Congenital infections Flashcards
1
Q
An infection of the fetus typically caused by viruses, or less commonly other infections,that infect the pregnant mother and may be passed to the fetus.
A
Congenital infections
2
Q
Congenital infections can be passed on when and how?
A
Can be before or after delivery
This can be via blood, vaginal secretions or even breast milk.
3
Q
what are the 2 viruses that can be passed down via breast milk?
A
- HIV
- CMV
4
Q
what are the 2 infections that can be passed down through the umbillicus?
A
- staphlococci
- tetanus
5
Q
what is TORCH?
A
- Toxoplasmosis
- Others - HIV, enterovirus, parvovirus, varicella, hepatitis, syphilis
- Rubella
- Cytomegalovirus
- Herpes
6
Q
Toxoplasmosis is caused by?
A
Toxoplasma gondii - protozoan parasite (which is typically asymptomatic)
7
Q
how is toxoplasmosis spread?
A
Vertical transmission of toxoplasma gondii, that occurs after acute maternal infection
8
Q
Toxoplasmosis: Frequency of fetal infection increases with?
A
steeply with advancing gestational age
9
Q
indications for toxoplasmosis screening
A
- High index of suspicion with significant cervical LAD, and high fever
- US findings of fetus
- calcifications and or cerebral ventricular dilation - MC
- Placental densities
- Pericardial effusions
- Ascites
- Fetal demise
- Hydrops fetalis
The US, UK, and Canada recommend against universal screening for toxoplasmosis in pregnancy
10
Q
Toxoplasmosis: Risk Factors for maternal to fetal transmission
A
- Maternal infection at advanced gestational age
- High Parasite load
- Maternal parasite source
- Higher risk of fetal infection when infected through cat feces than meat - Maternal immunocompromise
11
Q
s/s of toxoplasmosis
A
- Cataracts / Chorioretinitis- MC
- Abnormal CSF fluid
- cerebral calcification = convulsion
- Anemia
- Microcephaly / Hydrocephalus
- Hearing loss
- Small for gestational age (SGA)
- Early onset jaundice
- HSM-hepatosplenomegaly
- Generalized maculopapular rash
12
Q
inflammation of the choroid (thin pigmented vascular coating of the eye) and retina of the eye.
A
Chorioretinitis
13
Q
dx for toxoplasmosis
A
- ELISA - detection of IgM and IgG antibodies
- Skull films and CT head - diffuse cortical calcifications
- acute infection - IgM Ab appear within 1 week - stay elevated for months
- IgG appear in 2 wks, peak @ 8, then persist for life
14
Q
Toxoplasmosis: How to spot prenatally
A
- confirmed/strongly suspected primary maternal infection during pregnancy
- abnml US findings
- Testing via amniocentesis after 18 wks preferred
15
Q
toxoplasmosis tx
A
- prevent transmission: Treat mom !!!
- < 14 wks gestation - Spiramycin
- > 14 wks - Pyrimethamine + Sulfadiazine + folinic acid until delivery - Infants treated postnatally still - Pyrimethamine + Sulfadiazine + folinic acid until delivery x 1 year
- Repeated eye examinations x q3mo until 18 mo
- Then q6-12mo
16
Q
toxoplasmosis prevention
A
- Cook meat until it’s well done
- Peel and wash thoroughly all fruits and vegetables
- Wash all surfaces after contact with raw meat
- Avoid untreated drinking water
- Wear gloves when gardening
- Avoid changing cat litter
17
Q
rubella: ?% lead to fetal death or premature stillborn delivery
A
40%
18
Q
s/s rubella
A
- “Blueberry Muffin Syndrome” - thrombocytopenia with petechiae or purpura
- Ophthalmologic - cataracts, retinopathy, glaucoma
- Cardiac - PDA and Peripheral pulmonary artery stenosis
- Auditory - sensorineural hearing loss
- Neurologic - behavior disorder, meningoencephalitis and mental retardation
- Microcephaly
19
Q
work up for rubella
A
- IgM ab = recent infection
- serial IgG over several months can be confirmation
- CX - blood, urine and CSF are detectable as well
20
Q
rubella: Tend to shed live virus in ___, ____, and ___ for up to 1 year
A
urine, stool, and respiratory secretions
21
Q
Is Rubella worse if mom gets it early or late in pregnancy?
A
early
22
Q
MC congenital infection?
A
CMV
23
Q
what type of virus is CMV?
A
Double stranded DNA herpes virus
24
Q
how is CMV transmitted?
