Infection in Pregnancy Flashcards
What are the complications of viral infections during pregnancy?
- Maternal Complications (e.g. influenza, VZV)
- Foetal complications
* Miscarriage/ Stillbirth/ Prematurity(e.g. rubella, measles)
* Teratogenicity (VZV/ZIKA)
* congenital disease (CMV + HSV)
* persistent infection (HIV, Hepb/C)
What are characteristics of Herpes Viruses
Large family of enveloped viruses with double stranded DNA
How is HSV transmitted?
What is the incubation period or HSV (1+2) ?
Via close contact
2-12 days oropharyngeal
4-7 days genital
Which Herpes Viruses can cause Problems in Pregnancy?
- HSV
- VZV
- CMV
- EBV
What maternal investigations are done for a suspected HSV infection?
- Viral Detection (PCR or lesions)
- Serology
How can HSV infect foetuses?
How common is it?
Very uncommon
Active maternal genital infection needed and ascending infection with PROM (therefore highest risk in 3rd trimester)
How common is neonatal HSV infection? What are the complications?
Very severe due to potential development of HSV encephalitis
What is the most common route of Transmission for Neonatal HSV infection?
Generally can all be primary, non-primary or recurrent genital HSV infections
- Direct contact with infected maternal secretions during delivery (genital Herpes)
- oral herpes: kissing babies
- Tansmission via other relatives, hosptial staff etc.
What are the complications of in utero HSV infection?
- Primary infection only
- Miscarriage
- Congenital abnormalities (ventriculomegaly, CNS abnormalities)
- Preterm birth
- IUGR
What is the management of maternal HSV infection during pregnancy?
- GUM clinic referral
- Aciclovir
- HSV antibody testing
- C-Secion (consider if active HSV in final 6 weeks before delivery)
What is the prognosis of neonatal HSV infecion?
Untreated: mortality >80%
(nreutological involvement common and severe
What are the three types of neonatal HSV infections?
- Skin, eyes , mouth (SEM)
- CNS involvement (+/- SEM)
- Disseminated
How and when does neonatal SEM (Skin eye mouth) HSV infection present?
How is it managed?
Can be initially benign, usually First 14 Days to max 6 weeks
1. Vesicular skin lesions
2. Eyes: watering (initially), progressing to Keratoconjunctivitis (may lead to cataracts anc choriorentinitis)
Management
* Must be treated due to high risk or cataracts and CNS progression
* Aciclovir
When and how does neonatal HSV infection with CNS involvement present?
What is the management?
Presents
Weeks 2-3 of life (up to 6)
Presentation with Meningoencephalitis
- Seizures
- Lethargy
- Irritability
- Poor feeding
- Fevers
Management
- Need CSF sample
- Acyclovir (hard treat)
How does disseminated neonatal HSV infection present?
Very severe, probably lethal
Presents like sepsis
Often in 1st week of life
Multi-organ involvement (liver, lungs, CNS, heart, GI tract, renal tract, bone marrow)
What is the Route of Transmission for Varicella Zoster and Herpes Zoster?
How likely is transmison?
Respiratory transmission (with 70% infection rate in susceptible individuals)
What is the incubation period of VZV?
3-14 days
How many women of childbearing age are susceptible to varicella inection? What are the maternal complications=
10-20% of women of childbearing age are susceptible
* 10-20% of pregnant women with varicella will have varicella pneumonia.
* Encephalitis is rare but has mortality of 5-10%
What are the foetal complications of foetal varicella infection during pregnancy?
Congenital Varicella Syndrome
What are the risk of vertical transmission of varicella to the foetus?
Generally transmission in first and 2nd Trimester
0.4% if maternal infection weeks 0-12
2% if weeks12-20
What are the complications of congenital varicella syndromes?
Low Birth Weight
- Hypertrophic scars (cicatricial skin lesions)
- Limb defects (e.g., hypoplasia)
- Ocular defects (e.g., chorioretinitis, cataracts, microphthalmia)
- CNS defects (e.g., cortical atrophy, seizures, intellectual disability), hydrocephalus
What is the management plan for Varicella exposure in pregnancy in a woman, who has had chickenpox or shingles before or had 2 doses of varicella vaccine ?
Sufficient evidence of immunity
What is the managemnet of Varicella exposure in pregnancy in a woman, who has never had previous infection or immunisation?
- Urgent Antibody testing on recent blood sample
If VZV IgG <100 mlU/ml offer PEP
(Pre-conception and post partum counceling considered if no immunity documented)
What is the Management of a pregnancy women with VZV IgG <100 mlU/ml presenting within 10 days from exposure?
If under 20 Weeks: IVIG
If >20 Weeks:IVIG or Antivirals
Oral aciclovir 800mg
OR
Oral Valaciclovir 1000mg TDS
until day 14 post exposure
What is the epidemiology of CMV infection?
