Congenital Infections Flashcards
What is the incidence of primary VZV infection in pregnancy?
3:1000
RCOG GTG
What type of virus is VZV?
DNA virus
Herpes family
How is VZV transmitted?
Highly contagious
Respiratory rollers
Direct personal contact with vesicle fluid
Indirectly via fomites
How does the primary infection of VZV present?
Fever
Malaise
Pruritic rash that develops into crops of maculopapules, which become vesicular and crust over before healing
What is the incubation period of VZV?
1-3 weeks
When is VZV infectious?
48 hours before the onset of the rash
Until the vesicles crust over (usually within 5 days of appearing)
What type of vaccine is the VZV vaccine?
Live attenuated vaccine
How long should women be advised to avoid conceiving for, after having the VZV vaccine?
4 weeks
What are risk factors for serious morbidity from primary VZV infection in pregnancy?
Second half of pregnancy
Immunocompromise (including systemic steroids within the last 3 months)
Smoking
Chronic lung disease
If a woman has been exposed to VZV, what should be offered? (And when and how does it work?)
VZIG
Varicella zoster immunoglobulin
ASAP, but up to 10 days after exposure (or up to 96 hours *ASID)
A second dose may be required if a further exposure is reported and 3 weeks have elapsed since the last dose
Human immunoglobulin product from plasma donors
Prevents or attenuates chickenpox in non-immune individuals
May reduce the risk of development of FVS (Fetal Varicella Syndrome)
What are the manifestations of severe VZV infection in adulthood?
Pneumonia
Hepatitis
Encephalitis
Death (rare)
What should a pregnant women be offered if she develops a chickenpox rash, and presents within 24 hours of the onset of the rash?
Oral Aciclovir
Synthetic nucleoside analogue
Inhibits replication of VZV
RCT: reduces duration of fever and symptomatology when compared to placebo
Accumulating data: no risk of major fetal malformation
What should a pregnant woman be offered if she develops severe VZV infection?
IV Aciclovir
Synthetic nucleoside analogue
Inhibits replication of VZV
Accumulating data: no risk of major fetal malformation
Up to what gestation, is there a risk of developing FVS with VZV?
28/40
What are the benefits and disadvantages of amniocentesis in the context of VZV in pregnancy?
VZV PCR
High sensitivity but low specificity
Good negative predictive value but poor positive predictive value
What are the manifestations of Fetal Varicella Syndrome?
Skin scarring in dermatomal distribution
Eye defects: microphthalmia, chorioretinitis, cataracts
Limb hypoplasia
Neurological abnormalities: microcephaly, hydrocephalus, cortical atrophy, mental retardation, dysfunction of bowel and bladder sphincters
With VZV in pregnancy, where should regional analgesia be performed?
At a site free of cutaneous lesions
Which neonates should receive prophylaxis with VZIG +/- aciclovir
For babies born to mothers who have had chickenpox within the period 7 days before delivery and up to 7 days post-delivery (up to 2 days from ASID)
(RCOG)
AND
Maternal chicken pox >2-28 days after delivery if infant <28 weeks or <1000g BW
What is the leading cause of congenital infections?
What is its prevalence?
CMV
0.64 - 0.7%
What is the meaning of CMV specific IgG avidity? What information does it provide?
Low avidity: recent primary infection
Intermediate avidity: recent primary infection cannot be excluded (manage as primary infection)
High avidity: past infection
How does CMV normally present?
Asymptomatic
Viral illness associated with atypical lymphocytosis
What is the difficulty with interpreting CMV IgM?
CMV IgM can persist for months after primary infection, or reappear with reactivation or re-infection
CMV IgG Avidity may assist in timing of CMV infection
Of all women with positive CMV IgM, only 25% are eventually diagnosed with a primary infection
What are risk factors for maternal CMV acquisition?
Frequent, prolonged contact with young children (in particular, those shedding CMV)
Day care workers
Parents with child in day care
Immunocompromised
Blood transfusions
Sexual contact
What is the % risk of congenital CMV infection to a fetus if mother has secondary CMV infection?
1%
When would an amniocentesis for CMV be performed?
6 weeks or more after primary maternal infection but not < 21 weeks gestation
PCR and culture
> 21/40: 80-100% sensitivity
<20/40: 45% sensitivity
High specificity at all times
Sensitivity also increased by waiting for 6/52 after maternal infection
What are non-invasive tests that can be performed once primary maternal CMV infection has been confirmed?
