Infections in pregnancy

Question 1

Describe the risk of infection of chickenpox during pregnancy

Answer 1

Risk of Fetal varicella syndrome (FVS):
- skin scarring
- eye defects (microphthalmia) and cataracts
- scars and significant skin changes located in dermatomes
- limb hypoplasia
- microcephaly
- learning disabilities

Question 2

What are the congenital TORCH infections? [5]

Answer 2

Toxoplasmosis
Others (syphilis, VZV, parvovirus B19, listeriorsis)
Rubella
CMV
Herpes Simplex V

Question 3

severe neonatal varicella:
* if the mother develops rash between [] days before and [] days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

Answer 3

severe neonatal varicella:
- if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

Question 4

How do you manage a patient who is unsure if they have previously had chickenpox? [1]

Answer 4

maternal blood should be urgently checked for varicella antibodies

Question 5

Describe how you manage chickenpox exposure during pregnancy [1]

Describe how you manage chickenpox infection during pregnancy [1]

Answer 5

oral aciclovir (or valaciclovir) is now the first choice of PEP for pregnant women at any stage of pregnancy who are exposed to chickenpox
- antivirals should be given at day 7 to day 14 after exposure, NOT immediately

Infection:
- consensus guidelines (Health Protection Authority and RCOG) suggest oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
- if the woman is < 20 weeks the aciclovir should be ‘considered with caution’

NB why wait: n a study evaluating the comparative effectiveness of 7 days course of aciclovir given either immediately after exposure or starting at day 7 after exposure to healthy children, the incidence and severity of varicella infection was significantly higher in those given aciclovir immediately (10/13 (77%) who received aciclovir immediately developed clinical varicella compared with 3/14 (21%) who started aciclovir at day 7

Question 6

Rubella infection causing congenital rubella sydnrome is caused by maternal infection within the first [] weeks of pregancy.

When is there the highest risk? [1]

Answer 6

First 20 weeks - but first 10 weeks poses highest risk

Question 7

Describe the features of congenital rubella syndrome [5]

What is the clinical triad? [3]

Answer 7

• Congenital deafness
• Congenital cataracts
• ‘Salt and Pepper’ chorioretinitis
• Congenital heart disease (PDA and pulmonary stenosis)
• Learning disability
• Cerebral palsy

Triad:
- Microcephaly
- PDA
- Cataracts

Question 8

Describe how should vaccinate with regards to rubella and pregnancy? [1]

Answer 8

Women planning to become pregnant should ensure they have had the MMR vaccine.
- BUT should NOT recieve whilst pregnant as is a live vaccine

Question 9

How do you manage non-immune mothers to MMR? [1]

Answer 9

non-immune mothers should be offered the MMR vaccination in the post-natal period
* MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant

Question 10

Pregnant women are advised to avoid high-risk foods (e.g. blue cheese) and practice good food hygiene to prevent which infection? [1]

What is the clinical manifestation of having this infection in pregnancy? [1]

Answer 10

Listeria:
- Listeriosis in pregnant women has a high rate of miscarriage or fetal death.
- It can also cause severe neonatal infection.

Question 11

The features of congenital CMV are [5]

Answer 11

The features of congenital CMV are:
* ‘Blueberry muffin rash’
* Petachial rash
* Fetal growth restriction
* Microcephaly
* Hearing loss
* Vision loss
* Learning disability
* Seizures

Question 12

How do you treat congenital CMV? [1]

Answer 12

IV ganciclovir / PO valganciclovir

Question 13

Bilateral cataracts in a newborn would most likely indicate..[1]

Answer 13

Congential rubella infection

Question 14

There is a classic triad of features in congenital toxoplasmosis.

What is it? [3]

Answer 14

Intracranial calcification
Hydrocephalus
Chorioretinitis (inflammation of the choroid and retina in the eye)

Question 15

How do you treat listeriosis infection in pregnancy? [2]

Answer 15

Ampicillin and gentamicin

Question 16

Fetal hydrops would indicate infection from..?[1]

Answer 16

Parvovirus B19

Question 17

Blueberry muffin rash has which 2 key ddx? [2]

Answer 17

CMV
Rubella

Question 18

Infections with parvovirus B19 in pregnancy can lead to several complications, particularly in the first and second trimesters. Complications are: [4]

Answer 18

• Miscarriage or fetal death
• Severe fetal anaemia
• Hydrops fetalis (fetal heart failure)
• Maternal pre-eclampsia-like syndrome

Question 19

What causes fetal anaemia from parvovirus B19 infection? [1]
What effect does this have? [1]

Answer 19

Fetal anaemia is caused by parvovirus infection of the erythroid progenitor cells in the fetal bone marrow and liver.
- This anaemia leads to heart failure, referred to as hydrops fetalis.

Question 20

What is the triad of seen in pregnant parvovirus b19 infection? [3]

Answer 20

It involves a triad of hydrops fetalis, placental oedema and oedema in the mother
- + hypertension and proteinuria.

Question 21

Women suspected of parvovirus infection need which tests? [3]

Answer 21

• IgM to parvovirus, which tests for acute infection within the past four weeks
• IgG to parvovirus, which tests for long term immunity to the virus after a previous infection
• Rubella antibodies (as a differential diagnosis)
  *

Question 22

A baby born with congenital Zika syndrome which would [2]

Answer 22

Microcephaly
Fetal growth restriction
Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy