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Gynaecology > Infections In Pregnancy > Flashcards

Infections In Pregnancy Flashcards

1
Q

Presumptive Diagnosis chorioamnionitis? (4)

A

Maternal fever 39 or more, or 38 - 39 on 2 occasions 30 minutes apart without another clear source

And 1 or more:

  • maternal / foetal tachycardia - fetal hr > 160 for 10 mins or more, excluding accelerations decelerations and marked variability
  • purulent vaginal discharge
  • maternal wCC > 15 ooo/mm3 in absence corticosteroids

(Monitor maternal temperature, pulse, foetal hr auscultation every 4-8 hours)

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2
Q

Define intra-amniotic infection (5)

A

Infection of amniotic fluid, membranes, placenta, umbilical cord and decidua (transient layer between foetal membranes and myometrium)

Can be overt, sublinical or histological with no clinical features

Polymycrobial

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3
Q

How confirm Diagnosis chorioamnionitis? (7)

A

All clinical features and 1 or more lab findings:

  • amniotic fluid: positive gram stain /culture; low glucose concentration;or high wCC
  • histological: infection /inflammation in placenta, foetal membranes or funisitis (inflammation of connective tissue of umbilical cord)
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4
Q

Name 5 maternal complications intra-amniotic infection

A
  • Maternal infections eg Endometritis
  • impaired uterine contractility
  • labour abnormalities
  • need for c/s: increased risk pelvic abscess, wound infection, endomyometritis
  • uterine atony
  • PPH
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5
Q

Management chorioamnionitis (4)

A

Start broadspectrum antibiotics immediately

  • ampicillin 2 g iv 6 hourly +
  • gentamicin 240 mg daily (aminoglycoside G-)
  • add clindamycin or metronidazole in case of c/s
  • Continue until asymptomatic and afebrile at least 24 hours
  • only cure is delivery - deliver promptly ( NVD best )
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6
Q

Name 8 neonatal complications intra-amniotic infection

A
  • Perinatal death
  • Asphyxia
  • early onset neonatal sepsis
  • septic shock
  • Pneumonia
  • meningitis
  • Ivh
  • long term neurodevelopmental delay
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7
Q

Management malaria in pregnancy? (2)

A
  • Quinine
  • clindamycin
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8
Q

Chemoprophylaxis malaria in pregnancy? (3)

A

mefloquine weekly, start one week before travel and continue 4 weeks after leaving

  • in 2nd + 3rd trimester recommended
  • Breastfeeding
  • only in first trimester if travel to high risk chloroquine resistant p falciparum area is essential (otherwise give chloroquine)

Doxycycline + atovaquone - proguanil contraindicated!

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9
Q

Management hepatitis A in pregnancy? (3)

A
  • Usually self limited (only supportive therapy for acute infection), no perinatal transmission
  • inactivated HAV can safely be used for prevention
  • exposed pregnant women can receive immune globulin injections
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10
Q

Interpret hep B panel:
- hbsag negative
- anti- HBC negative
- anti-HBs negative

A

Susceptible to infection
0% risk vertical transmission

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11
Q

Interpret hep B panel:
- hbsag negative
- anti- HBC positive
- anti-HBs positive

A

Immune because of natural infection
0% risk vertical transmission

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12
Q

Interpret hep B panel:
- hbsag negative
- anti- HBC negative
- anti-HBs positive

A

Immune because of hep B vaccine
0% risk vertical transmission

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13
Q

Interpret hep B panel:
- hbsag positive
- anti- HBC positive
- anti-HBs negative
- anti- HBc IgM positive

A

Acutely infected

Risk vertical transmission
- First trimester: 10%
- third: 80 - 90%
- hbeag -: 10 - 20%
- hbeag +: 90%

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14
Q

Interpret hep B panel:
- hbsag positive
- anti- HBC positive
- anti-HBs negative
- anti- HBc IgM negative