Fetal USS
- sensitivity <30-, low specificity
Fetal MRI
Congenital CMV infection:
Does risk of congenital infection increase or decrease with gestational age?
Does the severity and sequelae of congenital infection increase or decrease with gestational age?
Risk of infection increases with gestational age.
1st trimester 36%
2nd trimester 40%
3rd trimester 65%
Severity and sequelae decrease with gestational age
What are the fetal USS features associated with symptomatic congenital CMV infection?
Neuro: microcephaly, hydrocephalus, intracranial calcification,
Hydrops: ascites, polyhydramnios, pleural or pericardial effusions,
Abdo: hepatomegaly, abdominal calcification, hyperechogenic bowel, pseudomeconium ileus
Oligohydramnios or polyhydramnios
IUGR
What is the overall risk of long term sequelae in a child infected with CMV congenitally?
10-20%
With maternal CMV infection, what is the risk of fetal transmission in a primary vs non-primary infection?
Primary = 30% Non-primary = 1%
With transmission of CMV across the trimesters, what are the patterns of fetal outcomes?
First half of pregnancy: severe adverse neurological outcome
Late in pregnancy: acute visceral disease: hepatitis, pneumonia, purpura, severe thrombocytopenia
What are the main concerns of a symptomatic congenital CMV infection?
- Early mortality rate (first 3 months) between 5-10%
- Neurological sequelae of microcephaly, seizures, chorioretinitis, developmental delay
- Sensorineural hearing loss
What are the main concerns of an asymptomatic congenital CMV infection?
- Sensorineural hearing loss
2. Chorioretinitis
Outline management of a woman confirmed to have CMV in pregnancy
Maternal tx: nil needed if immunocompetent.
Fetal tx:
- Amniocentesis for PCR and culture: not predictive of fetal damage. Sensitivity improved if waits >=6 weeks after maternal infection and if >20 weeks GA.
- Serial USS +/- fetal MRI
- Consideration of TOP if amnio PCR positive
- Traditionally, no tx for prevention of congenital infection but if CMV amnio PCR +ve, can given CMV immunoglobulin to improve infected baby outcomes.
- recent RCT published in the Lancet found that giving mum Valciclovir reduces fetal transmission of CMV, after maternal infection in early pregnancy
What tests should neonates affected by congenital CMV have at birth?
Serology: CMV IgM
CMV PCR: Urine, saliva, blood
If either serology or PCR positive, for Head USS, MRI, hearing and ophthalmic review
FBC, LFTs
Hearing screen at birth
Hearings assessment 6 monthly until age of 2 and then annually until age 6 due to possibility of delayed onset of sensorineural hearing loss
What should neonates affected by congenital CMV be treated with?
Valganciclovir
What are practices for pregnant women to reduce CMV infection?
- Assume that children under age 3 years have CMV in their urine and saliva
- Thoroughly wash hands with soap and warm water after diaphragmatic change, feeding or bathing a child, wiping child’s nose / drool, handling children’s toys, pacifiers, toothbrushes
- Do not share cults, plates, utensils, toothbrushes or food, towels or wash clothes with child
What postnatal advice would you give a mother of a CMV congenitally infected baby?
- Baby will be high CMV shedder for first years of life; use CMV hygiene precautions.
- Wait at least 6 months after primary CMV infection before trying to conceive
How does enterovirus present in adults?
90% asymptomatic or non-specific febrile illness
Sore throat, flu-like symptoms, vomiting. Diarrhoea less common.
Meningo-encephalitis far less common.
How does neonatal enterovirus present?
Wide spectrum: from non-specific febrile illness to fatal multisystem disease
Fever, irritability, poor feeding, lethargy
Maculopapular rash (50%)
Respiratory symptoms 50%
Gastrointestinal symptoms (20%)
Hepatitis (50%)
May have myocarditis, meningo-encephalitis
How is enterovirus transmitted?
In-utero transmission in late gestation has been described
Intrapartum exposure to maternal blood, genital secretions and stool
Postnatal exposure to oropharyngeal secretions from mother and other contacts
How is enterovirus diagnosed?
RT-PCR: rapid, sensitive and specific
Detection in blood, CSF, tissue most reliable
Genotype got possible by PCR sequencing of structural protein genes
- traditionally cell culture is slow and insensitive
- serology has very limited use
What is the treatment for neonatal enterovirus?
No antivirals currently available
IVIG may be of benefit - one small RCT showed subtle clinical benefits and faster resolution of viraemia
How can we prevent enterovirus?.
