Infections in Pregnancy Flashcards
Describe toxoplasmosis?
- Parasite excreted in cat faeces
- Incubation period of 5-23 days
- Transmission is faeco-oral route
- Increased risk of vertical transmission with increasing gestational age - 5% 1st, 80% 3rd trimester
- Risk of congenital toxoplasmosis reduced with increasing gestational age - 60-80% 1st, 5% 3rd
What are the risk factors for toxoplasmosis?
- Household cats
- Increased incidence in rural areas and France
What are the signs and symptoms of toxoplasmosis?
- Mother = often asymptomatic → if symptoms fever, malaise, arthralgia
- Child:
- 60% asymptomatic at birth → may develop deafness, low IQ, microcephaly
- 40% symptomatic at birth
- Chorioretinitis
- Convulsions
- Hydrocephalus (microcephaly)
- Intracranial (‘tram-like’) calcifications - scattered throughout the brain (CMV = peri-ventricular
- Hepatosplenomegaly/jaundice
What are the investigations for suspected toxoplasmosis?
- Sabin Feldman Dye Test
- Bloods
- IgM = active - may persist for months/years
- IgG = immunity
- USS - foetal anomaly scan
- Amniocentesis and PCR to detect foetal infection - if USS raises suspicion
What is the preventative strategy for toxoplasmosis?
- Mother should avoid:
- Eating raw/rare meat
- Handling cats and cat litter
What is the management of toxoplasmosis?
- Toxoplasmosis PCR +ve in mother and -ve in baby = Spiramycin (3-week course, 2-3g/day)
- Spiramycin prevents vertical transmission
- Toxoplasmosis PCR +ve in mother and +ve in baby = Pyrimethamine + Sulfadiazine
- Treat baby for up to 1 year after delivery
- Also adjunct Prednisolone
What is a potential consequence of chorioretinitis?
Cataracts
Describe parvovirus B19.
- Erythema infectiosum is consequence
- Incubation period 4-20 days
- Infective from 10 days prior of rash until 1 day after appearance of rash
- Transmission by aerosol, blood-borne or vertical
- Risk period if vertically transmitted <20w GA; low risk >20w
What are the signs and symptoms of parvovirus B19?
- In the young child/mother:
- Rash - ‘slapped cheek’ appearance (erythema infectiosum)
- Malaise
- Fever
- Arthralgia
- Transient aplastic crisis
- 25% asymptomatic)
- Infant – coryzal symptoms, headache, rash
- In the neonate/antepartum:
- Severe anaemia due to RBC destruction → hydrops fetalis → 10% infant mortality
What are the appropriate investigations of suspected parvovirus B19?
- IgM and IgG
- USS - foetal anomaly scan 4 weeks after onset of illness, then serial scans in 2-week intervals until 30/40
- Rubella serology (similar presentation)
What is the management of parvovirus B19?
- Maternal/Infant = Self-limiting (lasts up to 3w)
- Intrauterine = Blood transfusion if foetal hydrops
What are the complications of parvovirus B19?
- Miscarriage (15%)
- Foetal hydrops (3%)
Which pregnant women are tested for Hepatitis B?
All women
- Vertical transmission = 20%
- 90% if +ve for HBeAg
What is the treatment for babies born to chronically HBV infected mothers?
- Vaccination - given at birth, 1 month, 6 months → serological test for HBV at 12 months
- HBV IVIG - 0.5mL within 12 hours of birth
- C-section does not reduce vertical transmission
- Hepatitis B is NOT transmitted via breastfeeding
How is Hepatitis C monitored/managed in pregnancy?
- Detect anti-HCV antibodies
- Confirm with PCR for the virus
- Treatment contraindicated in pregnancy (ribavirin + interferon)
How is Hepatitis E monitored/managed in pregnancy?
- Causes a severe reaction if contracted in the third trimester → sometimes a Fulminant hepatitis
- Pregnant mothers should stay away from pork and shellfish
Describe VZV.