A
Requires intimate contact: blood, saliva, etc.
25
CMV: Severe problems can occur at any trimester but greater if exposed when?
first trimester
26
congenital CMV is 3-7x greater in what type of pregnancies
| hint: age group
adolescent pregnancies
27
Leading cause of non-hereditary sensorineural hearing loss
CMV
28
presentation of CMV
* **sensorineural hearing loss**
* Microcephaly
* Intracranial calcifications / periventricular
* Hepatosplenomegaly / Jaundice
* Mental Retardation
* Retinal Disease
* Cerebral Palsy
* Thrombocytopenia / Petechiae
29
how to dx CMV?
* **DX: Clinically**
* Elevated liver transaminases, thrombocytopenia, bilirubin
* CMV detection in urine or saliva (_within first 3 wks of life_)
* CT: intracranial lesions - usually periventricular
* IgM and IgG
* PCR studies (check viral load)
* Detection of CMV _w/n first 3 wks_ after birth = congenital CMV infection; _after first 3 wks_ = perinatal exposure
30
CMV tx
* **No antivirals currently approved**
* Very symptomatic - **ganciclovir and valganciclovir** - NEED APPROVAL
* Long term tx - PT, Birth to Three, Children with Special Health Care Needs, Hospice.
31
?% pregnant women have evidence of past HSV infection
30-60%
32
which HSV type accounts for 70% or more of neonatal herpes infections or congenital cases
HSV 2
33
Primary genital herpes infection and vaginal birth: ?% risk of infecting baby
25-50
34
HSV: Highest risk intrauterine is during what trimester
3rd trimester
35
?% infants who acquire HSV infection are born to mothers with no previous hx or clinical findings consistent with HSV infection
75
36
HSV: Disseminated infection should be considered in any infant and neonatal with symptoms of ?
sepsis, liver dysfunction and negative bacteriologic cultures.
neonate - fever, irritability and / or abnml CSF findings and seizures
37
Congenital HSV - Triad of symptoms:
1. Skin vesicles
2. Ulcerations
3. Scarring eye damage
38
additional HSV presentations
* Organomegaly (usually liver and lungs)
* CNS abnormalities
* Prematurity (< 36 wks gestation)
* Localized infections of skin, eyes and mouth is usually first indication of infection (45%)
39
how to DX HSV?
* **Specimen CX** - vesicles, eyes, urine, nasopharynx, blood, CSF, stool or rectum
* PCR - sensitive for detecting HSV DNA in blood, urine and CSF
40
HSV tx
**IV Acyclovir **
given to all infants suspected to have infection or dx of HSV.
41
recommendations for HSV
* USPSTF does not recommend screening asx mothers
* ACOG recommends c-section delivery for ALL mothers with active genital lesions
* DO NOT KISS THE BABIES
42
if mom is infected with VZV during the first half of pregnancy, what are the chances for transmission?
low
43
Congenital Varicella syndrome s/s
* **Cicatricial skin lesions** (**zig zag skin** scarring and limb atrophy)
* Ocular defects - cataracts, retinitis
* CNS - hydrocephalus, microcephaly, seizures, mental retardation
* Death 20-30% for a child of a mother who develops varicella 5-7 days after delivery
44
how to dx varicella?
* Usually based upon the characteristic appearance of skin lesions
* Scraping of vesicle base and testing PCR for varicella
* IgM may be detected 3 d after sx appear
* IgG increased in serum confirms dx and may be present as early as 7 d after sx appear
45
Varicella : treatment? can you breastfeed?
1. **VariZIG - varicella zoster immune globulin** (**IVIG**)
- Prophylaxis Exposure
- Given to any infant with perinatal exposure
- Given to all infants < 28 wks gestation following postnatal exposure
2. Isolation
3. Acyclovir - 30 mg/kg per day TID IV
4. Breastfeeding encouraged in exposed newborns d/t antibodies in breast milk
46
3 ways Parvo B19 is known as:
* Human Parvovirus B19
* Fifth’s Disease
* Erythema Infectiosum
47
what type of virus is Parvo B19
Single-stranded DNA virus
48
Parvo B19 has highest infection rates in what professions?
teachers and daycare workers
49
s/s of parvo B19?
* Mild systemic sx - fever, **lacy rash, slapped cheeks**
* **Fetal anemia**
* Myocarditis
* **Hydrops fetalis**
* Children infected have 1-4 days of systemic sx before the appearance of rash.
* **Arthropathy** - joints of hands, wrists, knees and ankles; lasts 1-2 wks.
