Exam 2 Flashcards
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What is asymptomatic bacteriuria?
An asymptomatic urinary tract infection with a urine culture that has colonies of greater than or = to 2 different micro organisms obtained via clean catch midstream urine sample.
What is the relationship of asymptomatic bacteriuria to Foley catheter.
No Foley catheter within 7 days.
What organism count is diagnostic in asymptomatic bacteriuria?
Great in 100000 organisms per milliliter
How would you treat a symptomatic bacteriuria empirically?
Macrobid 100 mg at bedtime times 10 days or 100 mg BID times 7 days
What are additional treatment options for asymptomatic bacteriuria?
Amoxicillin, ampicillin, cephalospirin, nitrofurantoin, tx-smp, cipro, levofloxacin
What is acute cystitis?
An infection limited to the lower urinary tract.
What are the signs and symptoms of acute cystitis?
Dysuria, Urgency, frequency
How is acute cystitis diagnosed?
Via UA
How is acute cystitis treated?
Macrobid 100 mg at bedtime times 10 days or 100 mg BID times 7 days
What are alternative treatments for acute cystitis?
Amoxicillin, ampicillin, cephalospirin, nitrofurantoin, tx-smp, cipro, levofloxacin
What is pylonephritis?
An infection ascending to the renal system.
What are signs and symptoms of pylonephritis?
Fever, flank pain, with or without symptoms of lower urinary tract infection but with bacteriuria.
What are the differential diagnosis for pylonephritis?
Labor, chorioamnionitis, adnexal torsion, appendicitis, placental abruption, infarcted leiomyoma
How is pylonephritis Diagnosed?
Urine sample via straight cath.
What will you see in a urine sample of pylonephritis?
Leukocytes in clumps and numerous bacteria
How do you treat pylonephritis Empirically?
Ampicillin, gentamicin, cefazolin, ceftriaxone
What is noted on exam with pylonephritis?
Unilateral -z mostly right, Fever, shaking chills, aching pain in one or both lumbar regions, anorexia, nausea/vomiting, CVA tenderness
How is pylonephritis managed?
Repeat urine cultures and blood cultures if temperature is above 39ﾟC elsius.
IV to ensure adequate urinary output
Antibiotics - Initially may worsen endotoximia from bacterial lysis
Surveillance - BP, HR, temp, O2 sat
Use cooling blanket for high fever.
What is preterm labor?
Birth prior to 37 completed weeks gestation.
What are risk factors for preterm labor?
Low maternal pre pregnancy weight, smoking, substance use, shorter interpregnancy interval, history of preterm birth, vaginal bleeding, UTI, genital tract infections, periodontal disease.
Discuss racial and ethnic the spirities in preterm labor.
Native Hawaiian/Pacific islander 11.8% American Indian/ Alaska native 11.5% Non Hispanic black women 14.4% 50% higher than both white and Hispanic women Hispanic 10% White 9.3%
What are the differential diagnosis for preterm labor?
Braxton Hicks contractions, dehydration, lax vaginal tone, round ligament pain, infection, abruption, trauma, appendicitis
What is fetal fibronectin?
A fibronectin produced by fetal cells found at the interface of the chorion and decidua. It is the adhesive or glue that binds the fetal sac to the uterine lining.
When is fetal fibronectin Present in cervicovaginal secretions?
Prior to 20 weeks and after 37 weeks.
When is the presence of fetal fibronectin In cervico vaginal secretions atypical?
Between 24 and 34 weeks.
What could the presence of fetal fibronectin Between 24 and 34 weeks indicate?
Inflammation or uterine activity which could lead to preterm birth
When is fetal fibronectin Testing used?
Between 24 and 34 weeks
What is the criteria for fetal fibronectin Testing?
It is not to be used as a screening test.
Is the negative predictability offetal fibronectin high or low?
Fetal fibronectin testing has a high negative predictability (97.6).
What does the high negative predictability of fetal fibronectin testing mean?
That birth will not occur in the next 7 days.
Of what use is a positive fetal fibronectin test in symptomatic women?
A positive fetal fibronectin test in symptomatic women has limited clinical utility and should not be used alone to determine management.
Of what use is a negative fetal fibronectin test?
