exam one: self paced module one Flashcards
causative agent of chlamydia
- bacteria
- Chlamydia trachomatis
transmission of chlamydia
-sexual activity
-transmitted to fetus via infected birth canal
symptoms of chlamydia
-Asymptomatic
-Abnormal vaginal discharge
-Painful urination (dysuria)
- Can lead to pelvic inflammatory disease which could cause scaring and infertility or increased risk of ectopic pregnancy
fetal effects of chlamydia
increased risk of preterm labor, premature rupture of membranes, low birth weight
neonatal affects of chlamydia
-common cause of ophthalmic neonatorum (prevent with e-mycin ointment), and chlamydial pneumonia
treatment of chlamydia
- Azithromycin
- Also treat partner with this
- Repeat test in 1-3 months after completion of tx
causative agent of gonorrhea
-Bacterium:
-Neisseria gonorrhoeae
transmission of gonorrhea
- to fetus is through contact in birth canal
symptoms of gonorrhea
- asymptomatic especially in women
effects on the newborn of gonorrhea
ophthalmia neonatorum, sepsis, joint infection
treatment of gonorrhea
- Usually ceftriaxone IM injection
- Treat all partners
- Test 1-3 months after finished tx
prevention of gonorrhea
- Safer sex
- E-mycin ophthalmic ointment after delivery
HSV (herpes simplex visrus) causative agent
Viral:
HSV1 and
HSV2
transmission of HSV
-neonatal: direct contact with lesion during birth after membranes rupture
-transplacental is rare
-sexual contact
-skin to skin
-primary infection (1st one) is most severe and has higher risk of virulence if exposure
Symptoms of HSV
-genital lesions
-blisters that are painful
-as erupt- yellow crusting and oozing from lesion
-asymptomatic shedding
-may notice prodrome symptoms before outbreak: vaginal fullness, tingling, swelling, irritation
effects on the neonate from HSV
-50-60% mortality with exposure to primary lesion, neurological complications, sepsis
treatment of HSV
- prophylactic anti viral medications starting at 35-36 weeks
- Acyclovir 400 mg BID
- Valacyclovir 500 mg BID or 1000mg daily
- Begin anti-viral medications if 2-3 outbreaks during pregnancy (even if before 35 or 36 weeks)
delivery with HSV
-c section if active lesions
-vaginal delivery if there are no active lesions for 7 days
Causative agent of HPV
Viral: over 150 genotypes
transmission of HPV
-sexually
-skin to skin
-transplacental transmission is controversial
-HPV in genitals is low risk
- virus that can impregnant into the cervix is high risk
symptoms of HPV
-HPV in genitals results in: genital warts (condyloma)
-warts should be: painless, flat, vary in color, single or diffuse
-virus that can impregnant into the cervix can lead to cervical cancer
effects on the neonate from HPV
juvenile laryngeal papillomatosis, more a risk with initial outbreak HPV and direct contact
treatment of HPV
- TCA (tricholoracetic acid), laser, surgery
- Often resolve without treatment
prevention of HPV
- HPV vaccine
delivery with HPV
-c-section delivery is not warranted if active. Can still have vaginal delivery.