Hand washing / infection control contact precautions
Prophylactic IVIG may reduce disease severity in some exposed neonates
All HbsAg positive women require medical referral either during pregnancy or postpartum to…
- Assess the need for maternal treatment
- Hepatocellular carcinoma surveillance
- Reduce risk of vertical transmission
What is the treatment for a women who is HbsAg positive, with HBV DNA <10x7 IU/mL
HB IG and birth dose
HBV vaccine
Follow up of infant
What is the treatment for a women who is HbsAg positive, with HBV DNA >10x7 IU/mL
Treat mother with antiviral tenofovir from 30/40.
HBIG and birth dose HBV vaccine for infant (schedule at birth, 6 weeks, 3 months and 5 months)
Monitor for postpartum flare: check ALT every 4 weeks, for 2-3 months
The optimal time to stop therapy postpartum is not clear.
Stop 6 weeks postpartum.
If someone is HbsAg positive, what are the blood tests to organise?
HepB e antigen
HBV viral load
LFTs
What is the timeframe for HBIG and HBV vaccination in a newborn with an affected mother?
Ideally within 12 hours of delivery
Do not delay beyond 7 days of life
For a women with HBsAg positive, what is the neonatal management
HBIG and Hep B vaccine within 12 hours
Further HepB vaccine at 6 weeks, 3 and 5 months
Follow up serology at 9 months including HBsAg and anti-HBs.
- If HBsAg negative and anti-HBs <10IU /mL, consider further vaccine doses
- if HBsAg negative and anti-HBs >10IU/mL, no further action
- if HBsAg positive, refer for ongoing management by paeds gastro.
Note: LBW infants do not respond as well to Hep B courses so they require the normal vaccination as outlined above
PLUS
Measuring anti-Hbs at 7 months and if anti-HBs <10IU/mL, giving booster at 12 months
OR empirically giving a booster at 12 months
How do you a manage a pregnant woman who has potentially been exposed to Hep B?
Check anti-Hbs.
If >10IU/mL, suggests immunity.
Nil further action required. Hep B vaccine to the infant at birth, 2, 4, 6 months of age
If <10IU/mL, suggests non-immune
HepB Vaccine and HBIG within 72 hours of exposure
Vaccine to also be given at 1 and 6 months after first dose
Repeat testing of mother for HBsAg at 3 months
IgM other becomes HBsAg positive, further management required
What mode of delivery is recommended for a pregnant women with Hep B?
No specific advice
Insufficient evidence that offering a CS provides additional protection against perinatal Hep B transmission over the recommended neonatal regiment f Hep B IgG and vaccination.
What are the breastfeeding implications of maternal Hep B?
None. Breastfeeding is recommended
What are the considerations antenatally and in labour for a woman with Hep B?
Avoid invasive procedures antenatally: CVS, transplacental amniocentesis.
Use NIPT as alternative to IPT.
Avoid invasive procedures intrapartum (FSE, FBS, ventouse)
Particularly in women with high viral load, although the magnitude of benefit in preventing perinatal transmission is uncertain
What is the first thing to do when a pregnant woman has a HepC antibody positive result?
Confirm antibody test result unless known to be HCV positive
Hep C RNA and LFTs, HIV serology
If Hep C RNA positive, increased risk of vertical transmission of 5%; increased to 20% with HIV co-infection.
If Hep C RNA negative, may represent
- false positive antibody result
- past cleared infection
- past successful treatment
- low level viraemia below assay detection level
What are the considerations for a woman antenatally and in labour with Hep C?
Consider minimising invasive procedures antenatally and intrapartum, particularly in women with high viral load, although the magnitude of benefit in preventing perinatal transmission is uncertain
What is the recommendation regarding mode of delivery for a woman with Hep C?
CS only for obstetric indications.
No clear evidence that Caesarean section reduces perinatal HCV transmission
What is the recommendation regarding breastfeeding for a woman with Hep C?
No increased risk of transmission unless niples are cracked or bleeding.
Express and discard milk until cracked nipples healed.
What is the treatment for HepC in pregnancy?
Treatment during pregnancy is contraindicated
However, HepC RNA positive women should be referred to a gastroenterologist or ID physician for consideration of treatment postpartum
What is the neonatal management of maternal HepC?
Bath baby prior to any injections.
HCV RNA test at/after 3 months
- if negative, consider testing for HCV antibody (Ab) at /after 18 months to demonstrate passive maternal antibody clearance
OR can skip 3 months test and just do HCV antibody at 18 months.
