Congenital, perinatal, neonatal infections

Question 1

What are examples of congenital infections

Answer 1

Rubella
Cytomegalovirus (CMV)
Toxoplasma gondii
Parvovirus
Varicella zoster
Syphilis

Question 2

What are the features of congenital rubella infection

Answer 2

Risk and extent of foetal damage are determined by gestational age at onset of maternal infection
<8 weeks gestation:
- Deafness
- Congenital heart disease
- Cataracts
13-16 weeks gestation:
- Impaired hearing
- Beyond 18 weeks, risk to the foetus is minimal

Question 3

What investigations and treatment should be done for rubella

Answer 3

Seroconversion on screening serology
Blood serology for IgM
Amniocentesis or CVS
PCR
Infant urine testing

Prevention via the MMR programme (13-14 months and 3 years)

Question 4

What are the features of congenital CMV

Answer 4

Most common congenital infection (0.5/1000 in the UK)
DNA virus from the herpes family (HHV-5)
90% will have a normal birth and develop normally
5% have clinical features at birth
- Hepatosplenomegaly
- Petechiae
- Jaundice ± blueberry muffin rash
- IUGR
- Chorioretinitis → cataracts
- Neurodevelopmental disabilities e.g. sensorineural hearing loss, cerebral palsy, epilepsy, cognitive impairment
- PERIVENTRICULAR calcifications
5% develop problems later e.g. sensorineural hearing loss

Question 5

What investigations should be done for congenital CMV

Answer 5

Seroconversion on screening serology
Blood serology for IgM
Amniocentesis or CVS
Infant urine testing for PCR

Question 6

What is the management for congenital CMV

Answer 6

Infants: Early antiviral therapy with oral valganciclovir for 6 months or IV ganciclovir

+ audiology follow up
+ ophthalmology follow up

Question 7

What is Toxoplasma gondii and what are the causes

Answer 7

Protozoan parasite
Consumption of raw or undercooked meat and contact with faeces of infected cats
Increased risk of vertical transmission with increasing gestational age (5% 1st, 80% 3rd trimester)
- Infection in 1st trimester- most likely to cause foetal damage but transmission rate is LOW (10%)
- In 3rd trimester- risk of foetal damage is low (10%) but transmission MUCH higher (85%)
Risk of congenital toxoplasmosis reduced with increasing gestational age (60-80% 1st, 5% 3rd)

Question 8

What are the clinical features of congenital toxoplasmosis

Answer 8

Most infected infants are asymptomatic, but 10% may have manifestations such as (The 4C’s):
- Retinopathy, an acute fundal chorioretinitis, which sometimes interferes with vision
- Cerebral scattered calcification (Tram-like)
- Hydrocephalus (microcephaly)
- Convulsions
+ hepatosplenomegaly/jaundice

Infants will usually have long-term neurological disabilities e.g. deafness, low IQ, microcephaly

Question 9

What are the investigations for congenital toxoplasmosis

Answer 9

Not usually screened
Sabin Feldmann Dye test
Bloods: IgM (active), IgG(immunity)
US: foetal anomaly scan
Amniocentesis + PCR to detect foetal infection

Question 10

What is the management for toxoplasmosis

Answer 10

Pyrimethamine and sulfadiazine + calcium folinate for 1 year

Mother should avoid raw/rare meat and handling cats/cat litter

Question 11

What are the features of parvovirus B19 infection

Answer 11

Up to 75% of women are immune to parvovirus B19
Infection is rare and usually uneventful
Can cause:
- Spontaneous miscarriage
- Stillbirth
- Hydrops fetalis (oedema and ascites from HF)

Question 12

What is the management for antenatal parvovirus B19 infection

Answer 12

Infection identified → serial ultrasound monitoring to detect foetal anaemia and need for intrauterine transfusion

Question 13

What are the features of congenital varicella zoster

Answer 13

<20 weeks
- Severe scarring of the skin
- Ocular damage
- Neurological damage
- Digital dysplasia

Last 4 weeks of pregnancy + 7 days after delivery - foetus is unprotected by maternal Abx
- Vesicular rash
- High mortality rate