-may impeded vaginal delivery is warts are very large and obstruct vaginal canal
causative agent of syphilis
Protozoan: Trichomonas
vaginalis
transmission of syphillis
-sexually
-transplacental
symptoms of syphillis
painless canker at route of transmission
fetal-neonatal effects of syphillis
-(if mom is left untreated): second trimester loss, still birth at term, congenital infection, live unaffected infant
treatment of syphillis
Usually Penicillin G
Screen at the beginning of pregnancy (partners too)
Tx needs to be immediate (partners too)
Trichomoniasis causative agent
Protozoan: Trichomonas
vaginalis
Trichomoniasis transmission
-sexually
Trichomoniasis symptoms
-Asymptomatic
-malodorous yellow green discharge
-vulvar irritation; strawberry patches on cervix
effects of Trichomoniasis
-preterm labor
-preterm birth
-premature rupture of membranes
-increased incidence of pre labor premature rupture of membranes, SGA (small for gestational age) baby
treatment of Trichomoniasis
Metronidazole (could lead to preterm labor)
bacterial vaginosis causative agent
Bacterial imbalance of vaginal flora
transmission of bacterial vaginosis
no direct transmission
symptoms of bacterial vaginosis
-asymptomatic
-fishy odor and discharge
effects of bacteria vaginosis
-preterm labor/birth
-premature rupture of membranes
-chorioamnionitis (infection transmitted from vaginal canal)
treatment of bacteria vaginosis
Metronidazole
Prevention measures
Toxoplasmosis causative agent
Protozoan:
Toxoplasma gondii
transmission of Toxoplasmosis
-eating raw or undercooked meat/game meats
-in the soil (gardening, playgrounds)
-contact with feces of infected cats
-transplacental (40% chance fetus will get it)
symptoms of Toxoplasmosis
-mild flu like symptoms
effects of Toxoplasmosis
- fetal infection: severe neonatal disorders (blindness, deafness, developmental delays, seizures -highest risk in 3rd trimester)
-severe fetal disease or death (hydrocephaly, microcephaly -highest risk of death in 1st trimester)
treatment of a recent Toxoplasmosis infection
- Spiramycin (decreases transmission to fetus but does not cross placenta to treat the fetus)
treatment of a fetal Toxoplasmosis infection
- Sulfadiazine, pyrimethamine and folinic acid (after the first trimester)
varicella causative agent
- Viral: Member of the herpes family
Chicken pox, shingles
transmission of varicella
-if unknown immunity check titer
-exposure: give varicella-zoster immune globulin within 96 hours
-high risk for exposure if exposed to patient with chicken pox or direct contact with shingles lesions
-virus crosses the placenta but the maternal antibodies do not
maternal effects of varicella
-high risk of death due to pneumonia
fetal effects of varicella
-infection in first 20W can lead to congenital varicella syndrome, limb hypoplasia, contractures, eye and CNS involvement
neonatal effects of varicella
-highest if maternal infection within 5 days prior and less than 2 days after delivery
treatment of varicella in a mother who has an active infection
- Acyclovir, valcyclovir or Famcyclovir to reduce symptoms, duration, and intensity
- If not immune should vaccinate postpartum (avoid pregnancy 30 days after vaccinate)
prevention of varicella
vaccine
other considerations of varicella
-shingles is not a fetal risk with proven immunity
-non immune patient can contract VZV from active shingles leasions
parvo (5th disease) causitive agent
Viral:
Human B19 parvovirus
transmission of Parvo virus
-common in daycare and school
-to fetus: transplacentally (30%)
-more than ½ pregnant women are already immune
symptoms of parvo
Adults:
-usually mild
-may develop slapped cheek rash, low grade fever, nasal discharge, head aches, Nausea, joint pain
Children: mild
effects of parvo
-fetal death (4-12 weeks after infection)
-non-immune hydrops-fluid collection and marked fetal anemia (1/3 will resolve on own but may need intrauterine fetal transfusion)
-development is normal if fetus survives infection
-fetal surveillance with ultrasound and evaluation of peak systolic velocity of the middle cerebral artery to see for increasing risk of hydrops
treatment of parvo
avoid exposure
causative agent of listeria
Bacterium:
Listeria
Moncytogenes
transmission of listeria
-eating soft cheeses, unpasteurized milk products, processed/deli meats
-processing exposure
-transplacentally
effects of listeria
-miscarriage, fetal death
-neonatal death related to pyogenic meningitis
treatment of listeria
-Avoid eating high risk foods:
-sprouts
-soft cheeses
-raw milk
-deli meats and hit dogs (cold not heated)