- if HCV antibody negative: not infected
- if HCV antibody positive: check HCV RNA and LFTs, and if HCV RNA positive, refer to Paeds Gastro or ID
Infant considered infect with HCV if HCV RNA detected in two samples 3 months apart in first year OR HCV antibody positive after 18 months.
What is the antiviral treatment offered to women who are HCV prior to pregnancy?
Ribavirin.
Considered teratogenic so not recommended in pregnancy or breastfeeding.
Reliable contraception during and for 6 months after tx.
Sustained viral response (absence of viral DNA at 12-24 weeks) in >90%.
What is the risk of transmission of HCV via percutaneous needlestick injury?
1-3% only if from HCV RNA positive patients.
How do we test for HIV in pregnancy?
Pre-test counselling!
Screen with ELISA
Confirm with Western Blot
What is the management of an indeterminate Western blot result?
Further testing needed
Discuss with HIV reference lab and physician specialising in HIV
What is the management of negative Western Blot result (after positive ELISA)
No further action
OR
Repeat HIV testing in 4 weeks if recent exposure of re-exposure to HIV likely
- if repeat testing negative, no further follow up
- if positive, treat
What ist he management of a positive Western Blot test result?
Multidisciplinary care approach
- physician specialising in HIV infection, Obstetric care, Paeds
Mother to child transmission counselling
Antiretroviral therapy
Sexual health screening
Lab testing: HIV RNA viral load, HIV resistance testing, CD4+ve lymphocyte subsets, others e.g FBC, LFTs, U+E, Creat
What is the management for a woman with known HIV who conceived on effective HAART?
Continue current therapy
No need for intrapartum zidovudine
Vaginal delivery if no obstetric contraindications
Formula (no breastfeeding)
What is the management of an pregnant HIV positive women naive to HAART, who is needing therapy for her own health?
Commence HAART as soon as possible
Check viral load at 36/40:
If <50copies/mL, no intrapartum zidovudine, vaginal delivery if no obstetric indications and formula
If 50-399 copies/mL, consider intrapartum zidovudine, planned CS, and formula
If >400copies/ML, definite intrapartum zidovudine, planned CS, and formula
What is the recommended mode of delivery for a woman that presents late, with HIV, not on HAART?
Caesarean Section
What is the management of a late presenter with HIV, not on HAART, who presents with a VL >100,000 copies / mL or unknown?
Commence HAART asap
Add raltegravir to regimen
Intrapartum zidovudine
Planned CS
What is the management of a late presenter with HIV, not on HAART, who presents >28/40?
Check Viral load
Commence HAART asap
Intrapartum zidovidune
Planned CS if viral load detectable
What is the management of a late presenter with HIV, not on HAART, who presents in labour at term?
Stat dose of nevirapine (crosses the placenta and loads the fetus pre-delivery)
Start fixed dose zidovudine / lamivudine
Add raltegravir to regimen (crosses the placenta and loads the fetus pre-delivery)
Intrapartum zidovudine
Planned CS
What is the management of a late presenter with HIV, not on HAART, who presents in labour pre-term?
Stat dose nevirapine Start HAART Use double dose tenor over and add raltegravir to regimen (these two cross the placenta and load the fetus pre-delivery) Intrapartum zidovudine CS - dependent on obstetric factors
With HIV, what is the MTCT risk if
- maternal viral load undetectable (<50 copies/mL)
- appropriate mode of delivery
- formula fed baby
- baby received PEP
MTCT risk is <2%
With HIV, what is the MTCT risk in developed countries in the absence of prevention of MTCT strategies?
In breastfed infants
In non-breastfed infants
Non-breastfed = 20% Breast-fed = 40%
What are the choice of HAART regimes for HIV?
Highly active antiretroviral therapy
Nucleoside:
Zidovudine + Lamivudine OR
Tenofovir + Emtricitabine OR
Abacavir + Lamivudine
Third agent:
Efavirenz
OR Nevirapine (If CD4 cell count <250cells/uL)
OR boosted PI (proteas inhibitor)
What clinical exam should a neonate with a mum affected by HIV have?
Clinical exam, growth parameters, neuro developmental assessment
Routine childhood vaccination
Exposed non-infected children should have regular follow up particularly during the first 5 years of life
What antiretroviral prophylaxis should a neonate born to a mum with HIV be given?
