General pregnancy care

Question 1

What is the infection rate if non immune and family contact with rubella

Answer 1

Almost 100%
30-50% casual contact

Question 2

What are the symptoms of rubella?

Answer 2

Maculopapular rash
Fever
Arthralgia
Lymphadenopathy

Mostly asymptomatic

Question 3

Rubella - Percentage risk of fetal infection first trimester and rate of congenital defects

Answer 3

80%
85%

Question 4

Rubella: Risk of fetal infection / congenital defects by gestation

Answer 4

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

Question 5

congenital defects ass with rubella

Answer 5

Cataracts, IUGR, PTB, IUFD, deafness, developmental delay, cardiac disease, pneumonia, hepatsplenomegaly, blueberry muffin spots, developmental delay

Question 6

What should you do if patient infected with rubella?

Answer 6

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

Question 7

How do you test for rubella after a possible contact

Answer 7

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

Question 8

What should you do at birth if fetus infected with rubella

Answer 8

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

Question 9

What is the mortality rate of AFLP

Answer 9

2% maternal
11% perinatal

Question 10

Clinical features AFLP

Answer 10

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)

Question 11

What is swansea criteria

Answer 11

6 or more of
- Vomiting
- Abdo pain
- Hypoglycaemia
- Hyperuricaemia
- Coagulopathy
- DI
- Raised ammonia
- Enecephalopathy
- Leukocytosis
- Elevated transaminases
- AKI

(liver biopsy gold standard)

Question 12

How do you manage
AFLP?

Answer 12

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!

Question 13

Varicella:
What is the rash like and how long are they infectious?

Answer 13

Maculopapules - become vesicles and crust over
infectious up to 48 hours prior to rash

Question 14

Is shingles and issue to the fetus

Answer 14

No

Question 15

What are the maternal complications of varicella infection in pregnancy

Answer 15

Severe infections
Pneumonia
encephalitiis
death

Question 16

Fetal complications of varicella

Answer 16

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

Question 17

What is the management / treatment of varicella if exposed but no rash yet?

Answer 17

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

Question 18

What is the management if expoed to varicella and have chickenpox lesions ?

Answer 18

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

Question 19

What is the risk to the baby of varicella primary infection in pregnancy

Answer 19

<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

Question 20

Risk to BABY with maternal chickenpox in relation to time till delivery

Answer 20

> 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.

Question 21

What is polymorphic eruption of pregnancy?

Answer 21

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

Question 22

How should you treat PUPPS

Answer 22

Menthol (1%) aqueous cream
Hydrocortisone 1%
Sedative antihistamine
No sedating antihistamines
Systemic steroids only occ used for severe pruritis

Question 23

What is pemphigoid gestationis

Answer 23

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

Question 24

How do you diagnose pemphigoid gestationis?

Answer 24

skin biopsy - shows completment deposition in basement membrane.

Question 25

What are the fetal considerations in pemphigoid gestationis?

Answer 25

low birthweight, preterm delivery, stillbirth
Infant can have bullous eruption (10%, usually mild and transient)

Question 26

What is the treatment of pemphigoid gestationis?

Answer 26

Relieve itch, prevent blisters, avoid secondary infection
- Potent topical steroids
- Most require systemic prednisone (40-60mg / day)
- Oral antihistamines for itch
- If unresponsive to oral steroids can use azathioprine, cyclosporin, IV IG, plasmapheresis

Question 27

Recurrence rate of pemphigoid gestationis?
What contraception should you avoid?

Answer 27

Usually recurs - usually earlier onset and severe course
May recur with COC

Question 28

How is parvovirus transmitted?

Answer 28

Resp secretion and saliva

Question 29

What issues does parvovirus cause?

Answer 29

Cytotoxic for erythroid progenitor cells - decreased survival of red cells (anaemia)
supression of bone marrow

Question 30

Who is at risk of parvovirus?

Answer 30

Childcare workers
School teachers
People with young children

Question 31

What is the risk of parvovirus transmission from mother to fetus?

Answer 31

50% (less if exposed at school rather than at home)

Question 32

What is the risk of fetal demise if confirmed parvovirus fetal infection?

Answer 32

10% <20/40
<1% >20/40

3% risk hydrops if infected before 20/40
- 30% spontaneously resolve
20% die without IUT
20% die with IUT

Question 33

What symptoms does parvovirus cause?

Answer 33

Rash - slap cheek sometimes
Arthralgia
Non specific viral illness

Question 34

How do you check for parvovirus?

Answer 34

IgM and IgG
(if both negative, or igg neg but igm +ve, repeat serology 2-4 weeks)
If IgM and IgG +ve then have infection

if confirmed maternal infection do ultrasound weekly to fortnightly until 10-12 weeks post infectino, if no issues then routine cares. if fetal anaemia - refer MFM for IUT

Question 35

What is alloimmune thrombocytopenia?

Answer 35

Fetal disorder - caused by feto-maternal incompatibility for platelet antigens

No maternal symptoms
Mother is NOT thrombocytopenic
Condition develops in utero, affects all children, including the first born but is usually diagnosed after birth

Hx: previously affected child - symptoms, severity (bruising, bleeding, ICH)

Need to rule out other causes: e.g. if mother has thrombocytopenia - autoimmune causes such as ITP, SLE etc

Question 36

How do you diagnose / investigate for alloimmune thrombocytopenia?

Answer 36

Confirm dx with prev affected infant
Confirm presence of anti-HPA autoantibodies against platelets in maternal serum
- Then do paternal genotype and check whetehr heterozygote or homozygote
If heterozygote could do NIPT, CVS, amnio
- Cross match maternal serum with paternal platelets, both untreated and chloroquine treated (removes HLA antigens that may cause a “false positive”)

Question 37

What are the risks to the baby if previous baby was affected with NAIT?

Answer 37

7% if prior child had thrombocytopenia but no ICH
75% if prior child had ICH
No prior affected pregnancies 15%

60-65% of babies do well
20% die
15% have neurological damage

Question 38

How should you treat someone at risk of NAIT?

Answer 38

If no prev baby affected with ICH - IVIG from 28/40 and IOL 38/40
If prior baby affected IVIG from 12-18/40 and elective deliveyr 38/40
Regular USS with MFM

This treatment decreases risk of ICH but doesn’t guarantee no adverse outcomes