-smoked seafood
causative agent of coxsackie
viral
transmission of coxsackie
-hand foot and mouth
-body fluids
Coxsackie fetal neonatal effects
-death
-chorioamnionitis, placental infection
-myocarditis, encephalitis
Coxsackie tx
none
rubella causative agent
viral
rubella transmission
-across placenta to fetus
-period of greatest risk is in the 1st 10 weeks (90%)
-in the next 11 and 12 the risk drops to 50%
neonate effects of rubella
-congenital cataracts
-sensorineural deafness
-congenital heart defects
-developmental delays
-cerebral palsy
treatment of rubella
-Vaccination of all children and non-immune individuals
-vaccinate all women of reproductive age (prior to pregnancy or postpartum)
-Childbearing women:
Vaccination prior to pregnancy or in postpartum period (live attenuated vaccine that is not safe when pregnant)
other considerations for rubella
-isolate infants with rubella- can shed the virus for 12 months
CMV (cytomegalovirus) causative agent
Viral: belongs to the herpes family
CMV transmission
-across placenta to fetus
-cervical route during birth
-daycare is high
-close contact with infected individual (viral shedding can occur continually over many years)
CMV symptoms
-asymptomatic in adults and children
CMV effects
-harmless in adults and children
-common cause of intrauterine infection
-fetal-neonatal:
Death, small for gestational age, microcephaly/hydrocephaly, cerebral palsy, mental retardation, no damage at all
treatment of CMV
No known treatment or vaccine at this time
DX of CMV
Dx: sero-conversion, amniocentesis
Hep B causative agent
viral
Hep B transmission
-blood exposure (during deliver)
-not transplacentally
Hep B treatment
Hepatitis B vaccine
Neonatal:
* HBIG
* Hepatitis B vaccine
How to prevent transmission to newborn:
-bathe immediately
-Hep B immune globulin
-Hep B vaccine
-other family members screened and treated
Dx of hep b
Dx: Hepatitis B surface antigen part of initial OB labs
-Hep E antigen positive= diagnosis of active infection
Hep C causative agent
viral
Hep C transmission
-blood exposure
-not placentally
-exposure with delivery
Hep C treatment
-Treatment controversial during pregnancy
-Screened with each pregnancy for HCV antibodies at the first prenatal visit if HCV exposure is prevalent
Hep C testing
serum hepatitis c antibody
HIV causative agent
Viral: human
Immuno-deficiency virus
HIV treatment
Pregnancy:
* AZT- reduces transmission rate to 70% to fetus- without 13-30% of neonates will get and 100% will die
Labor:
* IV AZT
Neonatal:
* highly active antiretroviral therapy
prevention:
-safe sex: mother can be reinfected and cause new viral load
HIV testing
-serum testing offered to all women
-two methods of rapid testing blood or saliva: oraquick rapid HIV test which gives you results in 20 minutes and has a 99% accuracy rate
HIV other considerations
-monitor CD4 count in positive mother
–observe for other infections in immunocompromised women
-if no treatment in pregnancy testing done postpartum to determine therapy needed
HIV labor
-IV zidovudine
-C section + intact membranes can decrease vertical transmission by 50% (depends on CD4 count)
-avoid FSE (fetal spiral electrode, scalp Ph, forceps, and vacuum extraction
HIV neonatal care
-wipe off secretions immediately
-bathe ASAP once stable
-use strict infection control techniques
-breastfeeding is contraindicated
-neonatal treatment: highly addictive antiretroviral therapy
TB causative agent
Bacterium:
Mycobaterium
tuberculosis
TB treatment
Active TB:
* Isoniazide, rifampin, ethambutol
* No direct contact with newborn until noninfectious
Inactive:
* May delay treatment until postpartum
* May breastfeed
TB testing
-recommended TB skin test or serum test in high-risk population
-chest Xray if TB test is positive
Zika causative agent
virus
Zika transmission
-spread through the aedes species of mosquito
-sexual contact from symptomatic or asymptomatic infected individual up to 6 months after exposure
-transplacentally
zika symptoms
Maternal: fever, rash, headache, arthralgias/myalgias, red eyes
Zika fetal risks
-10% risk with infected mother
-miscarriage, stillbirth, growth restriction
-congenital zika syndrome: microcephaly, decreased brain tissue, ocular damage, limb/joint defects, hypertonia
Zika testing
Serum or urine testing
covid transmission
-low rate of transplacental transmission in 3rd trimester
covid effects
- increased incidence of severe illness with pregnancy leading to hospitalization, ventilation, and death
Covid treatment
-Vaccinate prior to and during pregnancy