If low risk of MTCT (<2%)
Single agent (AZT), start within 6-12 hours of birth E.g. zidovudine for 4 weeks
PJP prophylaxis not needed
What antiretroviral prophylaxis should a neonate born to a mum with HIV be given?
If high risk of MTCT (>2%)
AZT (zidovudine) \+ additional ARV No consensus on optimal regimen Preferred regimen is AZT + Lamivudine (3TC) + Nevirapine
What are the adverse effects of in-utero / postnatal exposure to anti-retroviral therapy?
None confirmed
How can listeria present in pregnancy?
Unwell febrile, pregnant woman
Most often in the third trimester
Flu-like illness
What lab tests should be done when concerned about listeria?
Blood cultures
Gram stain and cultures of genital tract
What is the treatment for Listeria?
Amoxicillin/ Ampicillin for 14 days
+ Gentamicin for 14 days (severity of illness to be balanced against ototoxicity. Generally recommended for severe infections including meningitis)
Consider urgent delivery dependent on severity of maternal illness and gestation
Matenral listeriosis in the second/third trimester results in a fetal mortality rate of…
40-50%
What is the incidence of Listeria?
0.3/100,000
Uncommon
What is the treatment for Listeria in pregnant woman with a penicillin allergy?
Erythromycin or Cotrimoxazole (if not in the first trimester)
What are signs of an unwell neonate, possibly caused by Listeria?
Placental, cord or post-pharyngeal granulomas
Multiple small skin granuloma, papular or pustular skin rash
Meconium stained / discoloured liquor <34/40
Pneumonitis
Purulent conjunctivitis
What are the lab tests to do when concerned about neonatal listeria?
Culture placenta
Culture: superficial swabs, blood cultures, urine and CSF with gram stain
CXR
FBC, diff
What is the antibiotic treatment for neonatal listeria?
Amoxicillin / Ampicillin
+ Gentamicin
If CSF positive, for 21 days
If CSF negative, for 14 days
If well infant and culture negative, stop antibiotics at 48 hours
What is early-onset perinatal listeria?
Presents within 7 days of birth
Often associated with prematurity and fulminant disease
Mortality is high: 20-60%
What is late-onset perinatal listeria?
7 days - 6 weeks
Typically in term infants
Often presents with meningitis
Can also present with non-specific sepsis: fever, irritability, anorexia, diarrhoea, lethargy
Mortality is 10-20%
What class of antibiotics are listeria resistant to?
Cephalosporins
What high risk foods are associated with listeria?
Unpasteurised milk or food made from raw milk
Pate, dips, soft cheeses
Child precooked seafoods
Precooked meats and meat products which are eaten without further cooking or heating
Uncooked or smoked seafood
Pre-prepared salads and coleslaws
And use safe food handling practices
What test is done to assess whether a mum has Tb?
Tuberculin skin test (TST)
Interferon gamma release assay (IGRA)
If either is positive, perform a CXR
If a TST/IGRA test is positive, and a CXR shows evidence of old pulmonary TB, what is the management?
If TST conversion > 2 years or unknown
- Isoniazid prophylaxis postpartum
If TST conversion within 2 years OR HIGH risk (HIV, immunocompromised)
- Isoniazid prophylaxis from second trimester
If a TST/IGRA test is positive, and a CXR shows evidence of active TB, what is the management?
Test sputum, urine +/- other specimens.
Treatment:
Isoniazid (9 months)
Rifampicin (9 months)
Ethambutol (2 months)
If high risk of Isoniazid resistance, add Pyrazinamide (2 months)
- high risk should be presumed if HIV positive, from area with endemic TB, and those who have previously had treatment
Note: Pyridoxine should be co-prescribed with Isoniazid
Do the anti-TB drugs cross the placenta?
Yes
They reach a low concentration in fetal tissues
Isoniazid, Rifampicin and Ethambutal are all safe in pregnancy
Less safety data for Pyrazinamide but no clear evidence that it is teratogenic
Women taking Isonaizid in pregnancy should be monitored for what serious side effect?
Hepatotoxicity
Higher in women, and more so in the perinatal period
Monthly AST / ALT
If a mother has active pulmonary TB or TB likely to be associated with haematogenous spread, what investigations should be done for the neonate?
If clinical evidence of TB
- CXR, gastric aspirates x 3 and LP
If no clinical evidence of TB,
- CXR, gastric aspirates x 3
If a mother has had pulmonary TB and is on anti-TB treatment and not infectious, what investigations should be done for the neonate?
