Infection in pregnancy Flashcards
Classified into screened infections [4] and non-screened infections [8]
Screened infections Congenital syphilis Hep B HIV Asymptomatic bacteriuria
Non-screened infections GBS VZV Measles Parvovirus Listeriosis Chlamydia trachomatis Clostridium perfringens TORCH
Congenital syphilis
Presentation [6]
Investigation [3]
Presentation:
- IUGR, Stillbirth 1/3 cases
- Haemorrhagic rhinitis, Rash
- Lymphadenopathy
- Thrombocytopenia, anemia
- Hepatosplenomegaly, jaundice, ascites
- Meningitis, keratitis, sensorineural deafness
Ix:
- nasal discharge exam for spirochetes
- CSF (increased monocytes, protein)
- positive serology
Congenital syphilis
Management
Mother [3]
Neonate [3]
- Maternal syphilis: maternal IM BENZYLPENICILLIN for 10d
* Congenital syphilis: IM BENZYLPENICILLIN for 21d
Vertical Hepatitis B infection
Routes of transmission [2]
Complications [2]
Labour, delivery, breastfeeding implications
During labour or transplacental
Complications: chronic hep B infection, HCC
Labour and delivery: normal
Breastfeeding: safe
Vertical Hepatitis B infection
Management of neonate [4]
- Dose of immunisation within 24h of birth (+ HBIG if no anti-Hbe or HBeAg +ve or BW<1500g)
- 6 in 1 at 8, 12 and 16w
- then another dose of the monovalent vaccine at 1y
- serology at 12-15m (protected if HBsAg -ve and anti-HBs +ve)
HIV
Antenatal care [4]
Management of neonate born to positive mothers [2]
Antenatal care:
- Screen for other infections
- Give pneumococcal, HBV, flu vaccines
- Start HAART
- If on cotrimoxazole, give 5mg folic acid in first trimester
Mx:
- Oral zidovudine if viral load <50
- > 50 viral load, Triple ART therapy for 4-6w
HIV
Labour and delivery: PROM [4], NVD [1], LSCS [2]
Breastfeeding
o PROM: - deliver if >34w - give steroids - ERYTHROMYCIN - ensure on HAART if <34w o Vaginal delivery: - if viral load <50 copies/mL at 36w o Caesarean section: - ZIDOVUDINE infusion started 4h before
Breastfeeding is not safe - risk of transmission
Asymptomatic bacteriuria
Effect on fetus [3]
Management [3]
IUGR, fetal death, premature labour
Mx:
- Cefalexin
- Avoid trimethoprim in first trimester (folate antagonist)
- Avoid nitrofurantoin in third trimester (neonatal hemolytic anaemia)
GBS
Investigation [2]
Effect on fetus [3]
RF [4]
- Urine culture or high vaginal swab
- Severe/early onset infection - meningitis, pneumonia, sepsis
Risk factors for Group B Streptococcus (GBS) infection:
- prematurity
- prolonged rupture of the membranes
- previous sibling GBS infection
- maternal pyrexia e.g. secondary to chorioamnionitis
Rubella Maternal consequences How is it spread? Investigation If exposed, management? [2] If no autoantibodies, management?
- Stillbirth, miscarriage
- Spread by respiratory droplets
- Ix: rubella autoabs (means previous infection or immunization)
- Exposure: contact health protection, offer TOP if confirmed in first trimester
- No autoantibodies: offer mum post-natal immunisation
If a mother tests negative for rubella autoantibodies what precautions should you advise?
Avoid anyone with rubella
Congenital rubella syndrome features [8]
Deafness Cardiac lesions Purpura Jaundice, hepatosplenomegaly CP, LD, microcephaly Cerebral calcification Micropthalmia, salt and pepper chorioretinitis Cataract Growth disorder
Maternal HSV
Why is it only a problem if its a primary infection?
Investigation [3]
Management [2]
Only a problem if primary cos secondary infections have maternal antibodies
Ix: refer mum and partner to GUM for PCR of HSV (also check if primary) and other infections
Mx:
- Oral aciclovir until due date with elective LSCS at term
Neonatal HSV
Effects on neonate [7]
Mx [2]
Blindness, LD, epilepsy, jaundice, respiratory distress, DIC, death
Mx: high dose IV acyclovir
Maternal chickenpox
Ix
Mx [3]
Investigation: varicella ab
Mx:
- If not immune, give VZIG up to 10d after exposure
- Oral acyclovir
- Refer to fetal medicine for detailed scan at 16-20w
Fetal varicella syndrome [6]
- complicates 1% of mothers infected between 3 and 28w due to reactivation in utero
- skin scarring
- micropthalmia
- chorioretinitis, cataracts
- microcephaly, cortical atrophy, LD
- bladder and bowel sphincter abnormalities
Neonatal varicella prognosis
Can cause death if mum pelops rash 2d- 5d before birth
Measles
Maternal Ix [2] and Mx
Fetal measles [3]
Ix: IgM positive after 4d but before 1m, test viral RNA in saliva
Mx:
- HNIG if maternal rash 6d pre- or post-delivery
Fetal:
- Fetal loss
- Preterm delivery
- No congenital infection unless 6d before/after delivery
What does HNIG prevent in measles infection?