A

Chronically infected

Risk vertical transmission:
- hbeag -: 2-10%
- hbeag+: 80 - 90%

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15
Q

Interpret hep B panel: (4)
- hbsag negative
- anti- HBC positive
- anti-HBs negative

A

4 possible interpretations

  • recovering from acute HBV infection
  • Immune
  • susceptible with false + anti - HBc
  • Undetectable level of hbsag and person actually carrier
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16
Q

Management hepatitis C in pregnancy? (6)

A
  • Chronic HCV: HCV igg+ and detectable HCV RNA. Chronic active infection: chronic HCV + abnormal LFT
  • Evaluate with: HCV RNA viral load, hep B sAg, hep A antibody, LFT, HIV, gastroenterology referral, STI screening
  • high risk other hepatitis so nb to vaccinate
  • treat: alpha interferon + ribavirin for non-pregnant / post partum, but not during or immediately prior!
  • only deliver via c/s if hcv and HIV
  • breastfeeding contraindicated if HCV and HIV
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17
Q

Name 3 risk factors neonatal strep B transmission

A
  • Prolonged rupture of membranes 18 hours or more
  • preterm
  • temperature 38 or more
18
Q

Although not recommended routinely, how and when is GBS screened for?

A
  • 35 - 37 weeks gestation or 3-5 weeks before anticipated date of delivery
  • swab from lower vagina and anorectum. Place in non-nutrient transport medium eg Amies or Stuart.
19
Q

Prophylaxis at delivery to mom for group B Streptococcus?

A
  • Benzylpenicillin 3g iv ASAP after onset labour and 1,5g 4 hourly until delivery
  • cephalosporin or vancomycin if penicillin allergy
20
Q

Toxoplasmosis in pregnancy diagnosis?

A

2 blood samples 2 weeks apart shows seroconversion
IGM

21
Q

Toxoplasmosis effect on pregnancy? (3)

A
  • Increased risk foetal infection with increased gestation
  • No growth restriction or microcephaly, stillbirth rare. Good prognosis unless intracranial lesions. Causes intracranial hyperechogenic foci, ventricular dilatation, intrahepatic densities, hyper dense placenta, ascites, pleural/pericardial effusion
  • prenatal diagnosis with amniocentesis PCR
22
Q

Toxoplasmosis in pregnancy management? (2)

A
  • Spiramycin (macrolide) vs pyrimethamine (antiparasitic) (sulfonamides controversial)
  • rx in pregnancy decreases neurological sequence by 75%
  • Top discouraged as babies have good prognosis unless intracranial lesions
  • prevent by avoid source (cats)
23
Q

Syphilis in pregnancy diagnosis? (3)

A
  • Dark field microscopy
  • treponema specific serology: FTA - abs, tpha, mha-tp
  • non-treponemal: vdrl, wr, RPR
24
Q

Syphilis effect on pregnancy? (6)

A
  • Perinatal death
  • Preterm
  • congenital abnormality
  • lbw
  • congenital syphilis
  • long term sequalae

Incidence of infection increase with Ga but decrease in severity
Placenta: large, oedomatous - hydros, chronic villitis, necrotising funisitis, acute chorioamnionitis…

25
Q

Syphilis in pregnancy management?

A
  • Benzathine penicillin 2,4 mil iu iv 3 doses at weekly intervals
  • alternatives: amoxyl, probenecid
26
Q

Varicella zoster effect on pregnancy?

A
  • Congenital varicella < 28 w GA (un uncommon): cutaneous scars, neuro abnormalities eg hydrocephalus, ocular abnormalities eg chorioretinitis, limb abnormality, lbw (30% mortality)
  • risk transmission highest in uterO 13-20 weeks (2%), can also be perinatal and postnatal.
27
Q

Varicella zoster in pregnancy management? (2)

A
  • PCR amniotic fluid of vzv DNA , and u / s
  • acyclovir
  • neonatal varicella if vzv just prior to delivery or within 5-days before or 2 days after - consider iv ig
28
Q

