General pregnancy care Flashcards
What is the infection rate if non immune and family contact with rubella
Almost 100%
30-50% casual contact
What are the symptoms of rubella?
Maculopapular rash
Fever
Arthralgia
Lymphadenopathy
Mostly asymptomatic
Rubella - Percentage risk of fetal infection first trimester and rate of congenital defects
80%
85%
Rubella: Risk of fetal infection / congenital defects by gestation
Risk of infection high initially, low in midtrimester and then 100% by term
Congenital defects - high risk first trimester, very rare from 17/40 onwards
congenital defects ass with rubella
Cataracts, IUGR, PTB, IUFD, deafness, developmental delay, cardiac disease, pneumonia, hepatsplenomegaly, blueberry muffin spots, developmental delay
What should you do if patient infected with rubella?
Rubella PCR / culture / fetal IgM with CVS or amnio. Can get false +ve PCR with CVS
First trimester: consider TOP
>20/40: rarely ass with congenital rubella syndrome.
No treatment options available
Ophthalmology, cardiac and hearing from birth to improve outcomes
VACCINATION pre pregnancy
If Re-infection with good hx of prev +ve serology then risk of fetal infection is <10%, rare for congenital rubella syndrome
How do you test for rubella after a possible contact
IgG / IgM testing
If IgG +ve and IgM +ve possible recent infection. REPEAT to confirm
If both negative repeat test if <3/52 since contqact or <7 days since illness
If IgG -ve but IgM +ve, repeat to check for seroconversion (if +ve then infected)
IgG +, IgM -ve = past infection or immunisation
What should you do at birth if fetus infected with rubella
Birth attendants must be immune
Infant
- IgM serology
PCR urine and throat
- IgG
If IgG > maternal IgG and IgM +ve and PCR +Ve and clinical features –> symptomatic infected infant - breast feeding okay, no specific management, ophthalmology and cardiac and hearing assessements and regular assessments. Infants can be infective for up to 12 months
No clinical features CRS but IgM + and PCR + - keep close eye as can have late onset disease
No clinical features and IgM -ve and PCR -ve –> reassure, reconfirm at 9/12 with IgG
What is the mortality rate of AFLP
2% maternal
11% perinatal
Clinical features AFLP
Presents after 30/40
Nausea, anorexia, malaise, severe vomiting, abdo pain, jaundice
Severe elevation transaminases
DIC
AKI
Lactic acidosis
Raised ammonia
Hepatic encephalopathy
Hypoglycaemia
Features of diabetes insipidus
(women with low BMI, multiple pregnancy get it)
What is swansea criteria
6 or more of
- Vomiting
- Abdo pain
- Hypoglycaemia
- Hyperuricaemia
- Coagulopathy
- DI
- Raised ammonia
- Enecephalopathy
- Leukocytosis
- Elevated transaminases
- AKI
(liver biopsy gold standard)
How do you manage
AFLP?
Expedite delivery
MDT
ICU
7% require ventilation
Coagulopathy - prolonged PT time - treat with FFP and vitamin K prior to delivery
10-50% dextrose for hypoglycaemia
Look for liver flap
Low threshold to start Abx as AFLP carries high risk fo sepsis (tazocin)
N-acetylcysteine - antioxidant
Can give desmopression if urine volumes are excessive
High recurrence rates!
Varicella:
What is the rash like and how long are they infectious?
Maculopapules - become vesicles and crust over
infectious up to 48 hours prior to rash
Is shingles and issue to the fetus
No
What are the maternal complications of varicella infection in pregnancy
Severe infections
Pneumonia
encephalitiis
death
Fetal complications of varicella
Risk of complication low
- <12/40 0.4%
12-20/40: 2%
>20/40: RARE
prematurity
LBW
Microcephaly / mental retardation
eye abnormalities - cataracts, chorioretinitis
skin scarring
limb hypoplasia
childhood zoster
What is the management / treatment of varicella if exposed but no rash yet?
No treatment that prevents fetal transmission, just to prevent maternal morbidity / mortality
4-13% mortality rate if primary infection in pregnancy
Urgent VZV serology
if <96h since exposure: Passive immunisation with VZIG if IgG -ve
If >96h - consider oral aciclovir 800mg five x / day for 7/7. if high risk particularly (smoker, underlying lung disease, immunocompromised)
Seek medical attention immediately if rash develops or feeling unwell
What is the management if expoed to varicella and have chickenpox lesions ?
No complications and ≤24h since onset of rash - give oral aciclovir
No complications and >24 hours since onset of rash - nothing
Complciation or immunocompromised: admit to hospital and give IV aciclovir. Do CS if fetal compromise, maternal resp failure
What is the risk to the baby of varicella primary infection in pregnancy
<12/40 0.5%
12-28/40: 1.4%
>28/40 - 0%
Refer to MFM
Detailed scan for anomalies 5/52 post infection and then repeat USS until delivery. if abnormal could consider fetal MRI. Amnio not advised
Skin scarring
Eye abnormalities
limb abnormalities
prematurity / LBW
ID
Death
Risk to BABY with maternal chickenpox in relation to time till delivery
> 7/7 before delivery: no issue. No isolation from mother, breast feeding encourages
7 /7 before to 2 days after delivery: ZIG immediately! should be given within 24h of birth, but can be up to 72h. No isolation of term infants from mother. BF required
> 2 - 28 days after delivery: ZIG required.
Give as soon as possible but cna be given up to 10/7 post rash.
No isolation from mother required. BF encouraged.
If baby gets chickenpox from mother
- Preterm or <1000g - admit to NICU and give IV aciclovir
- Term infant - admit to paeds unit and give ZIG and only IV aciclovir if resp symptoms develop or severe disease.
What is polymorphic eruption of pregnancy?
Common pregnancy dermatosis
1/200 incidence
Stretching of the skin elicits an immune response - connect tissue damage
Onset is usually 3rd trimester - mean GA 34/40
More common in primips, multiple pregnancies
On striae, umbilical sparing
Pruiritic, urticarial papules, often red with pale halo around each papule. Lesions on breast rare
No effects for fetus
How should you treat PUPPS
Menthol (1%) aqueous cream
Hydrocortisone 1%
Sedative antihistamine
No sedating antihistamines
Systemic steroids only occ used for severe pruritis
What is pemphigoid gestationis
Rare but serious
Occurs anywhere from 9 weeks gestation to 1/52 PP
Rarely presents with trophoblastic tumours
Distribution: abdomen (with umbilicus), spreads to limbs, palms, soles
Eruption: intensely pruritic, urticarial erythematous papules and plaques, target lesions and annular wheals . After variable delay (usually 2 weeks), vesicles and large tense bullae form
Autoimmune process, possibly related to fetal antigens. Binding of circulating complement fixing IgG Ab to a protein in the basement membrane of teh skin - triggers and immune response
Exacerbating and remitting course
Lesions usually rsolve weeks to months after delivery, rarely can persist for years.
Ass with other autoimmune conditions: Graves, vitiligo, type 1 diabetes, RA
How do you diagnose pemphigoid gestationis?
skin biopsy - shows completment deposition in basement membrane.
