산모의감염진단이어렵다. 산모가임신 3 삼분기에감염되면태아로의전염확률은높지만임상증상은초기감염보다경하다. 임신초기산모감염의경우태아로의전염확률은낮지만감염된태아의증상은더욱심각하다 (Cherry et al., 2012). 2) 임상적증상두통, 미열, 인후통등일반감기증상과유사하며 30% 정도의환자에서반점, 발진등의피부증상을보인다. 자궁내태아감염시뇌실주변석회화, 뇌실확장증, 대뇌형성이상증, 소뇌증, 태아복수혹은흉막삼출액등을유발한다 (Istas et al., 1995). (1) 모체감염임신기간동안 3 4주간격으로검사했을때특이항체 IgG가양성으로전환되거나역가가 4배이상증가하면급성감염으로판단한다. 특이항체 IgM은 6개월이상지속될수있고다른바이러스감염에의한위양성의가능성이있다. 급성감염의확진을위해특이항체 IgG 접착검사를이용할수있다. 정기적선별검사는추천되지않는다 (Centers for Disease Control and Prevention, 2008). (2) 태아감염양수검사를이용한중합효소연쇄반응검사법 (PCR) 은민감도, 정확도가 90% 이상이다. 특히 20주이후에시행할때더욱정확하다. 산전초음파소견은태아성장지연, 소뇌증, 뇌실확장증, 간비대, 비장비대, 복수, 간석회화, 장의음영증가, 태아수종등이있다. 그러나감염된태아의 5% 25% 정도만초음파상특징적인소견을보인다 (Faure-Bardon et al., 2019). 4) 예방및치료예방백신이나태아감염을치료할수있는약제가없다. 따라서감염원으로부터의노출을방지하기위한개인위생관리가감염의예방에중요하다. 6. Herpes virus ( 헤르페스바이러스 ) - Varicella zoster ( 수두 ) 1) 개요호흡기혹은밀접접촉으로전염되는 DNA herpes virus 이다. 면역력이획득되어있지않다면접촉자의 60% 90% 가감염이된다. 예방접종으로많이감소했는데 CDC의보고에따르면 1995년부터예방접종이시행되었기시작했고 2000 2010년사이에 82% 가감소했다고한다 (Lamont et al., 2011). 2) 임상적특징초기감염은발열과발진을보이는 chicken pox ( 수두 ) 이고이후신경절에잠복해있다가 herpes zoster라는이차병변을유발한다. 하지만초기감염이후면역력을획득한다. 어린시기에감염은증상이경하지만성인의감염인경우뇌수막염, 폐렴으로진행할수있다. 모체감염의 1% https://doi.org/10.21896/jksmch.2020.24.3.133 137
Park CY Cho HJ. Prevention and Management of Perinatal Major Infectious Diseases 2% 에서태아감염을유발할수있다. 열, 서혜부림프절비대등이있으며무증상의경우도있다. (1) 모체감염수두자체의진단은특징적인발진을통해이루어진다. 임신초기에수두감염이나예방접종여부를확인하도록한다. 예방접종을하지않았다면특이항체 IgG 검사를시행한다. (2) 태아감염양수를이용한중합효소연쇄반응검사법 (PCR) 검사도시행할수있으나태아감염에위험정도와양수검사의합병증의위험정도를고려하여판단해야한다. 태아감염의산전초음파소견은태아수종, 간, 장의음영증가, 심기형, 사지기형, 소뇌증, 태아성장지연등이있다 (Koren, 2005). 4) 예방및치료면역력이확실하지않은임산부라면수두감염에대해주의를주고감염자와접촉을하면 VZIG (Varicella Zoster Immune Globulin) 을 96시간이내에투여한다. 임산부가감염된경우 acyclovir로치료한다. 태아감염에대해주의깊은초음파검사를시행한다 (Stone et al., 2004). - Herpes simplex ( 단순포진 ) 1) 개요생식기헤르페스단순바이러스는이중나선 DNA 바이러스로 HSV type 1, HSV type 2로나눌수있다. Type 1은입술, 잇몸, 결막공막에염증성병변을유발하며 type 2 가생식기감염을일으킨다 (Bernstein et al., 2013; McQuillan et al., 2018). 피부접촉으로감염되며한번감염되면신경절에잠복상태로남아있게된다. 항체는감염후 2 3주형성되어지속적으로인체내존재한다 (Pertel & Spear, 2008). 주로산도를통과하며태아로의수직감염이이루어지게된다. 