Parvo b19 effect on pregnancy? (7)

A
  • Ocular abnormalities
  • hydrocephalus
  • left lip/palate
  • webbed joints, musculoskeletal abnormalities, myosotis
  • hepatocellular damage
  • myocarditis, cardiomyopathy
  • fetal loss/ hydros fetalis

Highest risk stillbirth <12 weeks

29
Q

Rubella effects on pregnancy? (5)

A
  • Spontaneous abortion
  • foetal infection, ( >36 weeks 100% risk. Lowest in trimester 2 )
  • stillbirth
  • iugr
  • congenital rubella syndrome: cataract, deaf, heart disease
30
Q

Rubella in pregnancy management? (2)

A

Top if infection < 16 weeks, counsel if more.

31
Q

Define maternal sepsis according to WHO

A

Organ dysfunction resulting from infection during pregnancy, childbirth, post abortion or post- partum

32
Q

Define puerperal sepsis ( 6)

A

Infection of genital tract occurring at any time between onset of rupture of membranes or labour and 42nd day (6 weeks) post partum with 2 or more:

  • pelvic pain
  • fever > 38
  • abnormal vaginal discharge
  • abnormal smell of discharge
  • delay in rate of reduction of size of uterus ( < 2 cm/day during first 8 days)
33
Q

Define sirs (7)

A

2 or more:

  • temperature > 38 or <36 on 2 occasions > 24 hours apart
  • hr > 90
  • rr > 20
  • PaCO2 < 32
  • WBC > 12 x 10 ^ 9 / L; <4
  • hyperglycaemic with out diabetes
  • positive fluid balance > 20 ml/kg over 24 h
34
Q

Name 6 causes puerperal sepsis

A
  • acute pyelonephritis
  • neglected chorioamnionitis or endomyometritis
  • pneumonia (bacterial: staph, pneumococcus, mycoplasma, legionella; bacterial: H1N1 influenza, herpes, varicella)
  • unrecognised /inadequately Treated necrotising fasciitis from abdominal incision/ episiotomy/perineal laceration
  • sepsis outside genital tract: mastitis, infection related to regional anaesthesia, appendicitis…
  • retained products of conception
35
Q

Name 9 maternal complications severe puerperal sepsis

A
  • ICU admission
  • pulmonary oedema
  • ARDS
  • Acute renal failure
  • shock liver
  • septic emboli to other organs
  • myocardial ischaemia
  • Dic
  • death
36
Q

Broad Management puerperal sepsis? (4)

A

1 initial resuscitation phase (first 6 hours)
2. Haemodynamic management
3. Antimocrobial therapy
4. Search and eliminate source sepsis

37
Q

How perform initial resuscitation phase in management of puerperal sepsis (6)

A

Within 6 hours!

  • Blood cultures within 1h
  • empiric antibiotics within 1 h
  • central line place within 4h
  • cVp 8 mm Hg or higher within 6 hours
  • adrenaline infusion if indicated ( map < 65 mm Hg after resuscitation)
  • Transfusion of RBCs if indicated by hb < 7
38
Q

How perform haemodynamiC management of puerperal sepsis (5)

A
  • Rapid infusion 500 ml over 15 minutes. 3 hour goal total 30ml /kg
  • physiologic perfusion end point goals
    → CVP 8-12
    → map > 65
    → urine output > 25 ml/hour
  • Vasopressors if map < 65 after fluids; inotropes if central oxygen sats stay < 70%
  • Oxygen therapy
39
Q

Which empiric antimicrobials give for management of severe puerperal sepsis (2)

A
  • Tazobactam (beta lactamase inhibitor) or a carbapenem ( eg ertapenem) +
  • clindamycin (lincomycin)
40
Q

Which vaccinations are recommended during pregnancy? (3)

A

All women

  • Influenza (once per year)
  • t dap (tetanus, diphtheria, pertussis): if not already vaccinated, can get >20 weeks gestation

High risk women

  • rabies

Gynaecology (40 decks)

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