How is it transmitted?
- Transmission via Saliva/Respiratory secretions/urine
- Common childhood infection, 2-6% infected by 6 months, 40% infected by 16
What is the incumbation period of CMV?
4-8 weeks
(but virus persists lifelong)
What are the symptoms of CMV infection in childhood?
Mostly asymptomatic (unproblematic if not in prengnacy/immunocompromised)
Maculopapular rash, infectious mononucleosis-like illness
How is CMV diagnosed?
- PCR of urine/saliva/ amniotic fluid
- Serology
How is a maternal primary CMV infection transmitted to the baby? How likely is transmission?
- In utero: 1+2nd trimester 30%, 3rd: 70%
Also transmission preinatally and postnatall (also transmission via breast milk and saliva)
What is the presentation of Congenital CMV infection?
At birth (10% show symtpoms, 90% initially asymptomatic)
- jaundice, petechiae, hepatosplenomegaly
- CNS: microcepahtly, ventricumeglay
Later - progressive permanent sensorineural hearing loss (first 3 years of life)
- other cognitive complications (learning disability etc)
How is Congenital CMV infection Confirmed/ diagnosed?
- Maternal Serology
- Neonatal (Urine and Saliva PCR) –> within first 3 weeks of life
Options - Foetal Aminocentesis
What is the management of CMV infection in pregnancy?
Most important question: Is this primary infecion? (Check booking blood and and now)
If seroconversion susptected –> referal to foetal medicine (for USS and amniocentesis)
No treatment available
What neonatal tests need to be done with a maternal history of CMV infection in pregnancy?
Neonates are investigated – urine and saliva CMV PCR within 1st 21 days
What is the route of transmission and incubation period of Rubella?
12-21 days
Via respiratory
How likely if foetal transmission of maternal Rubella infection in Pregnancy?
Greatest risk is in the 1st trimester
If infection before 8 weeks -> 20% spontaneous abortion
If infection before 10 weeks 90% incidence of fetal defects
If infection after 18-18 weeks -> hearing defects and retinopathy
If infection after 20 weeks no documented cases
What are the consequences of foetal Rubella infection?
- Miscarriage, Stillbirth, Small birth weight, Foetal Growth Restriction
- Congenital Rubella syndrome
What is the presentation of congenital Rubella syndrome?
2/3 asymptomatic at birth and develop complicaitons over time
Triad of 3 cs
1. Cardiac (PDA, Pulmonary Artery stenosis)
2. Cataracts (and other eye manifestations)
3. Cochlear: bilateral sensorineurla hearing loss
Other early features
* CNS: Meningioencephalitis
* GI: hepatosplenomegaly, jaundice
* Haem: Petechiae, Haemolytic anaemia
Later
* CNS: Hearing loss, intelectual diasability, panencephalitis
* Endo: DM, thyroid disfunction
Later
* Hearing loss
Intellecual diability
Panenceoahlitis
Endocrine disfunction (diabetes and thyroid)
What are the maternal and foetal complications of measles infection in pregnancy
Maternal
- Secondary bacterial infections
- Otitis media / pneumonia (mortality 10%) / gastrointestinal
- Encephalitis
What are the foetal complications of Measels in Pregnancy?
Foetal
- Foetal loss
- preterm delivery
- SSPE (sub-acute sclerosing panencephalitis) 7-10 years later
What is the route of Transmission and incubation period for Parvovirus?
Respiratory, Blood Products
6-8 days
What is the presentation of Parvovirus 19?
Mostly asymptomatic
Erythema infectiosum/ slapped cheek/5ths disease
Polyarthropathy
Transient aplastic crisis
What are the foetal complications of maternal Prarvovirus infections?
Generally 30-60% of adults have antibodies
Before 20 Weeks
* 33% transmission –> hydrops fetalis, fetal abnormalities, fetal loss
After 20 weeks: no risk
What is Fetal hydrops/ Hydrops fetalis?
Cytotoxic to fetal red blood precursor cells
- anaemia
- accumulation of fluid in soft tissues and serous cavities (ascities, pleural effusionsoedema etcc. )
- can rapidly cause fetal death
What is the pregnancy managment of maternal Parvovorus before 20 weeks?
- Refer to fetal medicine for monitoring
- Check maternal booking IgG Parvovirus antibodies
- May require intrauterine transfusion
What is the prognosis of enterovirus infection in pregnancy?
Generally not associated with severe outcomes
Of all enterovirus: Coxacie virus is associated with highest risk
- Perinatal newborn infection can occur in last week of pregnancy
- Neonates are at risk of myocarditis, fulminant hepatitis , encephalitis , bleeding and multi-organ failure.
