Hepatitis B, Syphillis, HIV in pregnancy Flashcards
Differenital for jaundice in pregnancy?
Viral hepatitis
Acute fatty liver of pregnancy
HELLP syndrome
Cholestasis of pregnancy
How does acute hepatitis B viral infection affect pregnancy?
Preterm birth
Low birth weight
What is the perinatal transmission rate for hepatitis B if infection is contracted in 3rd trimester?
60%
What is the recommended management post delivery if the mother is hepatitis B surface antigen positive or has hepatitis B DNA in serum?
Baby should receive hepatitis B immune globulin + 1st dose of vaccine
What is the management if mom has high serum hepatitis B DNA levels near the time of delivery ?
Antiretrovirals
What is the treatment of acute hepatitis B in pregnancy?
Supportive treatment unless acute liver failure or protracted severe disease
What is the management option if you have acute hepatitis B and require antiretrovirals?
TDF
Tenofovir+disoproxil+fumarate
When is antiviral therapy recommended for patients with chronic hepatitis B?
Depends on the LFT tests and HBV DNA levels
- Persistenly elevated ALT >2times upper limit of normal
- Elevated HBV DNA >20,000 with e antigen or 2,000 without e antigen
What is the recommended lab monitoring for patients with hepatitis B in pregnancy?
Liver biochemical test and HBV DNA levels every 3 months during pregnancy up until 6 months postpartum
Can mothers that have hepatitis B infection breastfeed?
Yes
What are risk factors for transmission of hepatitis B from mother to baby?
- Not receiving appropriate ppx with HBIG+1st dose of vaccine within 12hrs of birth and finishing 3 or more doses of vaccine
- e antigen positive at time of delivery
- Elevated HBV DNA levels at time of delivery
What is the recommended screening test to order for hepatitis B at first prenatal visit?
HBsAg
Anti-HBc
Anti-HBs
What is the recommended management if a woman is HBsAg +?
Further testing for
HBV DNA level
LFTs
HB e antigen
HB e antibody
What is the recommended management if HBV DNA levels and LFTs are high or HB e antigen positive ?
Consult with hepatology
Consider antiretroviral therapy
What is the recommended management if HBV DNA levels are low?
Repeat at 26-28 weeks to ensure not elevating which can increase risk of transmission
What is recommendation if antiHBc and antiHBs are negative?
Means there was no previous exposure to virus or vaccination.
Recommend vaccination
What is syphillis?
Systemic infection causes by the spirochete treponema palladium
Why is syphillis important in pregnancy?
Because the infection can be transplacentally transferred to the fetus causing adverse outcomes and even death
What are the adverse outcomes in pregnancy with syphillis infection?
Spontaneous abortion
preterm birth
IUGR
COngenital infection
Stillbirth
Neonatal death
What are some risk factors for acquisition of syphillis infection
New sexual partner
Multiple sexual partner
Having a STI
Partner with STI
High prevalence community
Trading sex for money or drugs
Illicit drug use
Incarcerated
Partner incarcerated
How does primary syphillis present?
Painless chancre
How does secondary syphillis present?
Maculopapular rash of the palms, soles, trunk
regional lymphadenopathy
How does tertiary syphillis present?
Gumma lesions
Cardiovascular abnormalities
What are the screening tests for syphilis screening?
Nontreponemal test= RPR, VDRL
Treponemal tet= FTA-ABS
What is the recommended screening for syphilis in pregnant women?
- Screen all pregnant women at first prenatal visit
- If screening is nonreactive but patient is high risk recommended repeat screening at 28 wks and delivery
- If screening is reactive perform confirmatory test
- If confirmatory test is reactive syphilis is diagnosed. If confirmatory test is negative you based further management off the type of test that was used.
- If nontreponemal confirmatory test used then consider if patient is high risk, if so repeat testing in 2-4 weeks if not then likely false positive
- If treponemal confirmatory test used then rescreen with different antigen. If still nonreactive likely false positive.
What is the recommendation for high risk syphilis women during pregnancy if they screen negative for syphilis testing?
Repeat testing at 28-32 weeks
Repeat testing at delivery
What women are considered high risk for syphilis during pregnancy?
Unprotected sex with unknown partner
Unprotected sex with multiple partners
Sex worker
Trading sex for drugs
Diagnosed with STI during pregnancy
What is the treatment for neurosyphilis?
Aqueous PCN G IV 3-4million units q4hrs for 10-14 days
What is an alternative for syphillis treatment in pregnant women who cannot be PCN desensitized?
Erythromycin 500mg QID
What is a potential complication of syphillis treatment with PCN G?
Jarisch herxheimer reaction
What is Jarisch Herheimer reaction?
Febrile reaction that can lead to muscle aches, headaches, hypotension, rash
What is the management for Jarisch Heerxheimer reaction?
Supportive care
How do you monitor disease after treatment of syphilis?
nontreponemal test titers
RPR or VDRL titers whichever was used at start of treatment
Early syphilis should receive repeat titers at 6 and 12 months post treatment
Late syphilis should receive repeat titers at 6,12,24 months post treatment
How do you interpret treatment response for syphilis?
Looking at the titers
- If there is a four fold increase in titer from treatment initiation to repeat levels= treatment failure
- If there is a four fold decline in titer from treatment initiation to repeat titer level= acceptable response
When would you retreat a patient with syphilis in pregnancy?
For early infection there should be adequate response to therapy by 12 months. In pregnancy if an adequate response is not seen by 6 months you can retreat
For late infection there should be adequate response to therapy by 24 months. In pregnancy if an adequate response is not seen by 6 months you can retreat
Can syphilis be cured?
Yes if there are a loss of antibodies that is considered cured
What are ultrasound signs of congenital syphillis?
Placentomegaly
Hepatomegaly
Ascites
Hydrops
Polyhydramnios
How do you determine mode of delivery for HIV?
Mode of delivery is determined based on viral load obtained 4 weeks prior to expected delivery
Women with viral load 1000 copies or less= standard obstetric indications
Women with viral load >1000 copies= c-section at 38 weeks gestation
What is the intrapartum management for patient with HIV and viral load of <1000?
- Delivery mode based on obstetric indications
- Continue ART therapy during labor
- Give IV zidovudine during labor
- Avoid ROM, intrauterine monitors, operative delivery
What is the intrapartum management for patient with HIV and viral load of >1000?
- Delivery mode is c-section at 38 weeks
- Continue ART therapy during labor
- IV zidovudine 3hrs prior to c-section
- Avoid internal monitors
Which women with HIV should receive zidovudine during labor or prior to c-section?
HIV viral load >50 should receive zidovudine prior to delivery
What is the recommended dose of zidovudine for HIV patients on L&D?
Loading dose of 2mg/kg then 1mg/kg/hr until delivery
What is the purpose of delayed cord clamping?
Increase iron store and hemoglobin in the infant
What is the recommended infant treatment post delivery for women with HIV?
Undetectable viral load= zidovudine for 2-4 weeks
Viral load 50-1000= antiretrovirals
Viral load>1000= antiretrovirals
Which infants should you give antiretrovirals for HIV prophylaxis in mothers with HIV at time of delivery?
Women with primary/acute HIV infection
Not on antiretrovirals during pregnancy
Non adherence to antiretrovirals during pregnancy
Detectable viral load of 50 or more
What is the antiretroviral therapy for infants?
Lamivudine
Zidovudine
Retalgavir