임신기간동안 1차감염된경우가기존감염의재활성화경우보다신생아로의감염전파위험성이더욱높다. 신생아감염시경미한피부병증에서부터헤르페스성뇌염등신경계적후유증이남는문제를일으킬수있다 (Kimberlin et al., 2001). 2) 임상적특징생식기부위궤양, 수포, 작열감, 소양감, 배뇨곤란증, 발 (1) 모체감염임상적증상으로추정진단이가능하지만진단적검사로 PCR, 바이러스배양검사, 직접면역형광염색항체검사, 특이혈청검사등이있다. (2) 태아감염자궁내태아감염은매우드물며 3건정도보고된바있다 (Marquez et al., 2011). 모체의바이러스혈증혹은상행성감염으로일어날수있다. 보통태반경색, 괴사등으로인한문제가동반되며대부분사산에이른다. 상행성감염은양막파수시모체에활동성병변이있는경우일어날수있다. 극히드물어정립된진단방법은아직연구된바없다. 4) 예방및치료활동성병변이있는경우바이러스전파가가능해지므로접촉을피하도록한다. 임신시초기감염혹은기존감염의재활성의경우임상적증상중증도에따라항바이러스제 acyclovir 투여가가능하다. ACOG (The American Colleage of Obstetricians and Gynecologists) 는생식기헤르페스기왕력을가지고있는산모는 36주에분만시재발을방지하기위해예방적항바이러스제치료를받을것을권고한다. 신생아수직감염을예방하기위해분만시점에서생식기에활동성병변이있는경우제왕절개를권고한다. 질식분만시신생아로의감염률은 7.7%, 제왕절개시감염률은 1.2% 로위험률은낮아지지만완전히수직감염을차단할수는없다 (Workowski et al., 2015). 7. Seasonal influenza ( 독감 ) 1) 개요밀접접촉으로전파되며주산기여성의계절성독감의질환중증도및사망률은일반인인구에비해높다. 임신분기에상관없이적극적인백신접종이권고되며감염이확인되거나의심되는경우즉각경험적인항바이러스치료를시작하도록한다. 현재알려진종류로는 A, B, C, D형독감 4종류가있다. A형독감은여러아형으로존재하며스페인독감, 신종플루등이이에속한다. 태반을통한태아로의전 138 https://doi.org/10.21896/jksmch.2020.24.3.133
박채연 조현진. 주산기주요감염질환의예방및관리 파는매우드문것으로알려져있지만 H5N1 ( 신종플루 ) 의경우한건의케이스가보고된적이있다 (Gu et al., 2007) 1삼분기에이환된경우모체의고열증상이원인으로생각되어지는구개열, 신경관결손, 뇌수종, 심기형등의선천성기형의위험도가증가하는것으로나타났다 (Luteijn et al., 2014). 여로치료가가능하다. 뿐만아니라 CDC에서는출산및유산을모두포함하여산후 2주이내및임신한여성의경우확진자와접촉한 48시간이내예방적항바이러스제치료를개시하도록권고한다. 8. Pertussis ( 백일해 ) 2) 임상적특징고열, 두통, 근육통, 호흡곤란, 마른기침, 콧물, 인후통, 권태감등일반적인독감증상을일으킨다. (1) 모체감염임상적인증상으로진단이가능하며진단학적검사결과를기다리지않고바로경험적인항바이러스치료를시작하도록한다. 15분정도소요되는항원검출검사가있지만 PCR 등분자진단적검사에비해민감도가낮다. 기타바이러스배양검사, 혈청학적검사가있지만임상적으로사용되지않는다 (Treanor, 2015). (2) 태아감염태아에직접적으로미치는영향은아직잘연구되어있지않고태반을통한태아로의전파는매우드문것으로알려져있다 (Irving et al., 2000). 4) 예방및치료 CDC에서는주산기를포함하여가임기까지예방백신을접종받도록권고한다. 뿐만아니라매년생후 6개월이상모든연령대의접종을권고한다. 현재가능한백신종류는 A형독감 (H1N1, H3N2), B형독감 (Victoria, Yamagata) 4종류바이러스에효능이있는 4가백신, A형독감 (H1N1, H3N2) B형독감 (B/Florida/4/2006) 3종류에효능이있는 3가백신 2가지가있다. 임신한여성은불활성화백신을접종받아야하며접종군에서유의미하게이환율이 89% 감소되었고신생아의감염률도 41% 감소되는것을관찰할수있었다 (Demicheli et al., 2014). 모체의접종은신생아의접종가능한시기인생후 6개월전의수동면역을형성해준다. 태반에서직접적으로 IgG 항체가태아로이동하며생후모유로부터 IgA가분비되어신생아로이동하여수동면역을형성한다 (Madhi et al., 2014). 