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Practice bulletins > #151 Cytomegalovirus, Parvovirus B19, Varicella Zoster, and Toxoplasmosis in Pregnancy > Flashcards

#151 Cytomegalovirus, Parvovirus B19, Varicella Zoster, and Toxoplasmosis in Pregnancy Flashcards

1
Q

What type of virus is cytomegalovirus?

A

Double-stranded DNA herpes virus

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2
Q

How is cytomegalovirus trasmitted?

A

Sexual contact or direct contact with infected blood, urine, or saliva

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3
Q

What is the incubation period of cytomegalovirus?

A

28-60 days (mean, 40 days)

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4
Q

When can viremia be detected after CMV infection?

A

Can be detected for 2-3 weeks after primary infection

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5
Q

What are typical symptoms of adult CMV infection?

A

Usually asymptomatic. May experience a mononucleosis-like syndrome (fever, chills, myalgias, malaise, leukocytosis, lymphocytosis, abnormal liver function, and lymphadenopathy)

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6
Q

What is the incidence of primary CMV infection among previously seronegative pregnant women in th US?

A

0.7-4%

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7
Q

What is a secondary CMV infection?

A

Intermittent viral excretion in the presence of host immunity, can occur after reactivation of the latent endogenous CMV strain or by reinfection with a different viral strain

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8
Q

What is the incidence of secondary CMV infection (reactivation vs new strain) during pregnancy in US?

A

13.5%

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9
Q

How does vertical transmission of CMV occur?

A

Transplacental infection after primary or secondary infection, exposure to contaminated genital tract secretions, breastfeeding

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10
Q

What are the clinical findings of congenital CMV?

A

Most are asymptomatic at birth. Jaundice, petechiae, thrombocytopenia, hepatosplenomegaly,, growth restriction, myocarditis, and nonimmune hydrops

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11
Q

What is the most common congenital infection? How often does it occur in neonates?

A

CMV. Occuring in 0.2-2.2% of all neonates.

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12
Q

What type of transmission of CMV is associated with greatest risk of developing clinical sequelae?

A

Transplacental transmission

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13
Q

Is CMV exposure through breast milk associated with severe neonatal sequelae?

A

No, typically asymptomatic

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14
Q

Is CMV exposure through cervical secretions during delivery associated with severe neonatal sequelae?

A

No, typically asymptomatic

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15
Q

What is the risk of transmission of CMV to fetus with primary maternal CMV infection?

A

30-40%

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16
Q

During which trimester is the risk for vertical transmission of CMV the greatest?

A

3rd

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17
Q

What are the transmission rates for primary CMV infection by trimester?

A

30% in first
34-38% in second
40-72% in third

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18
Q

During which trimester is transmission of maternal CMV infection associated with more serious fetal sequelae?

A

First trimester

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19
Q

Of fetuses infected in utero after primary CMV infection, what % will have signs and symptoms of CMV infection at birth and how many will eventually develop sequelae?

A

12-18% at birth. Up to 25% will develop sequelae.

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20
Q

What % of infants severely affected by congenital CMV will die?

A

approximately 30%

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21
Q

What % of infants surviving congenital CMV infection will have severe neurologic morbidity?

A

65-80%

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22
Q

What is the rate of vertical CMV infection after a recurrent infection?

A

0.15-2%

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23
Q

What are the typical outcomes after infant infected with maternal CMV reactivation?

A

Most infants asymptomatic at birth. Congenital hearing loss is most severe sequela. Unlikely to produce multiple sequelae

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24
Q

What type of virus is Parvovirus B19?

A

Single-stranded DNA virus

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25
Q

What does Parvovirus B19 cause in children?

A

Erythema infectiosum (aka fifth disease). Slapped cheek appearance, fever, body rash, joint pain

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26
Q

What is the most common symptom of parvovirus B19 infection in immunocompentent adults?

A

reticular rash on the trunk and peripheral arthropathy, about 20% are asymptomatic

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27
Q

What is a possible manifestation of parvovirus B19, particularly in individuals with underlying hemoglobinopathy?

A

Transient aplastic crisis

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28
Q

How is parvovirus B19 typically transmitted?

A

Respiratory secretions and hand-to-mouth contact

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29
Q

When is someone typically infectious with parvovirus B19?

A

5-10 days after exposure before onset of rash or other symptoms (no longer infectious with rash)

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30
Q

What percentage of reproductive-aged women are seropostiive for parvovirus B19?

A

50-65%

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31
Q

Exposure to a household member with parvovirus B19 conveys what risk of seroconversion?

A

50%

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32
Q

What is the risk of transmission of parvovirus B19 in a classroom setting?

A

20-50%

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33
Q

What are the rates of maternal-to-fetal transmission of parvovirus B19 after acute infection?

A

17-33%

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34
Q

What adverse pregnancy outcome(s) has parvovirus B19 been associated with?

A

spontaneous abortion, hydrops fetalis, and stillbirth

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35
Q

What is the rate of fetal loss among women with parvovirus B19 infection before and after 20wks GA?