If clinical evidence of TB
- CXR, gastric aspirates x 3, LP
If no clinical evidence of TB
- no investigations required
What are the most common presenting features of perinatal TB?
Respiratory distress, hepatosplenomegaly, fever, lymphadenopathy and poor feeding
What is the effect of confirmed maternal parvovirus (in pregnancy) on fetal loss <20/40
Extra 10%
15% vs 5% in general population
What is the risk of fetal hydrops in confirmed maternal parvovirus, between 9-20/40?
What are the possible outcomes of this
3%
32% spontaneous resolution (usually within 8 weeks)
33% death without IUT, usually within 4-5 days of first abnormal USS
27% resolution after IU
6% death after IUT
What is the risk of congenital abnormalities in confirmed maternal parvovirus?
No excess or consistent pattern
With maternal parvovirus, what is the risk of transmission to the fetus?
50%
In parvovirus serology,
What is the interpretation of an IgG positive and IgM negative result?
What action is required?
Immune
Nil further action
In parvovirus serology,
What is the interpretation of an IgG positive and IgM positive result?
Recent infection
If confirmed <20/40
USS every 1-2 weeks for 12 weeks
If no fetal abnormality >30/40, nil action required
If fetal anaemia, refer to MFM for USS, FBS +/ - IUT
In parvovirus serology,
What is the interpretation of an IgG negative and IgM negative result?
Susceptible
Repeat IgG 2-4 weeks after exposure of if symptoms occur
If IgG negative, no further action required
If IgG positive, treat as recent infection
In parvovirus serology,
What is the interpretation of an IgG negative and IgM positive result?
? Recent infection
Repeat IgG in 2-4 weeks after exposure of if symptoms occur
If IgG negative, false positive. Nil further action required
If IgG positive, manage as recent infection
What intervention is available to prevent fetal infection or damage in Parvovirus?
None
Is TOP indicated in congenital parvovirus?
No
Low risk of fetal damage
Is amniocentesis recommended in congenital parvovirus?
Not for asymptomatic intrauterine fetal infection
How can fetal Parvovirus infection be confirmed?
PCR on amniotic fluid or fetal cord blood
At what level of Rubella IgG on routine antenatal screening, would you consider reimmunising for after delivery?
Non-immune
Or if IgG <15
With primary rubella infection in pregnancy, when is the highest risk of congenital defects?
1-12/40: 85%
13-16/40: 35%
Following this, congenital defects are rare
Therefore, consider TOP if maternal infection in first trimester
If maternal infection in second trimester, consider fetal testing
With primary rubella infection, when is the rate of fetal infection the highest?
> 36/40: 100%
31-36/40: 60%
1-12/40: 80%
13-16/40: 54%
The rest of the time, approx 30%
With reinfection of rubella in pregnancy (good history of previous positive serology), what is the risk of
- fetal infection
- congenital anomalies
Fetal infection = 10%
Congenital anomalies - rare, particularly if reinfection >12/40
How can rubella be diagnosed on prenatal fetal testing?
What is the best timing for this test?
CVS or amniocentesis
Rubella PCR, Rubella Culture and fetal IgM (can be false negative until late in pregnancy) can be performed
It is recommend at least 6 weeks after known maternal infection AND
Is best performed >20/40
What investigations should be done for a neonate when there is concern regarding congenital rubella syndrome?
Examination
Serology (IgM)
PCR (urine and throat swab)
Culture urine and throat swabs, tears (conjunctival swab), lens tissue
What is the management of a symptomatic, infected infant of rubella?
No specific management
Breastfeeding not contraindicated
Ensure ophthalmology, cardiac and hearing assessments at birth Regularly assessments (3-6monthly) in the first few years of life to detect late abnormalities relating to persistent infection
Infant should be isolated while in hospital
They are an infection risk for 12 months - female / pregnant staff to be aware, and not to contact if non-immune
What are the neonatal or early manifestations of congenital rubella syndrome?
Deafness: sensorineural hearing loss 60-75%
CNS dysfunction 10-15%:mental retardation, developmental delay, microcephaly
Cardiovascular defects 10-20%: PDA, PA stenosis, PS
Ophthalmology also 10-25%: Cataracts, microphthalmos, retinopathy, glaucoma, strabismus, cloudy cornea
IUGR
Haematological abnormalities
GI tract abnormalities
Pneumonitis
Osteitis
What are the late manifestations of congenital rubella syndrome?
