Congenital Transmission of Lyme Disease and Co-Infections During Pregnancy
Lyme Borrelia and other tickborne infections may be transmitted from mother to child during pregnancy, known as Congenital Lyme. How often this happens and the impacts on the child’s health are not well-established; however, studies show significantly fewer adverse outcomes when the mother is treated with antibiotics during pregnancy as prescribed by a Lyme specialist. Congenital transmission of Lyme disease involves the bacterium Borrelia burgdorferi and potentially other tick-borne pathogens, crossing the placenta from an infected mother to the fetus, resulting in infection in the newborn. This is acknowledged by health authorities such as the CDC, NIH and WHO, dating back to 1985, though the frequency is considered unclear due to limited epidemiological data.
Transmission can occur in mothers with acute, chronic, subclinical, or asymptomatic infections, even without a recalled tick bite or erythema migrans rash. Evidence includes detection of B. burgdorferi in placental tissue, fetal organs, and cord blood via PCR, culture, and microscopy, with case reports confirming viable spirochetes in both mother and child. A review of 31 studies found probable transmission in 42% and possible in 6%, with 19 documented cases of congenital infection in fetal or infant tissues. Co-infections, such as with Bartonella henselae, may occur alongside Lyme and complicate outcomes, though specific congenital transmission of co-pathogens is less documented; one case noted co-infection in a child with congenital Lyme.
Risks and Adverse Outcomes
Untreated or unrecognized Lyme during pregnancy heightens risks of miscarriage, stillbirth, preterm birth, intrauterine growth restriction, low birth weight, and neonatal death, often linked to placental infection and issues like decidual necrosis. Cardiac abnormalities are common in perinatal deaths, and any organ can be affected. Studies indicate adverse outcomes in up to 50-60% of untreated cases, dropping to 11-31% with antibiotic treatment. Pregnancy weakens immunity, increasing vulnerability to vector-borne infections, with knowledge gaps in long-term impacts.
Symptoms
In pregnant women, Lyme symptoms mimic pregnancy discomforts: severe fatigue, brain fog, cognitive issues, joint/muscle pain, headaches, stiff neck, swollen lymph nodes, erythema migrans rash, neurological problems like facial paralysis, and flu-like symptoms. Misdiagnosis as chronic fatigue syndrome, fibromyalgia, anxiety, depression, Lupus, arthritis, multiple sclerosis (MS) or other conditions is common.
In newborns, symptoms include respiratory distress, neonatal sepsis, hyperbilirubinemia (jaundice), hypotonia, neurologic issues (e.g., hydrocephalus, developmental delay), cardiac malformations, genitourinary abnormalities, ocular problems (e.g., cortical blindness), dermatological rashes, orthopedic anomalies (e.g., clubfoot, syndactyly), cyclical fevers, pain, hypersensitivity, and erythematous patches. Long-term effects in children may involve cognitive problems, learning disabilities, mood swings, fatigue, neuropsychiatric issues (e.g., ADHD, autism spectrum disorders in 9% of cases from one study of 102 births), sensory sensitivities, and PANS/PANDAS; symptoms may emerge months or years later.
Frequency of Gestational Lyme Symptoms in Children
According to Charles Ray Jones, M.D., most of the children born with gestational Lyme disease have manifestations of the disease at, or shortly after birth.
% Symptoms
- 40 Gastroesophageal reflux with vomiting and coughing
- 80 Irritability
- 60 Low grade fevers, pallor, and dark circles under their eyes
- 72 Fatigue and lack of stamina
- 23 Secondary rashes
- 45 Other rashes
- 30 Eye problems
- 40 Frequent upper respiratory tract infections and otitis
- 20 Abdominal pain
- 40 Noise, light and skin sensitivity
- 50 Arthritis and painful joints
- 18 Developmental delay, including language, speech problems and hypotonia
- 80 Cognitive problems, learning disabilities and mood swings
- 30 Cavernous hemangiomas
Diagnostic Tests
- 50 Positive Western blots
- 20 Positive PCRs
- 21 Positive LUATS
- 37 Positive Bb blood cultures
- 11 Positive Brain SPECT
- 80 Neuropsychological evaluation confirmed cognitive problems
Diagnosis
Diagnosis is challenging due to unreliable serology tests (e.g., two-tiered EIA/Western blot often negative despite infection), lack of standardized guidelines for pregnancy and infants, and variable rash presentation (only 6-9% classic bull's-eye). Diagnosis requires a careful review of maternal history, symptoms, tick exposure, and advanced methods like PCR for B. burgdorferi DNA in placenta, cord blood, or fetal tissue; confocal microscopy and culture can confirm viable spirochetes. Subspecialty consultations (e.g., cardiology, neurology) and histological exams are advised for infants.
Tools like Burrascano Checklist or Horowitz Questionnaire aid assessment. Women with unexplained symptoms should consult Lyme-literate providers ideally before conception.