-Daily low dose aspirin for all pregnant patients with COVID infection since COVID increases coagulopathy and pregnancy is already a hyper coagulopathy state
-anticoagulants may be used during or after pregnancy with more severe
-monoclonal antibodies recommended for pregnant patient with mild to moderate symptoms and one or more additional risk factor (BMI >25, chronic kidney disease, diabetes mellitus, CV disease
- Transplacentally
a. The pathogen can move through placenta to directly infect the fetus
Ascending
a. Infection introduced once the bag of water is broken through the vagina into the uterus
direct contact
a. The neonate is exposed during delivery or directly after
GBS is the leading cause of
early onset Neonatal Sepsis
GBS is what type of organism
Gram positive beta hemolytic cocci that likes to live in the GI tract
GBS and colonization
-due to women anatomy becomes the source of colonization of the GI tract
-10-30% of women are colonized
-Rates vary by ethnicity and age
African American are twice as likely to have GBS colonization
Young
Hispanic
primary risk factor for transmission of GBS to newborn
due to colonization of maternal GI and GU tracts
vertical transmission of GBS
through direct exposure to this organism during birth or an ascending infection after the membranes have ruptured
horizontal transmission of GBS
From cross contamination (from poor handwashing by caregivers)
what influences transmission rate of GBS
-How heavily colonized the woman is
-Site of colonization
-Chronic colonization
-Risk factors: pre term, prolonged rupture of membranes, low birth weight, presence of intra amniotic infection
*½ women colonized with GBS will pass on to their newborn
transmission symtoms
*Transmission may be asymptomatic but could cause maternal urinary tract infections, intra amniotic infections, or infections in the endometrium after birth
guidelines for universal screening
-All pregnant women should be cultured between 36-37 6/7 weeks with a vaginal-rectal culture
-Very accurate in predicting GBS colonization status at the time of delivery if birth occurs within 5 weeks of culture: If negative at this time it will remain negative in most cases through 41 and 0/7 weeks, 5% false negative rate
exceptions to universal screening
- Risk of transmission to the newborn is very high so these women will receive antibiotics prophylactically in labor
- History of infant with invasive GBS infection
-Increased risk of having heavy colonization and will not need the screening
-Will receive Antibiotics in labor to prevent transmission to newborn - GBS bacteria of any amount found in a clean catch urine sample which indicated there are high colony counts in the gi and gu tracts
-Treat UTI at diagnosis
-Antibiotics in labor to prevent transmission to newborn
vaginal-rectal culture
-Swab inserted into the outer third of the vagina
-Swiped down perineum
-Then inserted into the rectum just past the anal sphincter
-Not recommended to use a speculum or to do a cervical culture
-With education could perform culture themselves and oftentimes more comfortable this way
what is the point of Susceptibility testing for patients with PCN allergies
To ensure correct antibiotics are used prophylactically to treat a positive culture
Who should be treated with intrapartum prophylactic antibiotics?
- Any positive GBS vaginal-rectal culture in the current pregnancy
- History of:
-GBS bacteria at any time in this pregnancy
-Infant affected by invasive neonatal GBS infection (previous history of newborn affected by GBS disease)
-Universal screening cultures are not done because of the high risk of transmission
What if she hasn’t had the universal screening or you don’t have results?
Antibiotics should be given for these factors:
- Gestation less than 37 weeks (since don’t get screened till 36/37 weeks).
- Pre term pre labor rupture of the membrane (PROM)
- Ruptured membranes >/= 18 hours
- Intrapartum temperature of >/= 100.4: this indicates infection if it is suspected to be i
- intra amniotic infection the broad spectrum abx are given and antibiotics covering GBS
*. Greater than 37 weeks with unknown culture status in current pregnancy and have history of GBS colonization in previous pregnancy since there is 50 % chance she is colonized with GBS again and is at increased risk of transmitting to baby should get treatment as well
Reason for prophylactic treatment
Prevention of early onset neonatal sepsis
This is not the same as giving the newborn antibiotics for a GBS infection
When is prophylactic treatment started?
