Infections in Pregnancy Flashcards
What medication can be given to treat CMV in pregnancy?
Ganciclovir
(After CMV infection confirmed on bloods)
What infections are included in TORCH screen?
To - Toxoplasmosis
R - Rubella
C - CMV
H - Herpes Simplex Virus
What 3 infections should be screened for in every pregnancy?
Syphillis
Hepatitis B
HIV
(rubella screening discontinued as did not meet UK screening criteria)
Are most primary rubella infections in the UK caught within the UK?
NO!
Primary Rubella infection is rare in the UK and therefore most are imported.
What infections should be considered if a woman presents with a vesicular rash?
Varicella
What 2 infections should be considered if a woman presents with a non-vesicular rash?
- Rubella
- Parvovirus B19
At what core body temperatures would convulsions be likely to occur?
41.2C
(Brain damage at 42.2C and dead at 45.5C).
What proportion of women who have a NVD will have a temperature of 38C or more?
(What proportion of these women will have a microbial infection?)
6-9% have a temperature.
Only 1:3 of these will have a microbial infection.
What is the leading cause of direct maternal death in the UK?
Sepsis
What are the 2 most common organisms to cause maternal sepsis?
Group A beta haemolytic strep
E Coli
What should happen for baby if GAS is identified in pregnancy?
NNU informed
Prophylactic antibiotics for baby.
What is another name for puerperal sepsis?
Genital tract sepsis.
What are the risk factors for developing sepsis?
- Obesity
- Impaired glucose tolerance or diabetes
- Immunosuppression
- Anaemia
- Vaginal discharge
- Previous pelvic infection
- Previous GBS infection
- Amniocentesis or other invasive procedures
- Cervical cerclage
- PROM
- GAS (mum or her close contacts)
- BAME women
Is pyrexia present in all septic women?
NO!
Pyrexia can be absent in severe sepsis.
Presence of diarrhoea suggests gastro-enteritis, therefore should antibiotics be started?
Yes - if there is clinical suspicion of sepsis.
What is septic shock?
Life threatening host reaction to infectious process (driven by cytokine release).
(functional intra-vascular volume is less than vascular bed, therefore tissue hypoxia and organ failure).
What are the clinical criteria of septic shock?
- Hypotension requiring vasopressors to maintain MAP 65+
- Serum lactate 2+
What serum lactate is indicative of tissue hypo-perfusion?
4+
(But 2+ is criteria for septic shock)
What are the 3 stages of sepsis?
- Early aka warm shock
(warm skin and flushing, temperature instability, incRR, altered mental state, vasodilation, hypotension and increased cardiac output). - Late aka cold shock
(cool and clammy, oligourea, cyanosis, ARDS, peripheral vasoconstriction and increased peripheral resistance, and decreased cardiac output). - Secondary aka irreversible
(anuria, hypoglycaemia, DOC and myocardial failure).
What is chorioamnionitis?
Inflammation of the amniochorionic (foetal) membranes of the placenta..
What proportion of livebirths are affected by chorioamnionitis?
1%
What proportion of women with PROM will develop chorioamnionitis?
30%
What is the underlying cause of chorioamnionitis?
96% due to ascending infection.
4% due to septicaemia haematogenous spread.
What organisms cause chorioamnionitis?
POLYMICROBIAL
- Mycoplasmas
- E Coli
- GBS
- Anaerobic bacteria.
What are the risk factors for developing chorioamnionitis?
- P/PROM
- SROM with Mec
- Prolonged labour or multiple VE’s
- P0
- Infection (GBS colonisation or BV)
- Smoker or alcohol drinker
- FSE
- Epidural anaesthesia.
What are the maternal effects of chorioamnionitis?
2-3 fold increase risk of LSCS
Endometritis
Wound infection or pelvic abscess
Bacteraemia
PPH
What are the foetal effects of chorioamnionitis?
Early onset sepsis
Perinatal death
Asphyxia
Pneumonia
Intraventricular haemorrhage.