A

Before 20wks=8-17%

After 20wks = 2-6%

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36
Q

What percent of nonimmune hydrops fetalis are associated with parvovirus B19 infection?

A

8-10% (potentially up to 18-27%)

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37
Q

How does parvovirus B19 lead to hydrops fetalis?

A

Virus is cytotoxic to erythroid precursors, most often results from aplastic anemia, although can be related to myocarditis or chronic fetal hepatitis

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38
Q

When are severe effects most frequently seen among fetuses affect by maternal parvovirus B19 infection (what GA)?

A

Prior to 20 weeks, particularly second trimester

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39
Q

Within how long after maternal infection with parvovirus B19 would you expect to see hydrops fetalis?

A

Unlikely to develop if not occurred by 8wks after maternal infection

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40
Q

What type of virus is Varicella zoster?

A

DNA herpes virus

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41
Q

How is varicella zoster transmitted?

A

Respiratory droplets or close contact

42
Q

What is the infection rate among seronegative contacts for varicella zoster?

A

60-90%

43
Q

What is the incubation period of varicella zoster?

A

10-20 days, mean of 14 days

44
Q

When is the period of infectivity with varicella zoster?

A

48 hours prior to rash until vesicles crust over

45
Q

What does primary infection of varicella zoster cause?

A

Chicken pox: fever, malaise, maculopapular pruritic rash that becomes vesicular

46
Q

What happens with varicella zoster virus reactivation?

A

Herpes zoster (aka shingles)

47
Q

What percentage of women with varicella infection during pregnancy will develop pneumonia?

A

10-20%

48
Q

What is the maternal mortality risk of varicella pneumonia during pregnancy?

A

As high as 40%

49
Q

How does varicella transmit vertically to fetus?

A

Through the placenta

50
Q

What is the risk of congenital varicella syndrome?

A

0.4-2%

51
Q

What are the characteristics of congenital varicella?

A

Skin scarring, limb hypoplasia, chorioretinitis, microcephaly

52
Q

When is neonatal VZV infection associated with highest rake of neonatal death?

A

When maternal disease develops from 5 days before delivery to 2 days postpartum

53
Q

What is the causative agent of toxoplasmosis?

A

Intracellular parasite Toxoplasma gondii

54
Q

What is the invasive form of toxoplsam gondii?

A

A trophozoite

55
Q

How are humans infected with toxoplasmosis?

A

Human consumption of cysts in undercooked meat and infected animals, consumption of insect-contaminated food, contact with oocysts from the feces of infected cats or contact with infected materials or insects in soil

56
Q

How does toxoplasmosis present in adults?

A

Typically asymptomatic. most commonly Cervical lymphadenopathy (10-20%). Other symptoms: fever, malaise, night sweats, myalgias, hepatosplenomegaly

57
Q

What is the risk of congenital toxoplasmosis from an infected woman? How does rate change per trimester?

A

20-50% overall.
First trimester 10-15%.
2nd trimester 25%
3rd trimester >60%

58
Q

When during gestation is infection with toxoplasmosis associated with more severe sequelae?

A

The earlier the worse the disease

59
Q

What are infant sequelae of toxoplasmosis infection?

A

Chorioretinitis (subsequent severe visual impairment), hearing loss, severe neurodevelopmental delay, rash, hepatosplenomegaly, ascites, fever, periventricular calcifications, ventriculomegaly, and seizures

60
Q

How can you diagnose maternal CMV infection?

A
  • serum samples collected 3-4 wks apart in parallel for IgG
  • Seroconversion from neg to pos (or increase in titer)
  • IgG avidity assays (measures maturity of IgG antibody) – immature (low-avidity) produced in first 2-4 months
61
Q

What percentage of women with CMV-specific IgM have a primary infection?

A

10-30%. Useful, but not reliable indication of primary infection

62
Q

What ultrasound findings are concerning for congenital CMV?

A

abdominal and liver calcifications, hepatosplenomegaly, echogenic bowel or kidneys, ascites, cerebral ventriculomegaly, intracranial calcifications, microcephaly, hydrops fetalis, and growth restriction

63
Q

How can you diagnose congenital CMV prenatally? What is the sensitivity?

A

Culture or PCR of amniotic fluid.
culture sensitivity = 70-80%
PCR sensitivity = 78 - 98%

64
Q

Does the detection of CMV in amniotic fluid predict severity of infection?

A

No, just highly predictive of congenital infection

65
Q

What treatments are available for maternal or fetal CMV infection?

A

No therapies available. Only medications available for patients with AIDS or organ transplants (ganciclovir, valganciclovir, foscarnet)

66
Q

Which pregnant patients are at higher risk of CMV infection?

A

Day care/child care workers, family with young children, increasing parity

67
Q

Should women be screened for CMV before or during pregnancy?

A

Routine screening of pregnant women for CMV is not recommended.

68
Q

Does CMV immunity eliminate the possibility of fetal infection?

A

No, up to 75% of congenital CMV infections worldwide may be due to reactivation of latent virus or reinfection with a new viral strain.

69
Q

Are women with IgM neg IgG pos Parvovirus B19 at risk for vertical transmission?

