Infections during pregnancy Flashcards
TORCH infxns
Toxoplasmosis "Other" -Syphilis -HIV -Hepatitis B Rubella CMV Herpes
toxoplasmosis is what type of parasite
obligate intracellular parasite
what type parasite is transmitted thru raw/poorly cooked meat or contact w/ cat feces?
toxoplasmosis
prevention counseling for toxoplasmosis in pregnancy
thoroughly cook meats
careful handwashing after handling raw meats
wash fruits & vegetables
wear gloves when working in soil
keep cats indoors & fed only processed food
how is toxoplasmosis transmitted to the fetus?
transplacentally
vaginal delivery
severe sequelae usually occurs in newborn d/t infxn w/ toxoplasmosis occurring when in mother’s pregnancy?
infxn acquired in 1st trimester & goes untreated
sequelae in infant from toxoplasmosis that is mild or not apparent at birth usually d/t infxn when in mother’s pregnancy?
3rd trimester
went untreated
different rates of transmission of toxoplasmosis from mother to fetus depends on a few things
placental blood flow
virulence of virus
immune status
many infants infected w/ toxoplasmosis appear healthy at birth & have no S&S of infxn. If there are S&S, what are they?
chorioretinitis
intracranial calcifications
anemia, thrombocytopenia, jaundice at birth
microcephaly
toxoplasmosis affected survivors may have?
MR seizures visual defects spasticity severe neurologic sequelae
routine screening of toxoplasmosis in pregnancy is NOT recommended except?
maternal HIV infxn
positive IgG titer in toxoplasmosis infxn indicates?
infxn at some point in time
negative IgM in toxoplasmosis infxn r/o?
recent infxn
+IgM may persist for long periods- not reliable in assessing duration of dz
other tests that may help Dx toxoplasmosis
PCR
skin tests
Ab levels in aqueous humor/ CSF
perform amniocentesis @ 20-24 weeks’ gestation if congenital dz suggested
what is the DOC for maternal/ fetal toxoplasmosis?
Spiramycin (Rovamycine)
does not prevent sequelae in fetus if infxn has occurred
DOC for toxoplasmosis infxn in other populations besides maternal/fetal
pyrimethamine
sulfadiazine
if toxo infxn has occurred in fetus, what drugs might decrease risk of congenital infxn & severity of manifestations
pyrimethamine
sulfadiazine
what systemic dz is caused by motile spirochete Trepone pallidum?
syphilis
typical presentation of primary syphilis
painless ulcer w/in 6 wks following exposure
secondary syphilis presentation
skin rash
maybe condyloma lata
usually 1-3 months later
syphilis generally crosses the placenta to fetus when?
after 16 weeks gestation
can occur any time, sometimes as early as 6 wks
untreated syphilis complications in pregnancy
SAB
stillbirth
neonatal death
when is neonatal infxn w/ syphilis more likely to occur?
during primary/secondary infxn vs. teritiary
infants infected w/ syphilis usually develp evidence of dz how many days after delivery?
10-14
early evidence of syphilis dzy in infant?
maculopapular rash "snuffles" mucous patches on oropharynx hepatosplenomegaly jaundice lymphadenopathy chorioretinitis
later signs of syphilis infxn
Hutchinson’s teeth
Mulberry molars
Saddle nose
Saber shins
is congenital syphilis readily preventable w/ prompt & appropriate maternal tx?
yes
serological testing for syphilis should be done when?
as early as possible
again at delivery
*serologic testing is mainstay of dx
nontreponemal testing
VDRL (Venereal dz Research lab)
RPR (rapid plasma reagin)
both sometimes falsely +
treponemal specific tests
FTA-ABS (flourescent treponemal Ab absorbed)
TP-PA (T. pallidum particle agglutination)
+ test results indicate active dz or past exposure. regardless of tx, + for life in most individuals
DOC for syphilis
PCN
Jarisch-Herxheimer rxn
occurs most often among pts w/ early syphilis. If pregnancy this may precipitate preterm labor/ cause fetal distress. Observe closely
RPR & VDRL can follow what?
post tx titers of syphilis
If syphilis is adequately tx’d, you should see what?
a 4 fold decrease in titers by six months
rubella
“German measles”
risk of congenital dz related to GA at time of infxn- highes in 1st month of pregnancy, decreases w/ increasing GA
defects d/t rubella are rare if infxn occurs after when?