A negative fetal fibronectin test can be useful in avoiding unnecessary treatment in symptomatic women.
What is the predictability of a positive fetal fibronectin test?
Only 1% to 2% chance of birth within the next 7 to 14 days.
What is the purpose of corticosteroid use in preterm labor?
Maturity of fetal lungs
How and when is betomethasone used?
Betamethasone 12 mg IM q 24 hours X 2
Use at 34 to 36 6/7 weeks
How and when is dexamethasone used?
Dexamethasone 6 mg IM q 12 hours X 4
Use prior to 34 up to 36 6/7 weeks
Are scheduled repeat courses of corticosteroids used?
No, give one course
When may a repeat course of corticosteroids be given?
May repeat course X 1 when previous course wasvgiven 7 days earlier and there was risk for preterm birth at less than 34 weeks
How is cervical length measured?
Via transvaginal ultrasound
What is the relationship of cervical length to preterm birth?
Cervical shortening in the mid trimester increases the risk of premature birth. The risk of premature birth is inversely proportional to cervical length and significantly increases with decreasing cervical length.
What is considered short cervical length with a history of preterm birth?
25 mm
What is considered short cervical length with no history of preterm birth?
20 mm
Is hydration effective in preventing preterm birth?
No
Is bedrest effective in preventing preterm birth?
No
What is the role of progesterone in preterm birth in patients with short cervix?
Progesterone has been shown to decrease the risk of preterm birth impatience with short cervix.
In what forms are progesterone used to decrease the risk of preterm birth?
Vaginal
17 alpha hydroxprogesterone caproate (17-OHPC) - injectable
When is vaginal progesterone used in pts with short cervix?
Singleton, short cervix, no prior preterm birth, asymptomatic
When is 17 OHPC used in pts with short cervix?
History of preterm birth
Between 16 and 36 weeks
Not with multifetal gestation or PROM
How is 17 OHPC dosed in pts with short cervix?
250 mg weekly from 16 to 36 weeks
When is cerclage used?
In women with very short cervical length – 10 mm or less
What are tocolytics?
Medications to slow uterine contractions
What is the usefulness of tocolytics?
They may delay birth for 2 to 7 days?
What is an advantage if using tocolytics?
May provide short term prolongation of pregnancy enabling the administration of antenatal corticosteroids and magnesium for neural protection.
What tocolytics are used in preterm labor?
Beta adrenergic receptor agonists Calcium channel blockers NSAIDs Magnesium sulfate Indomethacin before 34 weeks with magnesium sulfate
What is the purpose of magnesium sulfate in preterm labor?
Magnesium sulfate is given for neuro protection and reduces the rusk of cerebral palsy if < 32 weeks
What are two assessments in preterm labor?
Assessment of cervical length
Assessment of the presence of fetal fibronectin in cervicovaginal secretions (low positive predictive value in asymptomatic women)
How can preterm labor be prevented?
Vaginal progesterone
IM progesterone
Cerclage
Cervical length monitoring and subsequent interventions
What is preterm premature rupture of membranes pPROM)?
PROM occurring before 37 weeks
What are the maternal risks of pPROM?
Intraamniotic infection
Post partum infection
Placenta abruption
What are the neonatal risks of pPROM?
Complications of prematurity Increasing according to gestational age
Respiratory distress Sepsis Intraventricular hemorrhage Necrotizing enterocolitis Increased risk of neuro developmental impairment.
What are differential diagnosis for pPROM?
Urinary incontinence
Vaginal or cervical discharge
Rarely rupture of the chorion alone
What are 2 things to remember about the exam for pPROM?
Visual cervical exam should be performed within 6 to 12 hours
No digital vaginal/cervical exam unless there are signs of active labor
What is the management of in a periviable pregnancy with pPROM?
23 to 24 weeks counseling, expectant management or induction, antibiotics
What is the management of a preterm pregnancy with pPROM?
Between 24 and 33 6/7
Expectant management, antibiotics, single corticosteroids, treat any intra amniotic infection, GBS culture, magnesium sulfate if less than 32 0/7 weeks
What is the management of late preterm labor with pPROM?