50
a serious fetal condition defined as **abnormal accumulation of fluid in 2 or more fetal compartments**, including ascites, pleural effusion, pericardial effusion, and skin edema.
Hydrops fetalis (fetal hydrops)
51
how to dx parvo B19
* Pregnant women exposed - **IgG + IgM; US; percutaneous umbilical cord blood sampling**
* Positive IgM test result indicates that infection probably occurred within the past 2-4 mo
52
tx for Parvo B19
* _acute infection > 20 wks gestation_ - US weekly looking for signs of fetal hydrops
* _Infants who survive_ - supp on management of hydrops.
* _Aplastic crisis_ - blood transfusions
53
what is syphilis caused by?
Spirochete Treponema pallidum
54
Syphilis is MC transmitted by ?
**transplacental infection of fetus**
- nearly **100%** chance of passage to fetus if active primary or secondary infection, but **can be acquired by contact with chancre**
55
syphilis: ?% result in spontaneous abortion
40%
56
how many infants are born with congenital syphilis asx at birth but will manifest sx by 3 months of age?
2/3
57
s/s syphilis
*not transferred through breast milk*
1. Before 2 y/o
- Hepatomegaly
- **Nasal Discharge - “Snuffles” (persistent)** - White and may be bloody
- Rash
- Generalized LAD
- Skeletal abnormalities
2. After 2 y/o
- CNS abnormalities
- Abnormalities to bones, teeth, eyes, skin
58
late s/s of syphilis
* **_Hutchinson’s Triad_**: **interstitial keratitis, CNVIII deafness and Hutchinson’s teeth**
* Rhagades - cracks and fissures around mouth and chin
* Bowing shins
* Saddle nose
* _Mulberry molars_: round cusps on enamel on permanent first molars
* _Clutton Joints_: symmetrical joint edema/synovial inflammation
59
What conditions would require further evaluation in regards to mom's syphilis status?
* Any child born to a mother with positive testing w/o adequate tx with PCN
* infants whose mothers were treated < 1 mo prior to delivery
* should not be DC w/o knowing mom’s syphilis status
59
how to dx syphilis
* Serum quantitative nontreponemal titer > fourfold mother’s titer
* **Direct visualization of *T. Pallidum* by dark field exam from bodily fluids**
60
syphilis tx
1. **Parenteral PCN**
- aq PCN G x 10 d - 50,000 U/kg q12h IV
- Procaine PCN G x 10 d - 50,000 U/kg QD IM
2. **Repeat antibody titers at 3, 6, 12 mo to document falling titers**
61
MCC of sexually transmitted genital infections in the US
chlamydia
62
chlamydia is transmitted to newborns via ?
exposure to an infected mother’s genital flora during vaginal birth
63
how are mothers screened for chlamydia?
via vaginal swab or first pass urine specimen
64
s/s chlamydia
* Conjunctivitis - incubation 5-14 days post delivery - Both eyes
* Pneumonia
65
chlamydia should be suspected in any infant how old and with what sign?
under a month of age with conjunctivitis if possibility of exposure
66
gold standard of dx chlamydia
**isolation of C trachomatis by cx**
Swabs of both _conjunctival and nasopharyngeal samples_
67
tx chlamydia
* **_Topical therapy not effective_**
* **Erythromycin PO** x 14 d
* All pregnant women should be screened at the first pregnancy visit
68
what pathogen causes gonorrhea
Neisseria Gonorrhoeae - G- diplococci
69
s/s gonorrhea
* **Eye MC frequent site of infection (BL)**
* **Purulent conjunctivitis**
* Profuse exudate and swelling of eyelid
* May also present as scalp abscesses, vaginitis and bacteremia
70
who to screen for gonorrhea
Screening for those at increased risk for infection:
* previous STD infection
* multiple sexual partners
* inconsistent condom use
* commercial sexual partners
* drug use
* in communities with high prevalence of disease
71
Neonatal prophylaxis gonorrha
Erythromycin ophthalmic ointment
72
dx for gonorrhea
Gram stain of conjunctival exudate
73
tx gonorrhea
* Single dose of **Ceftriaxone**
* asx infants whose mothers have untreated disease should **receive the same tx**
* Test for the others
74
how can HIV be transmitted?
from mother to baby transplacentally in utero, during birth or by **breastfeeding**
75
ways to decrease the risk of HIV transmission
* antiretroviral tx of mother before and during delivery
* tx of infant first 6 wks of life
* C-section
* avoidance of breastfeeding
76
what increases the risk of HIV transmission by 30-50%?
