Infections In Pregnancy Flashcards
Presumptive Diagnosis chorioamnionitis? (4)
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)
Define intra-amniotic infection (5)
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
How confirm Diagnosis chorioamnionitis? (7)
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)
Name 5 maternal complications intra-amniotic infection
- Maternal infections eg Endometritis
- impaired uterine contractility
- labour abnormalities
- need for c/s: increased risk pelvic abscess, wound infection, endomyometritis
- uterine atony
- PPH
Management chorioamnionitis (4)
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 )
Name 8 neonatal complications intra-amniotic infection
- Perinatal death
- Asphyxia
- early onset neonatal sepsis
- septic shock
- Pneumonia
- meningitis
- Ivh
- long term neurodevelopmental delay
Management malaria in pregnancy? (2)
- Quinine
- clindamycin
Chemoprophylaxis malaria in pregnancy? (3)
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!
Management hepatitis A in pregnancy? (3)
- 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
Interpret hep B panel:
- hbsag negative
- anti- HBC negative
- anti-HBs negative
Susceptible to infection
0% risk vertical transmission
Interpret hep B panel:
- hbsag negative
- anti- HBC positive
- anti-HBs positive
Immune because of natural infection
0% risk vertical transmission
Interpret hep B panel:
- hbsag negative
- anti- HBC negative
- anti-HBs positive
Immune because of hep B vaccine
0% risk vertical transmission
Interpret hep B panel:
- hbsag positive
- anti- HBC positive
- anti-HBs negative
- anti- HBc IgM positive
Acutely infected
Risk vertical transmission
- First trimester: 10%
- third: 80 - 90%
- hbeag -: 10 - 20%
- hbeag +: 90%
Interpret hep B panel:
- hbsag positive
- anti- HBC positive
- anti-HBs negative
- anti- HBc IgM negative
Chronically infected
Risk vertical transmission:
- hbeag -: 2-10%
- hbeag+: 80 - 90%
Interpret hep B panel: (4)
- hbsag negative
- anti- HBC positive
- anti-HBs negative
4 possible interpretations
- recovering from acute HBV infection
- Immune
- susceptible with false + anti - HBc
- Undetectable level of hbsag and person actually carrier
Management hepatitis C in pregnancy? (6)
- 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
Name 3 risk factors neonatal strep B transmission
- Prolonged rupture of membranes 18 hours or more
- preterm
- temperature 38 or more
Although not recommended routinely, how and when is GBS screened for?
- 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.
Prophylaxis at delivery to mom for group B Streptococcus?
- Benzylpenicillin 3g iv ASAP after onset labour and 1,5g 4 hourly until delivery
- cephalosporin or vancomycin if penicillin allergy
Toxoplasmosis in pregnancy diagnosis?
2 blood samples 2 weeks apart shows seroconversion
IGM
Toxoplasmosis effect on pregnancy? (3)
- 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
Toxoplasmosis in pregnancy management? (2)
- 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)
Syphilis in pregnancy diagnosis? (3)
- Dark field microscopy
- treponema specific serology: FTA - abs, tpha, mha-tp
- non-treponemal: vdrl, wr, RPR
Syphilis effect on pregnancy? (6)
- 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…
Syphilis in pregnancy management?
- Benzathine penicillin 2,4 mil iu iv 3 doses at weekly intervals
- alternatives: amoxyl, probenecid
Varicella zoster effect on pregnancy?
- 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.
Varicella zoster in pregnancy management? (2)
- 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
Parvo b19 effect on pregnancy? (7)
- Ocular abnormalities
- hydrocephalus
- left lip/palate
- webbed joints, musculoskeletal abnormalities, myosotis
- hepatocellular damage
- myocarditis, cardiomyopathy
- fetal loss/ hydros fetalis
Highest risk stillbirth <12 weeks
Rubella effects on pregnancy? (5)
- Spontaneous abortion
- foetal infection, ( >36 weeks 100% risk. Lowest in trimester 2 )
- stillbirth
- iugr
- congenital rubella syndrome: cataract, deaf, heart disease
Rubella in pregnancy management? (2)
Top if infection < 16 weeks, counsel if more.
Define maternal sepsis according to WHO
Organ dysfunction resulting from infection during pregnancy, childbirth, post abortion or post- partum
Define puerperal sepsis ( 6)
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)
Define sirs (7)
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
Name 6 causes puerperal sepsis
- 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
Name 9 maternal complications severe puerperal sepsis
- ICU admission
- pulmonary oedema
- ARDS
- Acute renal failure
- shock liver
- septic emboli to other organs
- myocardial ischaemia
- Dic
- death
Broad Management puerperal sepsis? (4)
1 initial resuscitation phase (first 6 hours)
2. Haemodynamic management
3. Antimocrobial therapy
4. Search and eliminate source sepsis
How perform initial resuscitation phase in management of puerperal sepsis (6)
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
How perform haemodynamiC management of puerperal sepsis (5)
- 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
Which empiric antimicrobials give for management of severe puerperal sepsis (2)
- Tazobactam (beta lactamase inhibitor) or a carbapenem ( eg ertapenem) +
- clindamycin (lincomycin)
Which vaccinations are recommended during pregnancy? (3)
All women
- Influenza (once per year)
- t dap (tetanus, diphtheria, pertussis): if not already vaccinated, can get >20 weeks gestation
High risk women
- rabies