34 0/7 to 36 6/7
Expectant management or proceed toward delivery, single corticosteroids, GPS screening and prophylaxis, treat any intra amniotic infection
What is the management of any term pregnancy with pPROM?
37 0/7 or greater
GPS prophylaxis, Treat any intra amniotic infection, proceed toward delivery
What is intra amniotic infection (chorioamnionitis)?
Infection with resultant inflammation of amnionic fluid, placenta, fetus, fetal membranes, and/or decidua
What are the risk factors for intra amniotic infection?
Prolonged rupture of membranes Long labors Manipulative vaginal or intrauterine procedures Frequent cervical exams Dehydration
What is the clinical presentation Of intra amniotic infection?
Isolated maternal fever of or greater than 39ﾟC
What is the clinical presentation of suspected in of suspected intra amniotic infection?
Maternal intra partum fever and maternal leukocytosis, purulent cervical drainage, or fetal tachycardia
What is the clinical presentation of confirmed intra amniotic infection?
Positive amniotic fluid test result or placenta pathology demonstrating hysterologic evidence of placenta infection or inflammation
How is intra amniotic infection managed?
Intra partum antibiotics and antipyretics
There should be enhanced clinical surveillance of the infant for signs of developing infection.
What causes hepatitis B?
Hepatitis B virus
How is hepatitis B transmitted?
Sexually, IV drug use, perinatally
When are pregnant women tested for hepatitis B?
Hepatitis B screening takes place at the 1st prenatal visit.
How is hepatitis B diagnosed
Hepatitis B surface antigen
How does hepatitis B affect the pregnant woman?
Acute illness
Chronic Carrier
How does hepatitis be affect the fetus or newborn?
Chronic Carrier
Can develop significant illness
How is hepatitis B managed in pregnancy ?
Adequate rest
Herbs for immune support
Education on transmission
Post partum follow up with referral to GI
The risk of preterm birth is increased
Refer to infectious diseases and hepatitis specialties
Consult with pediatric provider
What causes hepatitis C?
The hepatitis C virus
How is hepatitis C transmitted?
Via blood
Perinatally
What are the screening recommendations for hepatitis C?
Every adult should be screened at least once
All pregnant women should be screened
What are the risk factors for hepatitis C?
I V drug use Sexual contacts Hiv positive women Hemodialysis patients Blood or Oregon recipient before 1992 Evidence of liver disease None's little body tattoos Ingestion of raw shellfish International travel Day workers Immigrants from Asia, Africa, Pacific islands, Haiti, Middle East, Eastern Europe
How is hepatitis C diagnosed?
IgG anti HCV
VIA EIA or CLIA
How does appetite to see affect the pregnant woman ?
All cause mortality is increased by infection with hepatitis C.
Significantly increases the risk of cholestasis by 20 times
How is Hepatitis C managed in the pregnant woman?
Referral to infectious disease or hepatitis specialist
Infant is referred to pediatrician.
Is breast feeding contraindicated in hepatitis C patients?
Breastfeeding is not contraindicated unless the patient is taking anti viral therapy.
What is the causative agent of Group B Strep?
Group B streptococcus bacteria
How is group B strep transmitted?
Via the vaginal birth process
How is group B strep diagnosed?
Group B strapped culture at 35 to 37 weeks of gestation
Positive group B strip in urine culture during pregnancy
Previous infant with group B strep disease
CBC
Cultures at birth of the amnion/placenta, infants axilla, groin, or earfold
What is the effect of group be strapped on the pregnant woman?
It might be harmless, she might have a uti, pneumonia, sepsis
What is the effect of group B strep on the fetus/newborn?
Early onset is associated with newborn sepsis and pneumonia or less frequently, meningitis which is more commonly seen in late onset and they’ve seen in late onset GBS disease
What are maternal signs and symptoms of GPS disease disease?
Febrile
Significant and persistent fetal tachycardia
Odor to amniotic fluid
Uterin tenderness
What are newborn signs and symptoms of GBS disease?
Fever Pallor and poor tone Respiratory distress Slow irregular pulse Difficulty feeding
How is GBS disease treated?