20th week of gestation
rubella fetal presentation in utero
SAB/ stillborn
microcephaly
IUGR
rubella fetal congenital presentation
deafness
cataracts/Glaucoma
neurologic: meningoencephalitis/ MR
cardiac: PDA/ PA stenosis
rubella presentation in early CH
radiolucent bone dz
blueberry muffin rash
thrombocytopenia/ HSM
rubella presentation in late CH
thyroid abnormalities
panencephalitis
screening & testing for rubella
routine in pregnancy
screen for IgM & IgG Ab’s for primary infxn
pregnant- do not vaccinate
delay becoming pregnant for one month after vaccine is recommended
Rubella vaccination
- offer postpartum
- breastfeeding NOT CI
- IVIG may be given to infected woman but does not prevent fetal infxn
- if rubella Dx during pregnancy, advise pt about fetal risks & counsel regarding continuing pregnancy
some S&S of HBV
jaundice joint pain fatigue nausea decrease in appetite
routine screening for HBV during pregnancy is done by looking for what?
hep B surfact antigen (HBsAg)
vertical transmission of HBV is related to the presence of what?
maternal HBeAg (indicates high viral load & active replication) fetus has 70-90% risk of becoming infected & most will become chronic carriers
tx of HBV
HBIG HBV vaccine (usually betwee 2 days & 2 months after birth) breastfeeding not CI in chronic carriers if infant has received both vaccinations & HBIG within 12 hrs of delivery
HIV infxn doesn’t seem to have a direct effect on pregnancy, but may be associated w/ what?
pregnancy complications or perinatal infxn (BV, HSV, HPV, syphilis, CMV, toxo, HBV, HCV, etc)
what is more accurate in pregnancy- % of CD4+ cells or absolute #’s
% of CD4+ b/c the decline in absolute # is 2/2 hemodilution
HIV transmission can occur when?
antepartum
intrapartum
postpartum w/ breastfeeding
most often occurs during/close to intrapartum period
initial screening for HIV
ELISA- enzyme-linked immunosorbent assay
most antibodies detectable by 3 months after infxn
if ELISA is +, confirm w/ what?
Western blot test
HIV screening in pregnancy is what?
standard, but voluntary
if they “opt out” make sure to document!
at risk population screening for HIV should be repeated when?
3rd trimester
HIV meds to avoid in pregnancy
Efavirenz during 1st triemester
combo stavudine (d4T) & didanosine (ddI)
nevirapine if CD4 count >250/mm3
when do start HIV meds during pregnancy
depends on immune status
may start after 1st trimester to avoid drug exposure
antiretroviral drug Zidovudine is known to reduce what?
risk of transmission
what type of ULS should be done in HIV + pt?
detailed ULS (level II) usually @ 18-20 weels
precautions during delivery to avoid transmission of HIV
chorioamnionitis
prolonged rupture of membranes
invasive fetal monitoring & mode of delivery are risk factors for vertical transmission
if HIV viral load >1000, what should be planned?
c-section at 38 weeks
if vaginal birth, avoid compromising fetal skin
HIV + mothers should avoid what after birth of baby?
breastfeeding
primary HSV poses the greatest risk to?
the fetus
how is the fetus infected w/ HSV?
ascending infxn 2/2 spontaneous rupture of membranes or passage thru infected lower genital tract
infants w/ localized herpes usually do well, but those w/________________dz do very poorly
disseminated
congenital HSV infxn presentation
microcephaly
hydrocephalus
chorioretinitis
vesicular skin lesions
3 subtypes of acquired HSV infxn have been ID’d, what are they?
- Dz localized to skin, eye, mouth (virtually no mortality)
- encephalitis w/ or w/o skin, eye, mouth involvement (mortality ~15%)
- disseminated infxn involving multiple sites, including the CNS, LU, LIV, adrenals, skin, eye, mouth (mortality ~ 57%)
morbidity related to HSV related encephalitis or disseminated dz may include
seizures psychomotor retardation spasticity blindness learning disabilities
testing for HSV
clinical exam
confirm w/ viral cx
PCR testing (more sensitive than cx)
serologic testing
*routine screening for HSV not currently recommended
mngt of HSV
Acyclovir (safe in pregnancy)
-for suppression begin at 36 weeks
-IV for severe maternal infxn
c-section if lesions ID’d
acyclovir in pregnancy reduces the risk of?