진단된혹은임상적으로의심되는경우항바이러스제 zanamivir, oseltamivir 투 1) 개요 Bordetella pertussis는공기를매개로비말전파되는매우전염력이강한세균성호흡기성질환이다. 성인의경우치료없이도호전되는질환이지만영유아의경우성인에비해합병증이심각하며사망률이 1% 에달한다. 특히백일해접종이가능한생후 2개월전영아의경우더욱심각하다 (Tubiana et al., 2015). 2) 임상적특징감염후 1 2주간콧물, 경한기침의증상을겪는카타르기, 발작적인심한기침, 기침후구토증상을겪는 2 4주간의경해기, 그후 1 2주간의회복기를거치는게전형적인백일해의경과로경한기침의증상을겪는카타르기에전염력이가장높다 (Cherry et al., 2012). (1) 모체감염유행하는시기의특별한원인이없는 2주이상의기침 ( 발작적기침혹은기침후구토를동반하는경우 ) 의증상을가지는경우 CDC, World Health Organization (WHO) 에서는임상적진단을내릴수있다고한다. 비유행기에는진단적검사를시행할수있으며감염후첫 2주간은 PCR 검사가가능하며 2 4주에는 PCR 및배양검사가가능하고 4주이상경과한경우혈청학적항체검출검사만유용하다. (2) 태아감염수직감염을일으키는감염군에속해있지않다 (Cunningham et al., 2018). 4) 예방및치료국가예방접종으로지정되어있어만 12세에접종이완료된다. 하지만접종후 5 10년에걸쳐면역력은감소되므로 Tdap 추가접종을하는것이추천된다. 19세이상 https://doi.org/10.21896/jksmch.2020.24.3.133 139
Park CY Cho HJ. Prevention and Management of Perinatal Major Infectious Diseases 의성인의경우특히가정의영유아가있거나, 보건업종사자, 비만, 천식을가지고있는경우는 1회의추가접종을권고한다 (Centers for Disease Control and Prevention, 2013). 차후 10년마다재접종을반복한다. 임산부의경우 27 36주사이추가접종을하도록하며매임신시권고되며지난임신으로부터 12개월이지나지않았어도추가접종을하도록한다. 수많은관찰적연구로부터임신중예방접종이영아기백일해감염의위험을낮춰준다는것이입증되어있으며모체의항체가태반을통과하여태아에게로전달되어생후첫 8주간접종전수동면역을형성해준다 (Romanin et al., 2020) 치료로 azithromycin, clarithromycin 항생제투여가가능하다 (Altunaiji et al., 2007). 9. COVID-19 1) 개요중증급성호흡기증후군코로나바이러스 (Severe Acute Respiratory Syndrom, SARS) 의새로운아형으로중증급성호흡기증후군코로나바이러스 (SARS coronavirus, SARS-CoV), 중동호흡기증후군코로나바이러스 (Middle East Respiratory Syndrome coronavirus) 에이어세번째코로나바이러스이다. 2019년 12월 31일중국에서첫공식적보고가되었고 2020년 3월 12일 WHO에서공식적인판데믹선언을하였다. 현재까지정립된치료법은없으며지금까지연구되어진바임산부에서코로나감염의위험도및중증도는일반인구와다르지않는것으로밝혀졌다. 비말접촉감염으로전파되며 2 m의안전거리를권고한다 (Elshafeey et al., 2020). 2) 임상적특징최장 14일간의잠복기를가지고있으며보통노출후감염증상이 4 5일안에나타난다. 증상은경미한폐렴이 81% 로대부분차지하며호흡부전및다발성장기부전에이르는중증감염은 5%, 사망률은 2.3% 에달하는것으로밝혀지고있다 (Wu & McGoogan, 2020). 임산부의감염증상은일반인구와비슷하게발열, 기침, 백혈구감소증, 두통, 권태감, 식욕감소등이있다 (Elshafeey et al., 2020). 중합효소연쇄반응검사법 (PCR) 검사로진단이가능하며아직검사의정확도및민감도에대해정립되어있지않으나 70% 의정도의민감도를가지고있는것으로보고있다 (Dashraath et al., 2020). 4) 예방및치료발열, 호흡기증상이있는경우산전진찰혹은분만을위해병원을방문하기전선별검사를시행하는것이권고된다 (Rasmussen et al., 2020). 