Treatment and Prevention
Prompt antibiotic treatment by a Lyme specialist, such as oral amoxicillin, cefuroxime, or IV ceftriaxone (avoiding doxycycline in pregnancy due to fetal risks), significantly reduces transmission and adverse outcomes. For co-infections, additional treatments (e.g., rifampin for anaplasmosis or bartonellosis or anti-malarial drugs for Babesiosis) may be needed. Prevention includes tick avoidance (e.g., repellents, clothing, checks), early maternal treatment, and pre-conception evaluation.
Breastfeeding Considerations
Lyme bacteria DNA has been detected in breast milk via PCR, but direct transmission through breastfeeding is not confirmed and appears unlikely or undocumented. Safe antibiotics like amoxicillin or cefuroxime can be used during breastfeeding, though monitoring for side effects is generally advised.
Resources:
Mothers Against Lyme
Lyme Disease and Pregnancy - LYMEHOPE
Treating Lyme With Antibiotics
Studies:
Lyme disease is by far the most common arthropod-borne disease in the Northern Hemisphere. It is caused by certain Borrelia species that are primarily transmitted to hosts by Ixodid ticks; however, transplacental transmission of the spirochete in both animals and humans has been reported. Here, we report imaging of intact spirochetes in an archived placental tissue sample that is immunoreactive to Borrelia antibodies and from which Borrelia DNA was isolated. Both mother and child showed evidence of seroreactivity to Borrelia spp. in the years following the child’s birth, although neither individual tested positive by the conventional two-tiered serological algorithm. Cultivation of viable spirochetes from a vaginal swab of the mother and from the urine of the child some years later supports the possibility of vector-free transmission of Borrelia from mother to child. By amplifying several genomic loci from the DNA of cultured and non-cultured Borrelia from blood and body fluid samples of the mother and child, the Borrelia in both were identified as the same species, Borrelia burgdorferi sensu stricto, a strain specific to North America.
A qualitative study investigating the research priorities of patients with Lyme disease in pregnancy | PLOS One (2024)
Twenty people participated in four semi-structured focus groups and one semi-structured individual interview. The majority of participants were from North America. Participants’ research priorities fell into five categories: transmission, testing, treatment, disease presentation, and education. All study participants expressed interest in future participation in research on Lyme disease in pregnancy and highlighted barriers and enablers to participation that could be addressed to facilitate future study recruitment.
An In-Depth Review of the Benefits of Antibiotic Use in the Treatment of Borreliosis in Pregnancy (2023)
Evidence of congenital transmission of Lyme disease from mother to fetus has been investigated since the 1980s. This study reports the results of a retrospective analysis of 31 studies described in 27 papers published in a 2018 review article. Analysis of these identified statistically probable transmission in 13 (42%) of the 31 studies and possible transmission in 2 (6%). Most studies included mothers who had been treated with antimicrobials. When no antimicrobials were used, 74% of the pregnancies had adverse outcomes. When oral antimicrobials were used, 29% of pregnancies had adverse outcomes. When intravenous (IV) antimicrobials were used, adverse outcomes dropped to 12% of the pregnancies. This is a six-fold reduction in risk compared with no antimicrobial treatment. Some studies did not define whether oral or IV antimicrobials were used. When these results were included, adverse outcomes were 30 times higher for untreated mothers. Adverse outcomes included deaths, heart anomalies, and preterm births.
Lyme borreliosis in pregnancy and associations with parent and offspring health outcomes: An international cross-sectional survey (2022)
A total of 691 eligible people participated in the survey, of whom 65% had Diagnosed LD, 6% had Suspected LD, and 29% had No LD ever. Both the Diagnosed LD and Suspected LD groups indicated a high symptom burden (p < 0.01). Unfortunately, direct testing of fetal/newborn tissues for Borrelia burgdorferi only occurred following 3% of pregnancies at risk of transmission; positive/equivocal results were obtained in 14% of these cases. Pregnancies with No Evidence of LD experienced the fewest complications (p < 0.01) and were most likely to result in a live birth (p = 0.01) and limited short- and long-term offspring pathologies (p < 0.01). Within the LD-affected pregnancy groups, obtaining treatment did not decrease complications for the parent themselves but did ameliorate neonatal health status, with reduced rates of rashes, hypotonia, and respiratory distress (all p < 0.01). The impact of parent LD treatment on longer-term child outcomes was less clear.