- Transmission is respiratory
- 70% attach rate in susceptible individuals
- Incubation 10-21 days → infectious 48 hours before rash until the vesicles crust over (lasts for 5 days)
- Transfer to baby can be transplacental, ascending vaginal or contact after delivery with lesions
- 90% of UK women immune
What are the signs and symptoms of maternal chickenpox?
- Prodromal fever, malaise, myalgia
- Generalised rash
- Macular → Popular → Vesicular - different lesions at different stages
- Risk of encephalitis, pneumonia or sepsis
What are the signs and symptoms of congenital varicella syndrome?
- Eyes - chorioretinitis → cataracts
- CNS - microcephaly
- MSK - limb hypoplasia, cutaneous scarring
- IUGR
- VZV antepartum - maternal transmission from 13-20w → 2% risk
What are the signs and symptoms of neonatal varicella infection?
- Usually a mild disease
- Disseminated skin lesions → purpura fulminans
- Pneumonia
- Visceral infections
- VZV intra-/post-partum – maternal infection 7 days before or after birth
What are the appropriate investigations for suspected VZV?
- Booking → check previous maternal exposure
- If No exposure = avoid contact during pregnancy - significant contact is being in the same room as someone for 15 mins or more
- If unsure of immune status = check VZV IgG before giving therapy
What is the management of antenatal chickenpox?
-
VZIG - before 20/40 gestation
- Infectious for 21 days without VZIG
- Infectious for 28 days with VZIG
- VZIG cannot be given when symptoms have developed
- Aciclovir - after 20/40 gestation
- Hospital admission - if risk factors are present:
- Smoking
- Chronic lung disease
- Corticosteroids for lung maturation
- Consider referral to foetal medicine specialist
What is the management of intrapartum chickenpox?
- Delay delivery until 7 days after onset of the rash - allow time for passive transfer of antibodies
- Neonatal VZIG if…
- Birth occurs <7 days onset of maternal rash
- Mother develops chickenpox <7 days of delivery
- No vaccination
What is the management of postpartum chickenpox?
- The infant should be monitored for signs of infection until 28 days after the onset of maternal infection
- Neonatal infection should be treated with aciclovir
- Neonatal ophthalmic examination should be organised after birth
What are the complications of VZV in pregnancy?
- Risks
- Bleeding
- Thrombocytopaenia
- DIC
- Hepatitis
- Varicella infection of the new-born
- Low risk of a non-immune pregnant woman getting chickenpox from someone with shingles
How is HIV transmitted?
- Present in vaginal fluid, semen, blood, breast milk
- Transmission through sexual contact, BB, vertical
- Less transmission through vaginal mucosa than through anal mucosa
What are the risk factors for vertical transmission of HIV?
- High viral load
- Low CD4 count
- Prolonged rupture of membranes (>4h)
- Breastfeeding
What are the signs and symptoms of HIV?
- Asymptomatic - 1-4 weeks for seroconversion
- HIV – fever, rash, lethargy, oral ulcers, lymphadenopathy, sore throat
- AIDs-defining diseases – PCP, Kaposi’s sarcoma, MAC, oesophageal candidiasis
What investigations are carried out to screen for HIV?
- Routine HIV testing in antenatal booking = regular viral load, CD4 count
- Baseline indication tests – FBC, UE, LFT, lactate, blood glucose
- Neonates test +ve for HIV antibodies due to passive transfer from mother → diagnosis of HIV in the neonate requires direct viral amplification by PCR
- Carried out at birth, on discharge, 6 weeks, 12 weeks and 18 weeks
What is the management of HIV in a pregnant mother?
- Monitoring:
- CD4 counts (at baseline and at delivery)
- Viral load (every 2-4 weeks, at 36 weeks and after delivery)
- Management of mother:
- ART:
- Maternal = continual
- Delivery (different for PROM/PPROM)
- SVD = undetectable (<50 copies/mL)
- ELCS @ 38 weeks = detectable (>50 copies/mL), HIV/HCV co-infection or on zidovudine monotherapy
- ART:
- Avoidance of breastfeeding → offer cabergoline to supress lactation + free formula
What is the management of HIV in an infant/newborn?