On admission until delivered
SCHEDULED C-section patients and prophylactic treatment
Universal screening culture done at 36 - 37 weeks
If positive:
-Antibiotics only given if they come in to labor on own or have ruptured Membranes- treat with abx prior to delivery
-Not in labor before scheduled c section and membranes in tact- no treatment needed (low transmission risk).
Benefit of intrapartum abx
- prevent neonatal GBS infection by temp. decreasing maternal vaginal GBS colony counts preventing fetal and newborn surface and mucus colonization and will reach levels in newborn to effectively kill GBS
recommended treatment agent for GBS
Penicillin G – narrow spectrum targets gram +
Initial dose: 5 million units IVPB X1
Then 3 million units IVPB Q 4 hours until delivery
acceptable alternatives to PCG
Ampicillian
2 g IVPB load, then 1 g Q 4 hours until delivery
when is treatment considered adequate
- Highest is obtained when there is at least four hours from the initial dose of the abx and the birth
Rapid decrease in maternal GBS colony counts and neonatal sepsis when 2 hours of abx exposure but much greater when at least 4 hours prior to birth
PCG allergies
- Important to determine type of reaction to PCN to determine if low or high risk
-High-risk for anaphylaxis–history of anaphylaxis, angioedema, respiratory distress, or urticaria after being given penicillin or cepalosporin, recurrent reactions, reactions to multiple beta-lactam antibiotics, positive skin testing, or rare delayed reactions.
-Low-risk for anaphylaxis–non-urticarial maculopapular rash without systemic symptoms, family history of penicillin allergy but no personal history, non-specific symptoms such as nausea, diarrhea, and yeast vaginitis, or a patient reports a history but cannot recall the symptoms or treatments.
-Consider Penicillin allergy skin testing in women with unknown severity of reaction or low risk
Helps eliminate need to use alternatives for prevention of GBS early onset disease
low risk for anaphylaxis
Cephazolin 2 g IVPB load then 1 g IVPB q 8 hours until delivery
High-risk for anaphylaxis and identified sensitivity of the GBS isolates
Clindamycin 900 mg IV Q 8 hours until delivery
High-risk for anaphylaxis and GBS is not sensitive to Clindamycin or don’t have sensitivity testing and at high risk
Vancomycin 20 mg/kg Q 8 hours
Max single dose is 2 g
Infuse over a minimum of 1 hour or 500 mg/30 min a dose for a dose of > 1 g
Unknown risk for anaphylaxis
No info available
Perform penicillin allergy testing
If not possible to test: any of the above alternatives can be used
neonatal implications of GBS
Long term neurological complications and can die
Mortality- less than 10% of neonates affected by GBS sepsis
Higher rate in pre term than term (under 37 weeks)
Morbidity- long term neurological complications are common
early onset neonatal sepsis
-First 7 days of life
-Caused by group b streptococci
-Symptoms
Temperature instability (cant maintain temp in normal range), hypothermia, poor feeding, lethargy
Respiratory distress, pneumonia, apnea, shock
Newborns not likely to be febrile or hypothermic
late onset neonatal sepsis
7 days to 3 months
Results in: meningitis
Can be caused by GBS
More frequently caused by other organisms
nursing considerations for GBS
- Review record on admission for GBS status
-Vaginal rectal cultures done
-History of GBS urinary in this pregnancy
-Pertinent past history of delivering a newborn who developed GBS sepsis - Prophylactic treatment if indicated
-Abx - Communicate
-To those caring for the newborn including pertinent history treatment given number of doses and length of time that has elapsed since the first dose - Care of the neonate:
-MONITOR for s/s of neonatal infection
-Intra partum prophylactic abx treatment able to prevent majority of sepsis cases but not all
-Greater risk to developed early onset neonatal sepsis if treatment is not adequate (not enough time elapsed since the first dose of abx given)
-Determine estimated risk of developing early onset sepsis using a neonatal sepsis calculator
-Monitor symptoms, lab testing, abx administration