Case Report: Lyme Borreliosis and Pregnancy - Our Experience - PubMed (2022)
Lyme Borreliosis (LB) is an infection transmitted by Ixodes sp. ticks. Its early manifestation includes erythema migrans rash. Since the discovery of LB in 1975, the question arose as to whether this infection could be vertically transmitted from mother to fetus during pregnancy, as transplacental transmission has already been known for other spirochetoses, such as syphilis, relapsing fever and leptospirosis. The first confirmed case with positive Lyme serology was described in 1985 in a 28-year- old mother who had acquired Lyme in the first trimester and then developed an erythema migrans rash. Subsequently, transmission of Borrelia burgdorferi sl. in humans from mother to fetus has been documented through identification of Borrelia spirochetes in fetal tissues/and or placenta by various methods including culture, PCR and indirect immunofluorescence. Adverse birth outcomes, which are limited in case of prompt LB treatment, included spontaneous miscarriage, preterm birth and hyperbilirubinemia, but also cardiac involvement and cutaneous angiomas have been documented although rarely. No significant associations were found between adverse outcomes at birth and the trimester of infection. Patients treated for gestational LB had a lower frequency of miscarriages and premature births, as also the frequency of congenital malformations was similar to that observed in the normal population. The recommended treatment for LB in pregnancy is Amoxicillin, 1 g 3 times a day for 14-21 days. In the present study, we report our case series, which includes 11 pregnant women, 6 of which developed erythema migrans during pregnancy (between week 8 and 34), 3 had myoarticular or neurological symptoms and 2 had positive serology, but did not develop any clinical symptoms. Our data stress on the importance of early antibiotic treatment also in seropositive gestating women without symptoms in order to avoid any possible complication to fetus and newborns.
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.
Gestational Lyme Disease Case Studies of 102 Live Births (2014)
Maternal Lyme borreliosis and pregnancy outcome - ScienceDirect (2010)
Treatment was administered parenterally to 66 (69.5%) women and orally to 19 (20%). Infection remained untreated in 10 (10.5%) pregnancies. Adverse outcomes were seen in 8/66 (12.1%) parentally treated women, 6/19 (31.6%) orally treated women, and 6/10 (60%) untreated women. In comparison to patients treated with antibiotics, untreated women had a significantly higher risk of adverse pregnancy outcome (odds ratio (OR) 7.61, p = 0.004). While mothers treated orally had an increased chance (OR 3.35) of having an adverse outcome compared to those treated parenterally, this difference was not statistically significant (p = 0.052). Erythema migrans did not resolve by the end of the first antibiotic course in 17 patients. Adverse pregnancy outcome was more frequent among these ‘slow responder’ mothers (OR 2.69), but this was not statistically significant (p = 0.1425) . Loss of the pregnancy (n = 7) and cavernous hemangioma (n = 4) were the most prevalent adverse outcomes in our series. The other complications were heterogeneous. Our results indicate that an untreated maternal Borrelia burgdorferi s.l. infection may be associated with an adverse outcome, although bacterial invasion of the fetus cannot be proven. It appears that a specific syndrome representing ‘congenital Lyme borreliosis’ is unlikely.
Transmission of Infectious Diseases Through Breast Milk and Breastfeeding - PMC (2010)
Little published information exists on whether B. burgdorferi can be transmitted via breast milk. One report showed the detection of B. burgdorferi DNA by PCR in the breast milk of two lactating women with untreated erythema migrans, but no evidence of Lyme disease or transmission of the spirochete in the one infant followed for 1 year.369 No attempt to culture the spirochete was made, so it is not possible to determine if the detectable DNA was from viable spirochetes or noninfectious fragments. In that same study of 56 women with untreated erythema migrans who had detectable B. burgdorferi DNA in the urine, 32 still had detectable DNA in the urine 15 to 30 days after starting treatment, but none had it 6 months after initiating therapy. Ziska et al466 reported on the management of nine cases of Lyme disease in women associated with pregnancy; seven of the nine women were symptomatic at conception and six received antibiotics throughout pregnancy. Follow-up of the infants showed no transmission of Lyme disease, even in the seven infants who had been breastfed.466
The lack of adequate information on transmission of B. burgdorferi via breast milk cannot be taken as proof that it is not occurring. If one extrapolates from data on syphilis and the Treponema pallidum spirochete, it would be prudent to discuss the lack of information on the transmission of B. burgdorferi via breast milk with the mother or parents and to consider withholding breast milk at least until therapy for Lyme disease has begun or been completed. If the infection occurred during pregnancy and treatment has already been completed, an infant can breastfeed. If infection occurs postpartum or the diagnosis is made postpartum, infant exposure may have already occurred. Again, discussion with the mother or parents about withholding versus continuing breastfeeding is appropriate.
After prenatal or postnatal exposure, an infant should be closely observed and empiric therapy considered if the infant develops a rash or symptoms suggestive of Lyme borreliosis. Treatment of mother and infant with ceftriaxone, penicillin, or amoxicillin is acceptable during breastfeeding relative to the infant’s exposure to these medications. Doxycycline should not be administered for more than 14 days while continuing breastfeeding because of possible dental staining in the neonate. Continued surveillance for viable organisms in breast milk and evidence of transmission through breastfeeding is recommended.
Detection of Borrelia burgdorferi DNA by polymerase chain reaction in the urine and breast milk of patients with Lyme borreliosis - PubMed (1995)
Stillbirth following maternal Lyme disease - PubMed (1987)
Human fetal borreliosis, toxemia of pregnancy, and fetal death - PubMed (1986)
Borrelia burgdorferi in a newborn despite oral penicillin for Lyme borreliosis during pregnancy (1986)