What micro-orgnanism causes syphillis?
(what type of organism is this?)
Treponema pallidum
(Spirochete bacterium)
What test is used to identify syphilis?
Serological tests.
Microscopic identification of bacteria can also be used.
What proportion of sexual contacts will develop syphillis infection after having UPSI with infected person?
1:3
Can syphillis cross the placenta?
Yes, vertical transmission is possible.
There were 17 cases between 2010 - 2015.
Who is screened for syphillis antenatally?
What proportion of these are positive tests?
Everyone is tested antenatally.
1:700 tests are positive.
What test is used to screen for syphillis in pregnancy?
If this is positive, how is infection status confirmed?
EIA (enzyme immunoassay) detects Treponema pallidum antibodies.
If positive, then TPPA (treponema palliudum partial agglutation) or TPHA (treponema pallidum haemagglutination) assay is used to confirm status.
What are the 3 stages of syphilis?
- Primary and Secondary
- Latent
- Tertiary
What are the symptoms of primary infection?
Chancre (genital ulcer that develops 10 days to 3 months after exposure, but generally 2-6 weeks).
(symptomatic, highly infectious stage)
What proportion of people infected with primary syphilis will develop secondary syphilis?
1:3
What are the symptoms of secondary syphilis and when does this develop?
A skin rash (brown sores) on palms of hands and soles of feet. May also develop fever and myalgia that self-resolves. q
Develops 3-6 weeks after Chancre and resolves within weeks-months. But can develop up to 2 years later.
What proportion of people infected with secondary syphilis will go on to develop tertiary syphilis?
1:3
What is the risk of miscariage/ preterm/ still birth /congential syphilis in:
1. primary infection
2. early latent infection
3. late latent infection.
- 70-100%
- 40%
- 10%
How can Syphilis be diagnosed antenatally in the foetus?
- NIFH (non immune hydrops fetalis)
- FGR (if syphilis in 1st trimester, can be severe IUGR from 2nd trimester)
- Oligohydramnios
- Foetal head lesions (cerebral calcifications, hydrocephaly, hydrancephaly, microcephaly)
- GI lesions (liver/spleen/bowel, ascities, hepatosplenomegaly).
What proportion of babies with congenital syphilis will be asymptomatic at birth?
2:3
(but most develop symptoms by 5 weeks)
What is the overall rate of foetal loss in women with untreated syphilis in pregnancy?
50%
What are the signs of congenital syphilis in the new born?
What is the mortality rate if these symptoms are present at birth?
Rhinitis
Diffuse maculopapular rash
Desqamative rash
Splenomegaly
Anaemia
Thrombocytopenia
Jaundice
50% mortality.
How is syphilis in pregnancy treated?
GUM referral.
Treat if acute infection or inadequate treatment prior to pregnancy.
Treat with Ben Pen.
(AVOID MACROLYDES).
Refer to FM by 26/40.
What serological test is used to detect herpes?
PCR
What type of virus is herpes?
DsDNA virus
Where does each type of herpes generally affect and how is it transmitted?
HSV1: orolabial infections (close physical contact).
HSV2: genital herpes (sexually transmitted).
How many new cases of genital herpes occur each year in the UK?
31,000 per year.
What proportion of adults have herpes antibodies?
23%
How long after exposure to herpes do symptoms develop?
3-7 days.
If primary infections occurs in which trimester is there a higher risk of maternal disseminated HSV?
Second Trimester
How should acute infection of herpes be identified?
Seroconversion
(IgM is unreliable)
Is it common to develop genital HSV1 from orogential contact?
No, this is rare.
What is the management of herpes in pregnancy?
- GUM referral
- 5 days PO Aciclovir
- Serology (differentiate primary vs non-primary infection)
- OD Aciclovir in last 4 weeks of pregnancy
- if infection in 1st/2nd trimester, aim for NVD
- If 3rd trimester, LSCS if lesions at time of labour or if lesions within 6 weeks delivery.