현재까지수직감염및양수, 모유에서의바이러스검출은보고되지않고있으며 (Chen et al., 2020) 질식분만, 모유수유는안전한것으로생각되며진단된산모와신생아의격리가주는이득보단모유수유의이득이더큰것으로판단된다 (FIGO, 2020). 신생아와접촉시손위생에주의를기울이고 fascial mask 를착용하도록한다. 현재정립된백신및치료법은없으며대증적치료를시행한다. 진단된경우즉시입원격리입원후산소공급, 2차감염예방을위한경험적항생제, 태아- 자궁수축모니터링을실시한다. 호흡부전증상을겪을시조기에적극적으로기계환기를시행하도록해야하며안전한분만을위해다학제적접근이필요하다. 태아폐성숙을위한스테로이드투여는폐렴의위험도를높일수있으므로신중하게고려하도록한다 (Rasmussen et al., 2020). 결론 TORCH 감염은비슷한임상적표현형을가진주산기감염의질환군이다. 자궁내혹은주산기감염은태아및신생아의사망률혹은아동전반기의질환유병률과연관율이높다. 그러므로산전진찰을통해이른진단및절절한치료와보건교육을통한예방을하는것이중요하다. 특히 Rubella는임신계획시항체보유여부를확인하여미리예방접종을하도록권유하는것이가장효율적이며 seasonal influenza, pertussis 또한임신기간동안적극적인예방백신을통해모체및태아, 신생아감염성질환유병률을낮추는데기여할수있다. 마지막으로개인위생및사회적거리두기를통해 COVID-19 virus 및기타주요감염성질환을예방하도록하는것이중요하다. 마지막으로주산기감염질환군의전파, 모체및태아증상, 진단및예방치료방법을 Table 1에정리하였으며모자보건분 140 https://doi.org/10.21896/jksmch.2020.24.3.133
박채연 조현진. 주산기주요감염질환의예방및관리 Table 1. Summary of perinatal infectious disease Disease Transmission Maternal symptom Fetal symptom Diagnosis Prevention & treatment Toxoplasmosis Contact None, fatigue Intracranial calcification, Maternal: IgM, IgG Prevention: none hydrops Fetus: amniotic fluid PCR Treatment: pyrimethamine, sulfadiazine, spiramycin Syphillis Sexually transmission Local ulcer, skin, mucosal lesion, FDIU, hydrops, anemia Maternal: VDRL, FTA- ABS, TPHA Prevention: none Treatment: benzylpenicillin organ involvement Fetus: amniotic fluid, blood but not advisable Parvovirus Doplet None, fever, rash FDIU, hydrops, anemia Maternal: IgM, IgG None Fetus: amniotic fluid PCR, IgM Rubella Airborne None, fever, cough FDIU, hearing loss, cataract, cardiac defect Maternal: IgM, IgG Fetus: amniotic fluid IgG, Prevention: vaccination Treatment: none IgM CMV Contact Headache, fever, Ventriculomegaly, Maternal: IgM, IgG None rash microcephaly, ascites Fetus: amniotic fluid PCR Airborne Fever, rash Cardiac defect, hydrops, limb defect, microcephaly, FGR Maternal: IgM, IgG Fetus: amniotic fluid PCR Prevention: vaccination Treatment: VZIG, acyclovir Herpes simplex Contact None, vesicle with pain, lymph node hypertrophy Ascending infection - FDIU