Question 14

What is the management for congenital varicella zoster

Answer 14

Varicella zoster Immunoglobulin
Treatment with aciclovir

Foetus: VZIG + monitoring + aciclovir for signs of infection

Question 15

What are the features of congenital syphilis

Answer 15

Gram-ve spirochete (Treponema pallidum)
Transmission is via sexual contact, vertically, or blood-bourne

Rash on the soles of the feet and hands
Bone lesions
Bloody rhinitis
Hepatosplenomegaly
Glomerulonephritis
“Hutchinson’s teeth” (small, widely spaced, notched)
Frontal bossing of skull, saddle-nose
“Saber’s shins” (anterior bowing)
“Clutton’s joints” (symmetrical knee swelling)

Question 16

What investigations should be done for congenital syphilis

Answer 16

Microbiolgy: Dark-ground (from chancre)
PCR +ve
Infant TP syphilis IgM test

Question 17

What is the management for congenital syphilis

Answer 17

If mothers with syphilis identified on antenatal screening are fully treated 1 month or more before delivery, the infant does not require treatment and has an excellent prognosis
If there is any doubt about the adequacy of maternal treatment, the infant should be treated with penicillin.

IV benzylpenicillin

Question 18

What are the risk factors for neonatal infection

Answer 18

Mothers previously had baby with invasive GBS
Current GBS colonisation, bacteriuria or infection in current pregnancy
Prelabour rupture of membranes
Intrapartum temperature ≥ 38oC or suspected chorioamnionitis
Rupture of membranes ≥ 18 hours
Premature (< 37 weeks)
Suspected or confirmed infection in another baby in case of multiple pregnancy

Question 19

Why are preterm infants at an increase risk of infection

Answer 19

IgG is mostly transferred across the placenta in the last trimester, with no IgA or IgM transfer
Infection in or around the cervix is also a cause of preterm labour
Higher risk of nosocomial infection, often associated with indwelling catheters of mechanical ventilation

Contributes to bronchopulmonary dysplasia, brain injury and later disability

Question 20

What are the causes of early neonatal sepsis

Answer 20

Early-onset (<72h after birth)
- Group B Strep
- E. Coli
- Klebsiella
- Pseudomonas
- listeria monocytogenes
Vertical exposure from ascending infection or exposure to high bacterial load during birth, after ROM

Question 21

What are the causes of late-onset sepsis

Answer 21

Late-onset (>72h)
- Coagulase-negative staphylococcus (CONS) - staph. epidermis
- Staph aureus
- Enterococcus faecalis
- E. Coli
- Pseudomonas
- Klebsiella

Transmission from contamination by staff, ventral venous catheters, invasive procedures and tracheal tubes

Question 22

What are the signs of neonatal sepsis

Answer 22

Respiratory distress: Tachypnoea (>60), Intercostal recessions, Grunting, Cyanosis
Temperature instability (hypothermia to hyperthermia)
Poor feeding, irritability, lethargy, drowsiness
Vomiting
Apnoea and bradycardia
Abdominal distension
Shock
Jaundice
Seizures

Meningitis: tense or bulging fontanelle, head retraction (opisthotonos)

Question 23

What are the red flags for neonatal sepsis and what should be done if they are present

Answer 23

RR >60 min-1 or >5 below normal, or grunting
Oxygen needed to maintain saturations >92 %
Pale/mottled or non-blanching (purpuric) rash
Prolonged capillary refill >5 seconds
Hypotension
AVPU = V, P or U
Abnormal behaviour*
Blood lactate >2mmol/L

→ immediate sepsis 6 pathway

Question 24

What is the management for neonatal sepsis

Answer 24

Admit
A-E
Involve seniors
Initiate sepsis 6 (Within 1 hours):
1. Administer high flow oxygen
2. Gain IV or IO access and order:
- Blood cultures (BEFORE Abx)
- Blood glucose, lactate (VBG/ABG), FBC, CRP, U&Es, Creatinine, Clotting screen
3. Administer broad-spectrum antibiotic* within one hour of sepsis recognition + monitor response by using CRP
4. Measure Fluids
- Given in hypotension or lactate >4mm/l
- Initial minimum 20ml/kg crystalloid 0.9% NaCl bolus over 5-10 minutes
- Vasopressors for hypotension that does not respond to fluid resuscitation
- Measure urine output
5. Involve seniors
6. Consider inotropic support