Deafness: sensorineural hearing loss Neurological deficiencies, epilepsy Cataracts, retinopathy Tooth defects Growth restriction IDDM Thyroid dysfunction Panencephalitis
What % women have GBS colonised in the genital tract?
10-30%
Detection of GBS is increased by up to _____% by collecting an anorectal swabs in additional to a low vaginal swab
25%
90% of neonates with EOGBS have onset of signs within ____hours of birth
12
Suggests intrauterine transmission
So Intrapartum antibiotic prophylaxis is the most effective means of prevention
What is the management of a neonate born to a mother with GBS, when the neonate has signs of sepsis?
FBC
Blood cultures,
Urine and CSF cultures
CXR.
If CSF not suggestive of meningitis: Benzylpenicillin + Gentamicin
If CSF suggestive of meningitis: Benzylpenicillin + Cefoxatime
What are symptoms of acute toxoplasmosis? (Maternal)
Malaise, fever, lymphadenopathy (cervical)
What test is useful if IgG positive/negative, and IgM positive for toxoplasmosis?
Suggests possible recent infection
Repeat IgM and IgG
AND check IgG avidity =/- IgA
If IgA negative and HIGH avidity, suggests past infection (>16w ago), nil further action
If IgA positive and LOW avidity, suggests recent infection, treat
IgA and IgG avidity useful because in toxoplasmosis, IgM can remain positive for months or years, so these tests are more specific for recent infection (within 3 months)
High IgG avidity >16/40 gestation does not exclude infection earlier in pregnancy
With maternal toxoplasmosis, what is the risk of fetal infection by trimester?
T1: Low risk 4-15%
T2: Intermediate risk 25=44%
T3: High risk 30-75%
With maternal toxoplasmosis, if the fetus is confirmed to have an infection, what is the risk of “damage” by trimester
T1: High risk 34-85%, likely to be severe
T2: Intermediate risk: 18-33%, less likely to be severe
T3: Low risk: 4-17%, usually asymptomatic at birth
With maternal toxoplasmosis, when should amniocentesis be performed to confirm infection?
18-20/40
Or >/= 4 weeks post-maternal infection
PCR on amniotic fluid
- high sensitivity and specificity
With maternal toxoplasmosis, what imaging helps to diagnose intrauterine infection?
USS
Fetal MRI
In maternal toxoplasmosis infection,
If amniotic fluid PCR negative and USS negative, what is the management?
If maternal infection certain, continue therapy
Either
Spiramycin alone
Or Pyrimethamine and Sulfadiazine (and folic acid) continuously or alternating with Spiramycin until delivery
In maternal toxoplasmosis infection,
If amniotic fluid PCR positive (with or without abnormal USS) what is the management?
Congenital toxoplasmosis
Consider TOP or treat mother
Promethazine and sulfadiazine (and folic acid) from >/= 18 weeks
Confirm diagnosis in infant
What is the issue with Pyrimethamine and sulphadiazine for treating toxoplasmosis in the first trimester?
Potentially toxic
Does spiramycin cross the placenta?
No
Therefore does not treat fetus infected with Toxoplasmosis
Used <18/40 in maternal toxoplasmosis to prevent vertical transmission, until an intrauterine diagnosis can be made (via amniocentesis)
What is the pharmaceutical management for an infant affected by congenital toxoplasmosis?
Pyrimethamine
Sulfadiazine
Recommended duration of treatment is 12 months
What are the neonatal symptoms of congenital toxoplasmosis?
Chorioretinitis / retinal scarring Intracranial calcification Hydrocephalus Hepatosplenomegaly Pneumonia Thrombocytopenia Lymphadenopathy Myocarditis and IgM positive / abnormal placenta / CSF PCR positive
What is the risk of fetal infection in
- primary Syphillis
- secondary Syphillis
- latent Syphillis
- tertiary Syphillis
- primary Syphillis: HIGH
- secondary Syphillis: MODERATE
- latent Syphillis: low
- tertiary Syphillis : negligible
How does primary syphilis present?
Chancre
Solitary, firm, red, painless papule
Becomes painless ulcer with well-defined margin and indurated base
How does secondary Syphillis present?
Systemic illness
Fever, rash, hepatitis, lymphadenopathy, menincoencephalitis
How does tertiary Syphillis present?
Cardiovascular
Neurological
Gummatous lesions
What is the treatment of maternal Syphillis?
- in general
- for women with penicillin hypersensitivity
- Penicillin according to stage
- Hypersensitivity: desensitise and then treat with Penicillin
Either
Procaine Penicillin
Benzathine Penicillin
Repeat VDRL / RPR monthly until delivery
If negative or 4 x fold drop in titre: successful treatment
Re-treat if rise in titre
What are the treatment regimens for maternal Syphillis?