but very rare Maternal: PCR, culture Fetus: none Prevention: none Treatment: acyclovir Seasonal flu Contact Fever, headache, cough Maternal fever related anomaly - cleft, neural tube defects, hydrops, cardiac defect Maternal: PCR Fetus: none Prevention: none Treatment: zanamivir, oseltamivir Pertussis Droplet Cough, rhinorrhea Transmission to fetus - Maternal: PCR Prevention: vaccination none Treatment: azithromycin, clarithromycin COVID-19 Droplet Pneumonia, fever, Transmission to fetus - Maternal: PCR None cough none FDIU, fetal death in utero; VDRL, venereal disease research laboratory; FTA-ABS, fluorescent treponemal antibody absorption; TPHA, treponema pallidum Hemagglutination assay; CMV, cytomegalovirus; PCR, polymerase chain reaction; FGR, fetal growth restriction; VZIG, varicella zoster immunoglobulin; COVID-19, coronavirus disease 2019. 야임상의료에도움이되었으면한다. 이해관계 (Conflict of Interest) 저자들은이논문과관련하여이해관계의충돌이없음을명시합니다. REFERENCES Altunaiji S, Kukuruzovic R, Curtis N, Massie J. Antibiotics for whooping cough (pertussis). Cochrane Database Syst Rev 2007;(3):CD004404. Bernstein DI, Bellamy AR, Hook EW 3rd, Levin MJ, Wald A, Ewell MG, et al. Epidemiology, clinical presentation, and antibody response to primary infection with herpes simplex virus type 1 and type 2 in young women. Clin Infect Dis 2013;56:344-51. Best JM, Icenogle JP, Brown DWG. Rubella. In: Zuckerman AJ, Banatvala JE, Schoub BD, Griffiths PD, Mortimer P, editors. Principles and practices of clinical virology. 6th ed. Chichester (UK): John Wiley & Sons, Ltd; 2009. p. 561. Bosma TJ, Corbett KM, O'Shea S, Banatvala JE, Best JM. PCR for detection of rubella virus RNA in clinical samples. J Clin Microbiol 1995;33:1075-9. Centers for Disease Control and Prevention (CDC). Knowledge and practices of obstetricians and gynecologists regarding cytomegalovirus infection during pregnancy--united States, 2007. MMWR Morb Mortal Wkly Rep 2008;57:65- https://doi.org/10.21896/jksmch.2020.24.3.133 141
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