- Cord clamped as soon as possible
- Baby bathed immediately after birth
- Zidovudine monotherapy
- Low/Medium risk = 2-4w
- High risk = 4w PEP combination
- Formula feeding/not to breastfeeding
- Give all immunisations including BCG
- PCR HIV virions at 6 and 12 weeks (at least 2 and 8 weeks after stopping prophylaxis)
What counselling should be given to a lady considering pregnancy/who is pregnant with HIV?
- Explain risk of vertical transmission antenatal, intrapartum and postnatally
- Stress the importance of good compliance with HAART
- Viral load measurement every 2-4 weeks and at 36 weeks
- Viral load <50 copies/mL at 36 weeks = safe vaginal delivery
- Viral load >50 copies/mL at 36 weeks = ELCS
- Explain neonatal treatment with oral zidovudine for 2-4w
What is PrEP and PEP?
- PrEP = two-drug ART
- PEP = three-drug ART for 1 month
How is rubella transmitted?
- Aerosol
- Vertical/Transplacental
What are the risk factors for rubella?
- Non-immunity
- Increased rates in ethnic minorities
What are the signs and symptoms of rubella?
- Coryzal symptoms - cold-like symptoms, arthralgia, rash
- Soft palate lesions
- Lymphadenopathy
- Maculopapular rash - starts behind ears, spreading to head and neck, then to rest of body
What are the signs and symptoms of congenital rubella syndrome?
- CRS → PDA → chorioretinitis → cataracts (blindness) → sensorineural hearing loss
- Infection <12w = CRS (90%), microcephaly, (20% miscarry at this stage)
- Infection 12-20w = SNHL, chorioretinitis → cataracts
- Infection >20w = low risk
What are the appropriate investigatiosn for suspected rubella?
- Blood serology – IgG and IgM (active or 4x increase in IgG titre)
- PCR virus
- USS – foetal anomalies
- Screening
- Screening not routinely offered (prevalence too low)
- For women screened and rubella antibody not detected → MMR after pregnancy
- Vaccine contraindicated in pregnancy because it is a live vaccine
What is the management of rubella?
- Rest, fluids and paracetamol - No treatment
- Offer TOP if <16w GA
- Refer to Foetal Medicine Unit and notify the Health Protection Unit
- Avoid work and pregnant women for 5 days after initial development of the rash
- No MMR vaccination (or any live attenuated vaccine) to be given during pregnancy/immunocompromised
What are the complications of rubella?
- Maternal
- Miscarriage
- Pneumonia
- Arthropathy
- Encephalitis
- ITP
- Foetal
- Death
- Congenital rubella syndrome - deafness, VSD, PDA, cataracts, CNS defects, IUGR, hepatosplenomegaly, thrombocytopenia, rash
Describe the Herpes Simplex Virus.
- Two types: 1 (oral>genital) or 2 (genital>oral)
- Spread to neonate through direct contact with infected maternal secretions
- Risk of neonatal transmission at SVD = 41% with primary lesion or 2% with recurrent lesions
- Spread to neonate through direct contact with infected maternal secretions
- DNA virus
What are the risk factors for HSV?
- Unprotected sex
- Immunosuppression
- Other STI’s
What are the signs and symptoms of HSV in an adult?
- Asymptomatic
- Oral herpes
- Genital herpes - dysuria, frequency
- Disseminated herpes
- Encephalitis
- Hepatitis
- Disseminated skin lesions
What are the signs and symptoms of HSV in a neonate?
- Skin, Eye and Mouth (SEM) disease - 45%
- Blistering vesicular rash
- Chorioretinitis
- CNS disease ± SEM - 30% → 6% mortality
- Presents 10d-4w postpartum
- Seizures
- Lethargy
- Irritability
- Poor feeding
- Temperature instability
- Bulging fontanelle
- Disseminated infection (MODS) - 25% → 30% mortality
- Encephalitis
- CNS
- Hepatitis
- Pneumonitis
- No skin lesions
- DOC
What are the appropriate investigations for suspected HSV?