Breastfeeding
77
HIV presentation
Newborns are typically **asx**
78
HIV dx
**HIV DNA PCR**
< 48 hrs of age, 2 wks, 1-2 mo, and at 2-4 mo
If 4 months and older with a neg PCR - HIV excluded
79
tx HIV
Antiretroviral prophylaxis (**Zidovudine**) for 6 wks for infants born to HIV-infected mothers
80
type of virus Hep C
HCV - small, single stranded RNA virus
81
primary source of pediatric infection of Hep C
Vertical transmission
82
Hep C: _5% transmission rate_ from mother to baby; what other condition increases risk?
HIV
83
RF for Hep C
* IV drug use
* tattoos (of the at-home or prison variety)
84
can you breastfeed while having Hep C?
yes, not CI
85
how to dx Hep C
* Anti-HCV (HCV antibody testing) present in blood after 18 mo of age is indicator
* confirmed with **HCV RNA test**, then HCV Genotyping
86
tx Hep C
decided by GI- interferon and ribavirin
87
presentation of Hep C
MC asx
88
presentation HPV
hoarseness in children later on in life
89
prevention of HPV
HPV or Gardasil vaccine
90
Congenital Zika Syndrome is caused by what
Arthropod-borne flavivirus transmitted by mosquitoes
91
pathway of infection of Zika
1. Maternal infection
1. placental transmission
1. virus targets neural progenitor cells in fetal brain
1. kills progenitor cells
92
presentation Zika syndrome
asx or sx
* Fetal growth restriction
* Fetal demise - 5-10%
* Ventriculomegaly
* **Microcephaly**
* **Ocular** - Optic nerve and retinal pathology; Retinal scarring
* **Hearing loss** - sensorineural, possibly delayed
* **Arthrogryposis** - Congenital joint contracture; Congenital club foot
* **Cardiac** - ASD, VSD, PFO
* **Neurogenic** - Hypertonia; Spasticity; Hyperreflexia; Seizures / Epilepsy
* **SGA**
93
describe the microcephaly in Zika
* Severe with partial skull collapse
* Thin cerebral cortices with subcortical calcifications
* Craniofacial disproportion
* Craniosynostosis
94
how to eval Zika
* H&P - Head circumference / development
* Lab studies
* Cranial U/S (primary screening tool)
* Hearing Assessment
* Radiologic findings
95
what lab shows definitive infection of Zika
(+) Serum + Urine for Zika RNA via PCR
96
what two labs show probable Zika infection
1. Serum Zika IgM
1. CSF for RNA and IgM
If both of these negative = Likely negative
97
tx Zika syndrome
1. No specific tx - multifaceted
1. Referrals
- Ophthalmology w/in 1 month of birth
- Hearing screen - newborn (ABR preferred)
- Neurology, ID, Genetics, Development
- Labs - Zika detection, CBC, CMP, genetics
1. Infants born to Zika (+) mothers w/o clinical findings
- Head US and ophthalmologic exam and ABR hearing test by 1 mo of age
98
Newborn is considered any child within the first ? days of life
28
99
Three major routes of perinatal infection
1. Bloodborne transplacental - CMV, etc.
2. Ascending with disruption of the amniotic barrier (PRM) - Bacterial infections after 12-18 hrs of ruptured membranes
3. Infection via passage through birth canal - HSV, HIV, GBS, etc.
100
Most with early-onset sepsis will present at what age
< 24 hrs of age
101
presentation of sepsis
* **Resp distress MC**
* hypotension, acidemia, and neutropenia
* Range from subtle to profound septic shock
* Temperature instability
* Irritability
* Lethargy
* Poor feeding
* Respiratory sx
* Tachycardia
* Poor perfusion
* hypotension
102
MC pathogen to cause sepsis
group B strep
103
newborn sepsis w/u for how long?
| (__ days of age)
7-90 days of age
104
rectal temp considered sepsis
100.4
105
Medical emergency, specifically ? days or under requiring a full work-up and hospital admission
60
106
work-up for newborn sepsis
* CBC
* BMP
* Urine cath and culture
* CXR
* CRP and Procalcitonin
* Blood cultures
* NP swab
* LP cultures
107
tx for newborn sepsis
* hospital admission with empiric abx until all cultures return
* **Ampicillin + Cefotaxime/Gentamicin**
* Questionable Acyclovir
* Close follow-up by PCP after discharge
