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Y5 O&G > Infections in Pregnancy > Flashcards

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
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2
Q

What are the risk factors for toxoplasmosis?

A
  • Household cats
  • Increased incidence in rural areas and France
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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
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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
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5
Q

What is the preventative strategy for toxoplasmosis?

A
  • Mother should avoid:
    • Eating raw/rare meat
    • Handling cats and cat litter
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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
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7
Q

What is a potential consequence of chorioretinitis?

A

Cataracts

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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
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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
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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)
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11
Q

What is the management of parvovirus B19?

A
  • Maternal/Infant = Self-limiting (lasts up to 3w)
  • Intrauterine = Blood transfusion if foetal hydrops
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12
Q

What are the complications of parvovirus B19?

A
  • Miscarriage (15%)
  • Foetal hydrops (3%)
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13
Q

Which pregnant women are tested for Hepatitis B?

A

All women

  • Vertical transmission = 20%
  • 90% if +ve for HBeAg
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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25
Q

What are the complications of VZV in pregnancy?

A
  • 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
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26
Q

How is HIV transmitted?

A
  • Present in vaginal fluid, semen, blood, breast milk
  • Transmission through sexual contact, BB, vertical
    • Less transmission through vaginal mucosa than through anal mucosa
27
Q

What are the risk factors for vertical transmission of HIV?

A
  • High viral load
  • Low CD4 count
  • Prolonged rupture of membranes (>4h)
  • Breastfeeding
28
Q

What are the signs and symptoms of HIV?

A
  • 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
Q

What investigations are carried out to screen for HIV?

A
  • 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
Q

What is the management of HIV in a pregnant mother?

A
  • 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
Q

What is the management of HIV in an infant/newborn?

A
  • 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
Q

What counselling should be given to a lady considering pregnancy/who is pregnant with HIV?

A
  • 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
Q

What is PrEP and PEP?

A
  • PrEP = two-drug ART
  • PEP = three-drug ART for 1 month
34
Q

How is rubella transmitted?

A
  • Aerosol
  • Vertical/Transplacental
35
Q

What are the risk factors for rubella?

A
  • Non-immunity
  • Increased rates in ethnic minorities
36
Q

What are the signs and symptoms of rubella?

A
  • 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
Q

What are the signs and symptoms of congenital rubella syndrome?

A
  • 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
Q

What are the appropriate investigatiosn for suspected rubella?

A
  • 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
Q

What is the management of rubella?

A
  • 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
Q

What are the complications of rubella?

A
  • Maternal
    • Miscarriage
    • Pneumonia
    • Arthropathy
    • Encephalitis
    • ITP
  • Foetal
    • Death
    • Congenital rubella syndrome - deafness, VSD, PDA, cataracts, CNS defects, IUGR, hepatosplenomegaly, thrombocytopenia, rash
41
Q

Describe the Herpes Simplex Virus.

A
  • 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
Q

What are the risk factors for HSV?

A
  • Unprotected sex
  • Immunosuppression
  • Other STI’s
43
Q

What are the signs and symptoms of HSV in an adult?

A
  • Asymptomatic
  • Oral herpes
  • Genital herpes - dysuria, frequency
  • Disseminated herpes
    • Encephalitis
    • Hepatitis
    • Disseminated skin lesions
44
Q

What are the signs and symptoms of HSV in a neonate?

A
  • 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
Q

What are the appropriate investigations for suspected HSV?

A
  • Clinical diagnosis ± STI screen
  • PCR virus
46
Q

What is the management of acute HSV infection in a pregnant women?

A
  • Aciclovir (400mg, TDS)
    • <26w primary infection → oral aciclovir; 36 weeks until delivery
    • >26w primary infection → oral aciclovir until delivery
47
Q

What is the management of acute HSV infection in a neonate?

A
  • Aciclovir (400mg, TDS)
    • IV aciclovir to child
      • 14d if SEM disease
      • 21d if CNS or disseminated
48
Q

What is the management of HSV primary infection at delivery?

A
  • 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
Q

What is the management of HSV recurrent infection at delivery?

A
  • 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
Q

What are the complications of HSV infection in pregnancy?

A
  • Neonatal mortality
51
Q

How many women carry commensal GBS?

A

25% - vagina and rectum

  • Majority of babies who come into contact are not affected
  • Some become colonised
  • Minority become ill
52
Q

What are the signs and symptoms of GBS?

A

Pretty much always asymptomatic

53
Q

What are the appropriate investigations for GBS?

A
  • HVS or LVS
  • Rectal swab
  • MSU
54
Q

What is the management of the mother with GBS?

A
  • 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
Q

What is the management of the neonate born to a mother with GBS?

A
  • 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
Q

What is the management of GBS sepsis in the neonate/

A

<72 hours = cefotaxime + amikacin + ampicillin

57
Q

How is Listeriosis transmitted?

A
  • Found in soil, decayed matter and animals
  • Faecal-oral transmission
    • Soft cheese
    • Pate
    • Unpasteurised dairy products
    • Unwashed salads
  • Vertical
    • Transplacental
    • During delivery
58
Q

What are the risk factors for listeriosis?

A
  • Pregnancy
  • Immunosuppression increase risk of infection
  • Very rare - 1 per 20,000 pregnancies in UK
59
Q

What are the signs and symptoms of listeriosis?

A
  • Often asymptomatic or non-specific
  • Diarrhoea and Vomiting
  • Malaise
  • Fever
  • Sore throat
  • Myalgia
  • Meconium staining
60
Q

What are the appropriate investigations for suspected listeriosis?

A
  • Isolation of the organism from blood
  • Vaginal swabs
  • Placenta
61
Q

What is the management of listeriosis?

A

IV amoxicillin/ampicillin

62
Q

What are the complications of listeriosis?

A
  • Pregnancy
    • Miscarriage
    • Chorioamnionitis
    • PTL
    • Foetal death
  • General
    • Septicaemia
    • Pneumonia
    • Meningitis
63
Q

What is the prognosis of listeriosis?

A
  • Good if treated
  • Sepsis = 50% mortality
  • Meningitis = 70% meningitis
  • Neonatal infection 80% mortality

Y5 O&G (69 decks)

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