Primary, secondary or early latent phase
Benzathine penicillin 1.8g IM stat
or Procaine penicillin 1.5g IM daily for 10 days
Late latent or tertiary
Benzathine penicillin 1.8g IM once weekly for 3 weeks
Or Procaine penicilllin 1.5g IM daily for 15 days
What neonatal assessment is required if congenital Syphillis is possible?
Clinical exam: rash, mucosal lesions, hepatomegaly, nasal discharge, bony tenderness, eye lesions
Infant serology: IgM, RPR to be run in parallel with maternal serology
Placental histopathological +/- PCR
If any of above three abnormal then
FBC, LFTs, EUC, X-ray, CSF
If congenital Syphillis or abnormal CSF (neurosyphillis)
Benzyl penicillin IV 10 days or Procaine penicillin IM 10 days
What is highest risk gestation for fetal varicella syndrome, in the context of maternal chickenpox?
12-28/40: 1.4%
<12/40: 0.55%
> 28/40: no cases reported
In maternal chickenpox, when is detailed fetal USS for anomalies recommended?
At least 5 weeks after primary infection
Repeat USS until delivery
If abnormal, consider fetal MRI
After travel to an area endemic with Zika / sexual contact with someone with Zika, how long should a couple wait before conceiving
(To avoid risk of congenital Zika)
6 months
RANZCOG
What can Zika virus infection be a trigger of?
Guillian Barre Syndrome
What are the cranial abnormalities seen in congenital Zika infection?
Microcephaly Cerebral and/or ocular calcification Ventriculomegaly Periventricular cysts Callosal abnormalities Microphthalmia Cerebellar atrophy Vermian agenesis Blake’s cyst Choroid plexus cyst Brain atrophy Cortical and white matter abnormalities
What are the extra-cranial abnormalities seen in congenital Zika infection?
Fetal growth restriction
Oligohydrmnios
Talipes
If concerned about congenital Zika infection, at what gestation is amniocentesis for PCR helpful?
> 20/40
Because that’s when fetus starts urinating, and virus is in urine only
What is the incidence of acute Parvovirus B19 infection in pegnancy?
2-4$
Describe the pathophysiology of how parvovirus causes disease in the fetus
- Infects rapidly dividing cells including erythroid progenitor cells.
- Causes fetal anaemia and secondary hydrops due to inhibition of erythropoeisis and stimulation of apoptosis.
- Causes fetal thrombocytopaenia.
What is the risk of stillbirth for a fetus affected by Parvovirus:
- Before 20 weeks?
- After 20 weeks?
Risk of stillbirth:
- Before 20 weeks: 10%
- After 20 weeks: <1%
What % of childbearing age women are susceptible to Parvovirus B19?
40%
What is the risk of hydrops for a fetus affected by Parvovirs B19 before 20 weeks?
3%.
Onset on average 5 weeks after maternal infection.
What are the outcomes of a hydropic fetus affected by Parvovirus?
- 32% spontaneous resolution
- 33% IUD without intrauterine transfusion (IUT)
- 27% resolution following IUT
- 6% death following IUT
What are the clinical features of Parvovirus B19 in a pregnant woman?
25% asymptomatic.
50% nonspecific: fever, myalgia, malaise.
25% have erythema infectiosum/fifth disease:
- Slapped check
- Lace-like erythematous rash
- Fever, malaise, diarrhoea, headache, nausea
- Arthropathy
- Transient aplastic crisis esp if sickle cell disease, iron deficiency
- Red cell aplasia
Outline your management of a woman with Parvovirus B19 before 20 weeks gestation
- MCA PSV monitoring every 1-2 weeks + USS for signs of hydrops (skin oedema, ascites, pleural and pericardial effusions)
- Fetal blood sampling may be needed to monitor anaemia and thrombocytopaenia + IUT.
- Delivery at tertiary NICU centre if develops hydrops and near term.
Specific recommended hygiene measures for CMV are:
- Don’t not share food, drinks, utensils used by young children (<3yo)
- do not put a child’s dummy in your mouth
- avoid contact with saliva when kissing a child (kiss on forehead)
- attention to hand hygiene, when changing nappies/contact urine/wiping child’s nose, thoroughly wash hands 10-20s
- clean toys, countertops, other surfaces, do not share toothbrush