IV intra partum prophylaxis with penicillin or ampicillin
1st generation cephalosporins (cefazolin)
Clindamycin is for c-sections,
Not necessary if c-section is performed prelabor
What causes HIV?
Human immuno deficiency virus
How is HIV transmitted?
Infected blood and bodily secretions
Breastfeeding
Perinatally
When does screening occur in pregnant women for hiv question
At 1st prenatal visit
What does opt out testing refer to with HIV?
Testing after advising of testing and of notifying of option to refuse
How is hiv diagnosed?
ELISA
western blot
Rapid
Anti retroviral drug resistance testing
How is hiv managed?
Refer to OB
What is the causative agent of Genital herpes?
Herpes simplex virus
How is genital herpes transmitted?
Via direct contact
What are signs and symptoms of genital herpes
Genital or anal blisters or ulcers
How does genital herpes affect the pregnant woman?
Painful outbreaks
How does genital herpes affect the fetus/newborn ?
No known effects from exposure to acyclovir?
Neonatal herpes is rare
How is genital herpes managed in pregnancy?
Consult with maternal fetal medicine and infectious disease.
Antiviral therapy with acyclovir, valacyclovir, famicyclovir
Refer infant to pediatric infectious disease. Treat with acyclovir.
What is the parvo virus?
Parvovirus is caused by the human parvo virus B19 which can lead to eyrthema infectiosum and is known as 5th’s disease
How is parvovirus transmitted it?
Yeah respiratory droplets, blood and blood derived products, perinatally
What are signs and symptoms of parvovirus infection?
Slapped cheeks Lacy red rash on the cheeks, legs, belly, and neck Arthralgia Arthritis Fever Or can be asymptomatic
What is a sequella of parvovirus infection ?
It is a potent inhibitor of a erythropoiesis.
How does the powerful virus affect the pregnant woman?
Symptoms of viral infection
Reduced feedle movements
Hydrops fetalis
How does the Powerful virus effect the fetus/newborn?
The greatest risk is in the 1st 22 weeks Vertical transmission can occur within 1 to 3 weeks of maternal infection May resolve or not Nonimmune hydrops Hyperechoic bowel myocarditis CNS damage Encephalopathy Cerebral migratory anomalies Neonatal encephalitis Intrauterine fetal demise
How can parvovirus be prevented?
Hand washing
Disposal of items with bodily fluids
Cover cough
Avoid exposure to those with 5th disease
How is parvovirus treated?
Weekly ultrasound to determine hydrops which necessitates urgent referral to tertiary care center.
What causes toxoplasmosis?
Toxoplasma gendii
How is toxoplasmosis transmitted?
By eating raw or undercooked meat infected with tissue cysts or by contact with cocysts from cat feces
Vertical transmission
What are signs and symptoms of toxoplasmosis infection?
Most maternal infections are sub clinical
Fatigue, fever, headache, muscle pain, maculopapular rash, posterior cervical lymphadenopathy.
Can be severe if immuno compromised
Encephalitis, retinal choroiditis, mass lesions
How does toxoplasmosis affect the pregnant woman?
There is a 4 fold increase in preterm delivery
How does toxoplasmosis affect the fetus/newborn?
There can be severe neonatal infections related to gestational age.
Risk of infection increases with pregnancy
Severity greater and early pregnancy
Low birth weight, hepatosplenamagaly, jaundice, anemia, intracranial calcifications with hydrocephaly or microcephaly, chorioretinitis, learning disabilities, convulsions
How is toxoplasmosis diagnosed?
There is no prenatal screening for toxoplasmosis.
If suspected, then anti toxoplasma IgG with 2 to 3 weeks after infection.
IgM antibodies appear by 10 days
Toxoplasma serological profile
Prenatal DNA or PCR of amniotic fluid
How is toxoplasmosis prevented?
Cook me to safe temperature Peel or wash fruits and veggies Is clean all preparation surfaces Is where gloves win changing cat litter Don't feed cat Is keep cat indoors
How is toxo plasmosis treated in pregnancy?
Spiramycin alone or with pyrimethamine - sulfonamide with folinic acid
What is bacterial vaginosis?
Is a polymicrobial clinical syndrome resulting from the replacement of the normal hydrogen producing lactobacillus in the vagina with high concentrations of anaerobic bacteria.