Question 25

What are the antibiotic regimens for neonatal sepsis

Answer 25

Early onset
- IV Benzylpenicillin + Gentamicin
- Stop after 36-48h if cultures and CRP are negative
Late onset
- First line: Abx - flucloxacillin + gentamicin
- Second line: specific Abx (e.g. vancomycin for CONS/enterococci) or *broad-spectrum Abx e.g. meropenem

Question 26

Describe transmission of congenital HIV

Answer 26

present in vaginal fluid, semen, blood, breast milk → transmission through sexual contact, BB, vertical
Less transmission through vaginal mucosa than through anal mucosa
HIGHEST risk of transmission if mother is newly diagnosed at the beginning of pregnancy or near delivery (as viral load is extremely high in acute phase of infection)

Question 27

what are the signs and symptoms of congenital HIV

Answer 27

Recurrent and severe infection
Unusual rash
Hepatosplenomegaly

Question 28

What is the management for congenital HIV

Answer 28

Decision to treat with PEP based on guidelines (i.e. only ‘considered’ if penetrative vaginal intercourse)
Cord clamped as soon as possible and baby bathed immediately after birth
Zidovudine monotherapy for 2-4w (low/medium risk) OR 4w PEP combination (high risk/confirmed)
Women not to breastfeed
Give all immunisations including BCG (unless a moderate-high risk of transmission)
Confirm or deny diagnosis of HIV in the neonate with direct viral amplification by PCR
(normally carried out at birth, on discharge, 6 weeks, and 6 months)

Question 29

What is the management for babies born to mothers with viral hepatitis

Answer 29

Hep B: HBV IVIG within 12h of birth + vaccinate at birth, 1 month, 6 months + serological test at 12 months
Hep A: resolves within 6 months
± phototherapy/exchange therapy

Question 30

What are the signs and symptoms of congenital HSV

Answer 30

Microcephaly
Encephalomalacia
Hydranencephaly and/or intracranial calcification
Scarring, active lesions, hypo- and hyperpigmentation
Microphthalmia, retinal dysplasia, optic atrophy and/or chorioretinitis

Question 31

What are the signs and symptoms of neonatal HSV infection

Answer 31

Skin/eye/mouth (SEM) disease: blistering vesicular rash, chorioretinitis
CNS disease ± SEM:
- Seizures
- Lethargy
- Presents 10d-4w postpartum
- Irritability
- Poor feeding
- Temperature instability
- Bulging fontanelle
Disseminated infection: encephalitis, CNS, hepatitis, pneumonitis, no skin lesions, DIC

Question 32

What is the management for congenital HSV infection

Answer 32

IV aciclovir to child (14d if SEM disease  21d if CNS or disseminated)

+ monitor neutrophil count

Question 33

What is the aetiology of neonatal GBS

Answer 33

Commensal bacterium of vagina and rectum carried by 25% women
Majority of babies who come into contact are not affected (some become colonised, minority become ill)
This is particularly dangerous if acquired around the time of delivery
Transmission occurs between the time of rupture of membranes to delivery
It is the most common cause of severe early-onset (within 7 days of delivery) infection in newborns 

Question 34

What is the management for GBS

Answer 34

Postpartum – new-borns with:
1 risk factor: remain in hospital for at least 24 hours for observations
≥2 risk factors or one red flag: sepsis ABx + septic screen
GOSH ABx in neonate <72 hours = cefotaxime + amikacin + ampicillin

Question 35

Describe listeriosis

Answer 35

Found in soil, decayed matter and animals
People with reduced cell-mediated immunity (i.e. pregnant women, neonates) are most at risk
Faecal-oral transmission (soft cheese, pate, unpasteurised dairy products, unwashed salads)
Vertical (transplacental or during delivery (ascending route through the cervix))

Question 36

What are the signs and symptoms of neonatal listeriosis

Answer 36

fever
Lethargy
Irritability
Diarrhoea
poor feeding
Vomiting
respiratory distress
skin rash - widely spread, small, pale nodules (granulomatosis infantiseptica)

Question 37

What is the management for neonatal listeriosis

Answer 37

IV ampicillin 2 g hourly for 14 days (or IV amoxicillin 6g/day) + gentamicin