Infections in Pregnancy Flashcards
1
Q
Describe toxoplasmosis?
A
- 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
2
Q
What are the risk factors for toxoplasmosis?
A
- Household cats
- Increased incidence in rural areas and France
3
Q
What are the signs and symptoms of toxoplasmosis?
A
- 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
4
Q
What are the investigations for suspected toxoplasmosis?
A
- 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
5
Q
What is the preventative strategy for toxoplasmosis?
A
- Mother should avoid:
- Eating raw/rare meat
- Handling cats and cat litter
6
Q
What is the management of toxoplasmosis?
A
- 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
7
Q
What is a potential consequence of chorioretinitis?
A
Cataracts
8
Q
Describe parvovirus B19.
A
- 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
9
Q
What are the signs and symptoms of parvovirus B19?
A
- 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
10
Q
What are the appropriate investigations of suspected parvovirus B19?
A
- 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)
11
Q
What is the management of parvovirus B19?
A
- Maternal/Infant = Self-limiting (lasts up to 3w)
- Intrauterine = Blood transfusion if foetal hydrops
12
Q
What are the complications of parvovirus B19?
A
- Miscarriage (15%)
- Foetal hydrops (3%)
13
Q
Which pregnant women are tested for Hepatitis B?
A
All women
- Vertical transmission = 20%
- 90% if +ve for HBeAg
14
Q
What is the treatment for babies born to chronically HBV infected mothers?
A
- 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
15
Q
How is Hepatitis C monitored/managed in pregnancy?
A
- Detect anti-HCV antibodies
- Confirm with PCR for the virus
- Treatment contraindicated in pregnancy (ribavirin + interferon)
16
Q
How is Hepatitis E monitored/managed in pregnancy?
A
- Causes a severe reaction if contracted in the third trimester → sometimes a Fulminant hepatitis
- Pregnant mothers should stay away from pork and shellfish
17
Q
Describe VZV.
A
- 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
18
Q
What are the signs and symptoms of maternal chickenpox?
A
- Prodromal fever, malaise, myalgia
- Generalised rash
- Macular → Popular → Vesicular - different lesions at different stages
- Risk of encephalitis, pneumonia or sepsis
19
Q
What are the signs and symptoms of congenital varicella syndrome?
A
- Eyes - chorioretinitis → cataracts
- CNS - microcephaly
- MSK - limb hypoplasia, cutaneous scarring
- IUGR
- VZV antepartum - maternal transmission from 13-20w → 2% risk
20
Q
What are the signs and symptoms of neonatal varicella infection?
A
- Usually a mild disease
- Disseminated skin lesions → purpura fulminans
- Pneumonia
- Visceral infections
- VZV intra-/post-partum – maternal infection 7 days before or after birth
21
Q
What are the appropriate investigations for suspected VZV?
A
- 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
22
Q
What is the management of antenatal chickenpox?
A
-
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
23
Q
What is the management of intrapartum chickenpox?
A
- 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
24
Q
What is the management of postpartum chickenpox?
A
- 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
25
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
26
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
27
What are the risk factors for vertical transmission of HIV?
* High viral load
* Low CD4 count
* Prolonged rupture of membranes (\>4h)
* Breastfeeding
28
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*
29
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
30
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
* Avoidance of breastfeeding → offer cabergoline to supress lactation + free formula
31
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)
32
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
33
What is PrEP and PEP?
* PrEP = two-drug ART
* PEP = three-drug ART for 1 month
34
How is rubella transmitted?
* Aerosol
* Vertical/Transplacental
35
What are the risk factors for rubella?
* Non-immunity
* Increased rates in ethnic minorities
36
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*
37
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
38
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
39
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
40
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*
41
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
* DNA virus
42
What are the risk factors for HSV?
* Unprotected sex
* Immunosuppression
* Other STI's
43
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
44
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
45
What are the appropriate investigations for suspected HSV?
* Clinical diagnosis ± STI screen
* PCR virus
46
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
47
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
48
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
49
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
50
What are the complications of HSV infection in pregnancy?
* Neonatal mortality
51
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
52
What are the signs and symptoms of GBS?
Pretty much always asymptomatic
53
What are the appropriate investigations for GBS?
* HVS or LVS
* Rectal swab
* MSU
54
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
55
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
56
What is the management of GBS sepsis in the neonate/
**\<72 hours = cefotaxime + amikacin + ampicillin**
57
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*
58
What are the risk factors for listeriosis?
* Pregnancy
* Immunosuppression increase risk of infection
* *Very rare - 1 per 20,000 pregnancies in UK*
59
What are the signs and symptoms of listeriosis?
* Often asymptomatic or non-specific
* Diarrhoea and Vomiting
* Malaise
* Fever
* Sore throat
* Myalgia
* Meconium staining
60
What are the appropriate investigations for suspected listeriosis?
* Isolation of the organism from blood
* Vaginal swabs
* Placenta
61
What is the management of listeriosis?
**IV amoxicillin**/ampicillin
62
What are the complications of listeriosis?
* Pregnancy
* Miscarriage
* Chorioamnionitis
* PTL
* Foetal death
* General
* Septicaemia
* Pneumonia
* Meningitis
63
What is the prognosis of listeriosis?
* Good if treated
* Sepsis = 50% mortality
* Meningitis = 70% meningitis
* Neonatal infection 80% mortality