What are signs and symptoms of better bacterial vaginosis?
Vaginal irritation and itching, dysparenia, gray or white discharge, fishy odor
75 % are asymptomatic
What is seen in BV on speculum exam?
Thin white/gray homogenous discharge, irritated vaginal mucosa and introitus, and possibly cervicitis
What is the effect of BV on the pregnant woman?
The ibcidence of preterm birth is increased.
How is BV diagnosed?
Gram stain with Nugent - rarely available Saline & KOH slides for pH Whiff test 3 of 4 Amsel's Thin homogenous discharge adhering to vaginal walls Clue cels on normal saline slide pH greater than or equal to 4.5 Positive whiff test
What is the cytomegalovirus?
Herpes family, varicella, Epstein-Barr
Establishes lifelong latency
How is cytomegalovirus transmitted?
Virus via body fluids Direct contact Sexual contact Breast milk Transplanted organs and transfusions
What are signs and symptoms of cytomegalovirus?
Fever, sore throat, fatigue, swollen glands, it can cause Epstein Barr virus or hepatitis
. In immuno compromised persons eyes, lungs, liver, esophagus, stomach, intestines can be affected
In babies brain, liver, spleen, lung, growth, can be affected
. The most common affectation is long term congenital hearing loss.
How does the cytomegalovirus affect the pregnant woman?
Fever, chills, malaise, headache, fatigue, sore throat, or they might be asymptomatic.
How does the cytomegalovirus affect the fetus?
20% are born with congenital infections, hearing loss, mental and physical developmental delays
How is the cytomegalovirus diagnosed?
Blood tests, saliva slash urine in newborn, serology, elisa, PCR is the standard, amnio testing for fetal
How is the cytomegalovirus treated in pregnancy?
There is no treatment.
How is the cytomegalovirus treated in the neonate?
Ganciclovir if they’re symptomatic the earlier the treatment starts the better the outcome
.
How is cytomegalovirus prevented?
Personal hygiene and hand washing.
What causes the zika virus?
Flaviviridae Aedes mosquito
Perinatal transmission
What are signs and symptoms of a zika virus?
Rash, headache, joint pain, red eyes, muscle pain
How does the zika virus affect the pregnant woman?
Mild illness
How does the zika virus effect the fetus/ newborn?
Birth defects, microcephaly, damage to back of eyes
What if there is possible exposure to the zika virus?
Get testing, evaluate and manage for possible dengue or chikungunya virus infection
How do you prevent the zika virus?
Avoid mosquitoes, wear condoms
How is the zika virus diagnosed?
Whole blood, serum or plasma for virus IG M and neutralizing antibodies
What is treatment for the zika virus?
Supportive care
What causes COVID-19?
Coronavirus SARS-Cov- 2
How is COVID-19 transmitted?
Airborne droplet, close personal contact
How is COVID-19 diognosed?
PCR
How does COVID-19 affect the pregnant woman?
Possible preterm birth and small for gestational age
How is rubella transmitted?
Nasal pharyngeal secretions
What are the signs and symptoms of rubella?
Fever, maculopapular rash beginning on face spreading to trunk and extremities, arthralgias, arthritis, head and neck lymphadenopathy, conjunctivitis
How is rubella diagnosed?
Serology testing
IgM antibody
ELISA from four to five days
How is rubella prevented?
Avoid exposure
Screening
When is it safe to administer the MMR?
One month prior to pregnancy or in postpartum
How does rubella affect the pregnant woman?
Mild or no symptoms
How does rubella affect the fetus?
Congenital rubella syndrome
Eye defects, heart defects, deafness, CNS defects, pigmentary retinopathy, neonatal purpura, hepatosplenomegaly, jaundice, radiolucent bone disease
Can the neonate shed rubella virus?
Yes
What is extended rubella syndrome?
Progressive panencephalitis and type one diabetes
What causes varicella?
Varicella zoster virus
How is varicella transmitted?
Direct contact, respiratory
What are signs and symptoms of varicella?
One to two days of flu like symptoms prodrome
Vesicular lesions that crossed over in three to seven days
Can cause pneumonia
Fever
How does varicella affect the pregnant woman?