clinical HSV
recurrence at delivery
c-section for recurrent lesions
risk of viral shedding at delivery
what is the MC congenital viral infxn
CMV
CMV is transmitted via
saliva semen cervical secretions breast milk blood urine
CMV S&S
most infants asymptomatic
-petechiae hepatosplenomegaly, jaundice, thrombocytopenia, microcephaly, chorioretinitis, nonimmune hydrops fetalis
long term sequelae of CMV
severe neurologic impairment & hearing loss
CMV general
no effective vaccine/ tx
routine screening NOT recommended
stress prevention (i.e. good handwashing)
test via PCR if testing
antivirals have been used neonates, but still experimental
risk for congenital infxn of VZV limited to what?
maternal infxn occurring during first half of pregnancy
VariZIG
purified immune globulin from plasma containing high levels of antivaricella antibodies
VariZIG should be considered w/in______hrs of exposure of nonimmune pts
96 hrs
screening for VZV is?
routine
what are some maternal complications of VZV infxn?
varicella pneumonia & encephalitis
more common in adults than children
varicella pneumonia occurs more frequently during?
pregnancy related infxn
assoc. w/ maternal mortality
tx w/ acyclovir
VZV fetal infxn during 1st 1/2 of pregnancy may result in?
varicella embryopathy
- limb atrophy
- scarring of skin on extremities
- CNS involvement
- ocular manifestations
VZV can be fatal for infant if mother develops infxn w/in when?
5 days before or 2 days after delivery
administer variZIG
possible peripartum infxn caused by GBS
endometritis amnionitis UTI sepsis miningitis (rare) postpartum fever & tachy
clinical manifestations of GBS in newborn
early-onset infxn: 1st wk of life, respiratory distress, septicemia/ septic shock, pneumonia, meningitis
late-onset infxn: reported beyond 3 months
late-late onset infxn:very low birth wt preterm neonates
universal screening for GBS happens between?
35-37 weeks
GBS + women should receive Abx prophylaxis when?
in labor or w/ rupture of membranes
if cx status unknown then prophylaxis given in following situation
preterm labor (<37 wks)
rupture of membranes 18 hrs+
maternal fever during labor (at/above 38 C)
GBS bacteriuria during current pregnancy
previously given birth to an infant w/ early-onset GBS dz
vulvovaginitis
spectrum of conditions causing vaginal/ vulvar sx’s
diagnostic tests for vulvovaginitis
testing for vaginal pH
saline “whiff” test
saline wet mount
10% KOH microscopy
bacterial vaginosis presentation
c/o “fishy” odor, esp. post-coital
gray-white/ yellow d/c
mild vulvar irritation
pH > 4.5
diagnosing BV
microscopic exam under saline wet mount increase in WBC's clumps of bacteria loss of normal lactobacilli characteristic "clue cells"- resemble ground glass
BV tx
oral/topical metronidazole or clindamycin
neither drug shown to have teratogenic effects
vulvovaginal candidiasis presentation
itching
burning, external dysuria & dyspareunia common
bright red
excoriation in severe cases
thick, adherent “cottage cheese” d/c, oderless
pH usually 4-5
Dx vulvovaginal candidiasis
microscopic exam made under saline wet mount or 10%
blastospores or pseudohyphae
cx
Tx of vulvovaginal candidiasis
topical application synthetic imidazoles: miconazole clotrimazole butoconazole terconazole
trichomonas vulvovaginitis transmission
sexual contact
fomites
survive in swimming pools/ hot tubs
what is trich associated with?
PID endometritis infertility ectopic pregnancy preterm birth *been shown to facilitate HIV transmission
trich presentation
mild to severe vulvar itching/burning copious d/c w/ rancid odor- "frothy", thin & yellow-green to gray color pH>4.5 dysuria sypareunia edema/ erythema of vulva petechiae or "strawberry patches" upper vagina or cervix- "classic signs"
Dx of trich
microscopic exam made under saline wet mount
large # if mature epithelial cells, WBCs
trich organism
Tx of trich
oral metronidazole/ tinidazole
partner notification & tx
avoid unprotected sex during tx
abstinence from EtOH- avoid disulfram like rxn
assoc. w/ pre-term deliver, PROM , SGA
tx may not prevent complications
f/u for test of cure- absolute resistance rare, relative resistance may be as high as 5%