A

No, have immunity

70
Q

How should you treat a pregnant woman who is positive for parvovirus B19 IgM?

A

Monitored for potential infection, regardless of IgG status

71
Q

What is the next step in management for pregnant woman with known parvovirus b19 exposure and negative IgG and IgM results?

A

Repeat testing in 4 weeks, if either positive, monitor for potential fetal infection

72
Q

How can you diagnose fetal parvovirus B19 infection?

A

PCR of amniotic fluid.

73
Q

When should testing for fetal parvovirus B19 be considered?

A

Ultrasound reveals hydrops fetalis

74
Q

What should be assessed on ultrasound in patient with parvovirus b19 infections?

A

Ascites, placentomegaly, cardiomegaly, hydrops fetalis, and impaired fetal growth, MCA dopplers peak systolic velocity

75
Q

How often and for how long after Parvovirus B19 infection should you ultrasound the fetus?

A

Every 1-2 weeks for 8-12wks after exposure

76
Q

What is the next step in management for fetus affected by parvovirus B19 and hydrops fetalis or severe fetal anemia?

A

Fetal blood sampling to test hematocrit in preparation for fetal transfusion

77
Q

Should all women be screened for parvovirus B19 before or during pregnancy?

A

Not recommended given low incidence of seroconversion during pregnancy

78
Q

How do you diagnose maternal varicella zoster virus infection?

A

Diagnosed on clinical findings (pruritic, vesicular rash). Can unroof lesion and test w/ PCR

79
Q

What is the risk of congenital varicella syndrome after maternal infection?

A

1-2%, but these rates may be overestimated

80
Q

What ultrasound findings are suggestive of congenital varicella?

A

Hydrops, hyperechogenic foci in the liver and bowel, cardiac malformations, limb deformities, microcephaly, and fetal growth restriction

81
Q

What should you give and when to pregnant women who contract varicella zoster virus?

A

Oral acyclovir started within 24 hours of developing the rash. IV acyclovir for varicella pneumonia.

82
Q

Does maternal treatment of varicella decrease risk of fetal congenital varicella syndrome?

A

No

83
Q

What should infants receive if mom develops varicella around birth? How much around birth?

A

Varicella-zoster immune globulin if mom develops varicella between 5 days before or 2 days after delivery

84
Q

What should infants who develop varicella within first 2 months of life receive?

A

Treatment with IV acyclovir

85
Q

How long after varicella vaccine should a woman wait to conceive?

A

Delay for 3 months since there is a small chance of mild varicella infection after life, attenuated vaccine

86
Q

How often does congenital varicella develop after accidental administration of varicella vaccine during pregnancy?

A

No reports of it happening

87
Q

How quickly after exposure to person with varicella should a pregnant woman receive treatment and what kind of treatment?

A

varicella immunoglobulin as soon as possible, ideally within 96 hours of exposure, but up to 10 days after exposure

88
Q

How do you test for maternal toxoplasmosis infection?

A

Serologic testing for detection of the specific antibody is primary method

89
Q

What is the next step to try and identify acute parvovirus b19 infection in a woman with positive IgM and IgG?

A

Repeat serologic testing in 2-3 weeks, increase in IgG antibodies is consistent with recent infection

90
Q

Do avidity assays have a role in detecting Parvovirus B19 infection?

A

Yes, low avidity indicative of primary infection within the past 5 months

91
Q

What ultrasound findings are found with congenital toxoplasmosis?

A

Ventriculomegaly, intracranial calcifications, microcephaly, ascites, hepatosplenomegaly, and IUGR

92
Q

What should be offered to pregnant women when feteal toxoplasmosis is suspected?

A

Amniocentesis should be offered with PCR

93
Q

When should amniocentesis be performed for suspected toxoplasmosis infection? Why?

A

After 18wks gestation to lessen chance of false-negative test result

94
Q

What is the goal of maternal treatment of suspected Parvovirus B19 infection?

A

Reduce congenital disease severity. Does not prevent fetal infection.

95
Q

What should be used to treat maternal toxoplasmosis infection?

A

Spiramycin, reduces transplacental parasitic transfer

96
Q

What type of antibiotic is spiramycin?

A

Macrolide antibiotic

97
Q

Why is spiramycin the choice for treatment of pregnant women with toxoplasmosis infection (without suspected fetal infection)?

A

It concentrates in, but does not readily cross, the placenta

98
Q

How is fetal toxoplasmosis infection treated?

A

Combination of pyrimethamine, sulfadiazine, and folinic acid. can lessen the severity of disease in the affected fetus

99
Q

How are infants with symptomatic congenital toxoplasmosis treated?

A

Pyrimethamine, sulfadiazine, and folinic acid for 1 year

100
Q

How should women be counseled on prevention of toxoplasmosis?

A

Proper hand washing techniques, pet care measures, and dietary recommendations. [cat feces, contaminated meat, dairy, produce, water; working in soil without gloves]

101
Q

Should women be screened for toxoplasmosis before or during pregnancy?

A

Not recommended, except for women who are immunosuppressed or HIV positive

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