to prevent neonatal subacute sclerosing panencephalitis
CMV
Maternal presentation [3]
Ix [3]
Route of transmission
Presentation
- Pyrexia
- Lymphadenopathy
- Sore throat
Ix:
- Paired sera
- Amniocentesis at >20w
- Viral shell culture (throat and urine)
Can be transmitted from toddler’s urine
Congenital CMV
Features [6]
Mx
- IUGR
- hepatosplenomegaly, jaundice
- thrombocytopenia
- chorioretinitis
- late onset problems are motor or cognitive impairment
- sensorineural deafness
90% of affected foetuses normal at birth; 10% are symptomatic (33% of these die)
Mx: supportive care
Maternal Toxoplasmosis
Presentation [3]
Ax [3]
- like glandular fever
- fever, rash
- eosinophilia
Ax: - transmitted from cat litter, lambing and uncooked meat
Maternal Toxoplasmosis
Ix [2]
Mx [5]
Ix: IgM and IgG
Mx:
Infected: SPIRAMYCIN
Symptomatic non-immune:
- re-test every 10w
- if +ve do amniocentesis to see if fetus infected
- if so give PYREMETHAMINE and SULFADIAZINE
Congenital Toxoplasmosis [7]
- intracranial calcification, hydrocephalus
- choroidoretinitis
- hepatosplenomegaly
- thrombocytopenia
- encephalitis, epilepsy
- physical and mental developmental delay
- skin rashes
Parvovirus B19
Maternal infection presentation [2]
Ix [3]
Mx [3]
- Asymptomatic
- Can get slapped cheek appearance
- Ix IgM and IgG (10d apart)
- Mx: serial USS looking for fetal anemia using MCA doppler
Parvovirus B19
Fetal infection pathophysiology [3]
Management [2]
Suppression of erythropoiesis and cardiac toxicity leads to cardiac failure > hydrops fetalis causing fetal loss
Fetal infection: tertiary fetal medicine centre and in utero red cell transfusion
Maternal Listeriosis
Presentation [5]
Ax [3]
Fetal listeriosis presentation [2]
Presentation
- fever (suspect in any unexplained fever >48h)
- shivering, myalgia
- headache, sore throat
- coughing, vomiting, diarrhoea
- vaginitis
Ax: transmitted from infected food (milk, soft cheese, pate)
• Fetal listeriosis: stillbirth, fetal distress in labour
Maternal Listeriosis
Ix - why not serology or swabs? [2]
Mx [2]
o Ix: blood cultures (serology and swabs unhelpful as can be commensal)
o Mx: IV AMPICILLIN and GENTAMICIN
Congenital Listeriosis
Presentation [5]
Ix [2]
Mx [2]
- pneumonia
- meningitis, convulsions
- hepatosplenomegaly
- pustular or petechial rashes
- fever, leukopenia
Ix: CSF, blood, placenta culture
Mx: IV ampicillin + Gentamicin
Chlamydia trachomatis
Fetal effects [3]
Neonatal effects [[2]
Mx [2]
- Fetal effects: LBW, PROM, fetal death
- Neonatal effects: opthalmia neonatorum
- Neonatal: cleansing and ERYTHROMYCIN IV
Clostridium perfringens maternal
Ax
Sequelae [5]
Mx [3]
- Transmitted during illegal TOP
- endometritis, sepsis and gangrene, AKI and death
Mx:
- surgical debridement of all infected tissue
- hyperbaric oxygen
- high dose IV BENZYLPENICILLIN
Puerperal pyrexia
Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.
Causes of puerperal pyrexia [5]
endometritis: most common cause Retained placenta? urinary tract infection wound infections (perineal tears + caesarean section) mastitis venous thromboembolism
Endometritis management
if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
GBS guidelines
Who to give maternal intravenous antibiotic prophylaxis [2]
Who would you treat for GBS?
Maternal intravenous antibiotic prophylaxis:
- Previous pregnancy GBS carry 50% risk (also offer testing in late pregnancy)
- Preterm labour
Treat:
- Women with pyrexia during labour
How do we carry out late pregnancy testing for GBS?
if women are to have swabs for GBS this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date