Discomfort, itching
How does varicella affect the newborn?
The first trimester congenital varicella syndrome Chorio right retinitis Microphthalmia Cerebral cortical atrophy Growth restriction hydro nephrosis limb hypoplasia Cicatricial skin kesions
How is varicella diagnosed?
Clinical diagnosis
Scrape vesical base for spell T ZANCK smear, tissue culture
Direct fluorescent antibody testing
NAATs for amniotic fluid
How do you treat a pregnant person that has been exposed to varicella?
If they have a history VZV serology testing, if they are sero negative they should be given a varicella zoster immune globulin Give within 96 hours of exposure Isolate from other pregnant women Supportive care IV acyclovir
When should you vaccinate for varicella?
Non pregnant women at least one month before they become pregnant and in postpartum
How do you prevent varicella?
Vaccine, avoid exposure
What is the difference between varicella IgG and varicella Vaccine
The VZIG developed from blood and antibodies, provides fast protection, but it’s not long lasting
Varicella vaccine provides long lasting protection.
What is endometritis?
Inflammation of uterine lining
When can endometritis occur?
Days two through 4 postpartum up to two to six weeks postpartum
What are the signs and symptoms of endometritis?
Triad is fever, tachyardia, uterine tenderness
Also may have chills malaise foul smelling lochia, anorexia
What is the treatment for endometritis?
Consultation
Broad spectrum antibiotics
IV Clindamycin is gold standard
Until woman is afebrile for 24 to 48 hours
If not afebrile and 48 to 72 hours, then change antibiotics
What is the testing for endometritis?
Physical exam to rule out others
UA to rule out pyelonephritis
Clinical diagnosis
Which bacteria is implicated in mastitis?
Staphylococcus aureus
Coagulase neg staph
Rarely strep or MRSA
What are the signs and symptoms of mastitis?
One or more segment of breast is hot, red, inflamed. Fever, flu like symptoms
How is mastitis diagnosed?
Clinical diagnosis
What is the differential diagnosis for mastitis?
Breast candida, breast Abscess, ductal infection
How is mastitis managed?
First line is dicloxacillin or cephalexin times 10 to 14 days
Clindamycin if penicillin allergy
Frequent emptying of breast
Adequate fluids and nutrition
What are signs and symptoms of wound infection after C-section?
Low grade fever, localized pain and edema accompanied by red inflamed repair edges
What is the management of wound infection in C-section?
Consult or refer if indicated
Treatment for wound infection in C-section
Antibiotics, maybe drainage, reclose dehiscence, maybe daily debridement, packing, antibiotics, drainage
What causes breast candida?
Candida albicans
What are the signs and symptoms of breast candida?
Nipple and areola are shiny, red, flaking skin.
Burning, itching, or deep stabbing pain that radiates
How do you diagnose breast candida?
History of infant with fresh or severe diaper rash
Management of breast candida
Diflucan
Mom and infant must be treated
What is the role of the phagocytic portion of the newborn immune system?
Move out of circulation
Engulf germs,
Wall off or localized infection
Why does the newborn immune system have trouble with the phagocytic portion?
If the infant is stressed or immature or if bacterial load is large, then neutrophils cannot respond rapidly enough or forcefully enough for containment
This allows germs to spread
Leading to systemic infection with generalized symptoms
What is the role of the humoral component of the newborn immune system?
The humoral component is antibody mediated immunity.
With assistance from helper T cells, B cells will differentiate into plasma B cells that can produce antibodies against a specific antigens
The humoral component deals with antigens from pathogens
How does the newborn humoral component limit immune response?
Neonate T cells do not stimulate B cells to switch from IG M to IGA or IgG
They’re primarily IG M with little IgG or IGA
What is the total immunoglobulin at birth?
55%
80% of adult value
For how long is IG G production reduced?
Until age 2
Compare neonate levels of IGA two adult levels of IGA
IGA is 72% of adults level
What happens to IG M levels in the newborn?
Igm levels drop as newborn uses up maternal supply
When do infants produce their own IG M?
Infants do not produce own IG M until six months
What is the difficulty with infant IG M and pathogens?
IG M is less able to respond to specific pathogens