If NVD then given maternal and foetal Aciclovir.
What is the risk of neonatal herpes infection if recurrent infection at the time of vaginal delivery?
1-3%
Is HSV1 or HSV2 associated with a poorer neonatal prognosis?
HSV2 associated with a poorer prognosis.
What is the mortality rate if congenital neonatal disseminated (or encephalitis) Herpes?
30%
What tests are used to detect chlamydia?
NAAT
(and POCT)
(these can be PCR, LCR, TMA or SDA based)
What can cause false positive tests when using first catch urine to detect for chlamydia in pregnancy?
bHCG
Nitrites
Hb
What type of bacteria is chlamydia?
Obligate intracellular bacterium.
How is chlamydia treated in pregnancy?
- STAT 1g Azithromycin + 500mg OD for 2 days.
- Erythromycin 500mg QDS for 7 days.
- Erythromycin 500mg BD for 14 days.
- Amoxicillin 500mg TDS 7 days.
(Doxycycline and Ofloxacin are CI in pregnancy).
Is a test of cure recommended after chamlaydia treatment in pregnancy?
Only if suspected poor compliance or persistent symptoms.
What proportion of babies, born to mum’s infected with chlamydia, become:
1 - colonised?
2 - develop conjunctivitis?
3 - develop pneumonia?
1- 50-60% colonised
2- 20-50% conjunctivitis
3- 10-20% pneumonia.
What proportion of gonorrhoea infection leads to disseminated gonococcal infection?
1%
What type of bacteria is gonorrhoea?
Gram negative diplococci
When is gonorrhoea screened for in pregnnacy?
Everyone is screened at booking, but at risk women are also screened in the 3rd trimester.
If untreated, what proportion of babies born to mothers with gonorrhoea will develop opthalmia neonatorum?
28%
(keratintitis, ulceration and perforation).
What is the management of Gonorrhoea in pregnancy?
- STAT IM Ceftriaxone.
- or STAT Spectinomycin 2g IM (but expressed in breast milk therefore use with caution).
- STAT PO 2g Azithromycin.
(Avoid quinolones and tetracycline).
What does HIV virus target?
Reverse Transcriptase
CD4 lymphocytes.
What is the chance of HIV vertical transmission?
25-40% in Sub-Saharan Africa
<1% if on appropriate HAART
0.57% if on cART adn
Increased risk if breastfeeding.
What is the prevelence of HIV in the pregnant population?
2.2/1,000 (0.22%)
(majority in sub sahara africa)
When will serological tests reflect true HIV status?
HIV antibodies take 3 months.
p24 antigen test takes 1 month.
What is the standard HIV treatment?
Combination of 3 HAART’s
What proportion of pregnant women with HIV are on HAART?
> 95%
When should HAART be initiated in pregnant women?
Between 20-28 weeks.
Symptomatic of HIV.
+/- CD4 <350.
How should women with untreated HIV be treated when presenting in labour?
STAT Nevirapine 200mg
PO Lamuvidine 150mg BD
Raltegravir 400mg BD
IV Zidovudine for duration of labour.
When should ElLSCS be offered to women with HIV?
If on HAART and viral load >50.
ZDV monotherapy.
HCV Co-Infection.
When should women with HIV be offered a NVD?
If on HAART AND viral load <50.
Women with SROM after 36/40 and HIV infection should receive what prophylaxis?
BenPen GBS prophylaxis.
(women with PPROM or SROM should also be offered immediate augmentation and aim to deliver <24 hours).
For a women presenting with a viral load between 50-399, what should the management plan be?
Offer LSCS, but account for actual viral load, trajectory, length of time of HAART etc
What is the recommended MOD and timing of delivery for women with HIV who present with a viral load>400 at 36/40?
ElLSCS.
38-39/40.
(immediate LSCS if SROM).
When should IM Zidovudine be given?
Women presenting in labour with a viral load >1,000.
Or women with untreated HIV (or unknown viral load).