- Clinical diagnosis ± STI screen
- PCR virus
What is the management of acute HSV infection in a pregnant women?
-
Aciclovir (400mg, TDS)
- <26w primary infection → oral aciclovir; 36 weeks until delivery
- >26w primary infection → oral aciclovir until delivery
What is the management of acute HSV infection in a neonate?
-
Aciclovir (400mg, TDS)
- IV aciclovir to child
- 14d if SEM disease
- 21d if CNS or disseminated
- IV aciclovir to child
What is the management of HSV primary infection at delivery?
- 1st episode ≥6w prior to EDD = SVD
- 1st episode ≤6w prior to EDD = C-section
- Perform HSV (type-specific) antibody testing
- If the woman chooses vaginal delivery
- Rupture of membranes and invasive procedures should be avoided
- IV aciclovir given intrapartum to the mother and neonate
- Avoid invasive procedures in labour → increased risk of neonatal HSV
What is the management of HSV recurrent infection at delivery?
- SVD - only a 2% risk of transmission if recurrent due to maternal IgG
- Daily suppressive aciclovir 400mg TDS from 36w
- Avoid invasive procedures during labour if genital lesions
What are the complications of HSV infection in pregnancy?
- Neonatal mortality
How many women carry commensal GBS?
25% - vagina and rectum
- Majority of babies who come into contact are not affected
- Some become colonised
- Minority become ill
What are the signs and symptoms of GBS?
Pretty much always asymptomatic
What are the appropriate investigations for GBS?
- HVS or LVS
- Rectal swab
- MSU
What is the management of the mother with GBS?
- Antenatal discovery → no prophylactic treatment
- Does not reduce the likelihood of GBS colonisation at the time of delivery
- Intrapartum treatment → antibiotic prophylaxis treatment
- 1st line = IV benzylpenicillin
- Pen-allergic = IV vancomycin (severe allergy) or cephalosporin (non-severe allergy)
- Elective caesarean with membrane rupture → no need for Abx
What is the management of the neonate born to a mother with GBS?
- Monitoring neonate in prior maternal prophylaxis with no fever
- Mother has >4hrs prophylactic Abx before delivery = neonate does not need monitoring
- Mother has <4hrs prophylactic Abx before delivery = monitoring neonatal vital signs
- 0 hours → 1 hour → 2 hours → every 2 hours for next 12 hours
- Sepsis monitoring
- Postpartum - new-borns with
- 1 risk factor = remain in hospital for at least 24 hours for observations
- ≥2 risk factors or 1 red flag = sepsis Abx + septic screen
- Red Flags:
- Intrapartum Abx for confirmed/suspected sepsis
- Respiratory distress starting >4 hours postpartum
- Seizures
- Need for mechanical ventilation in a term baby
- Signs of shock
- Postpartum - new-borns with
What is the management of GBS sepsis in the neonate/
<72 hours = cefotaxime + amikacin + ampicillin
How is Listeriosis transmitted?
- Found in soil, decayed matter and animals
-
Faecal-oral transmission
- Soft cheese
- Pate
- Unpasteurised dairy products
- Unwashed salads
-
Vertical
- Transplacental
- During delivery
What are the risk factors for listeriosis?
- Pregnancy
- Immunosuppression increase risk of infection
- Very rare - 1 per 20,000 pregnancies in UK
What are the signs and symptoms of listeriosis?
- Often asymptomatic or non-specific
- Diarrhoea and Vomiting
- Malaise
- Fever
- Sore throat
- Myalgia
- Meconium staining
What are the appropriate investigations for suspected listeriosis?
- Isolation of the organism from blood
- Vaginal swabs
- Placenta
What is the management of listeriosis?
IV amoxicillin/ampicillin
What are the complications of listeriosis?
- Pregnancy
- Miscarriage
- Chorioamnionitis
- PTL
- Foetal death
- General
- Septicaemia
- Pneumonia
- Meningitis
What is the prognosis of listeriosis?
- Good if treated
- Sepsis = 50% mortality
- Meningitis = 70% meningitis
- Neonatal infection 80% mortality
