Infections in Pregnancy Flashcards
List the TORCH infections
T - Toxoplasmosis O - Other (Parvovirus, Syphilis, Varicella Zoster Virus) R - Rubella C - Cytomegalovirus H - Herpes simplex virus
What is toxoplasmosis and how is it transmitted?
- Toxoplasma is a protozoan parasite
- Cats are hosts
- Transmission is faeco-oral route (found in infected meat and cat faeces)
List the symptoms of toxoplasmosis
- Fever
- Malaise
- Arthralgia
*Often asymptomatic
What investigations should be done if toxoplasmosis is suspected?
Bloods:
- Toxoplasma IgM (active inf) and IgG (immunity)
USS:
- Fetal anomaly scan
Other:
- Amniocentesis (to detect fetal infection)
What is the treatment of toxoplasmosis?
Antibiotics - Spiramycin (reduces risk of vertical transmission)
List the risks associated with toxoplasmosis in pregnancy
- Miscarriage
- Preterm labour
- Death
- Congenital toxoplasmosis
List the features of congenital toxoplasmosis
- Hydrocephalus
- Chorioretinitis
- IUGR
- Intracranial calcification
- Hepatosplenomegaly
- Thrombocytopaenia
- Rash
What is Parvovirus B19 (slapped cheek) and how is it transmitted?
- Erythema infectiosum (fifth disease)
- DNA virus
- Aerosol transmission
What is the incidence of Parvovirus?
- Common infection = 60% immunity in adults by age 20
- Effects 1 in 400 pregnancies
What is the risk period for parvovirus in pregnancy?
Between 4-20 weeks
List the symptoms of Parvovirus
Hx:
- Rash
- Malaise
- Fever
O/E:
1. Slapped cheek rash
What investigations should be done if Parvovirus is suspected?
Maternal - Bloods:
1. Parvovirus serology IgM and IgG
Fetal - USS:
1. Fetal anomaly scan 4wks after illness, and then every 1-2wk intervals until 30/40
What is the treatment of Parvovirus infection?
Maternal:
- Symptomatic tx
- Mild self limiting illness
Fetal:
- Intrauterine blood transfusion (if fetal hydrops)
List the risks associated with Parvovirus B19 infection in pregnancy
- Miscarriage 15%
2. Fetal hydrops 3%
What is syphilis and how is it transmitted?
- STI caused by Treponema Pallidum
- Transmission = sexual contact, blood borne or vertical
What features are present on history and examination of primary syphilis?
Hx:
- Painless but infectious skin lesions (chancer)
- Develop in incubation period of 1-90 days
- Disappear spontaneously after 1wk
O/E:
- Painless genital chancre (papule, often ulcerated)
- Regional lymphadenopathy
What features are present on history and examination of secondary syphilis?
Hx:
- 1-10wks after appearance of chancre
- Maculopapular skin rash
- Sore throat
- Fever
- Headache
- Arthralgia
O/E:
- Examine skin, mucosal membranes, lymph nodes, neurological and CVS systems
What features are present in the history of tertiary syphilis?
- 1-20yrs after initial infection
- Can develop neurosyphilis (paresis, dementia, psychosis, epilepsy, tabes dorsalis)
- Can develop CVS syphilis (aortitis, aortic regurg, heart failure, angina
- Gummatous syphilis (granulomatous lesions in skin and bone)
What investigations should be done if syphilis is suspected?
Maternal - Bloods:
- RPR (rapid plasma reagin)
- VDRL (venereal disease research laboratory)
- Both above can give false positives with EBV, TB, lymphoma, malaria; therefore combine with below*
- TPHA (agglutination assay)
- FTA-ABS (fluorescent treponemal antibody absorption test)
Fetal - USS:
- Fetal anomaly scan
What is the treatment for syphilis?
Penicillin G
List the risks associated with syphilis infection in pregnancy
Maternal:
1. CNS, CVS disease etc
Fetal:
- Increased risk of stillbirth and neonatal death
- Overall risk of transplacental infection of the fetus is about 60-80%, likelihood increased in second half of pregnancy
- Congenital syphilis
List the features of congenital syphilis
- Characteristic skin lesions
- Lymphadenopathy
- Hepatosplenomegaly
- FTT
- Blood stained nasal discharge
- Perioral fissures
- Meningitis
- Choroiditis (inflammation of thin pigmented vascular coat of eye)
- Hydrocephalus
- Seizures
- Intellectual disability
- Osteochondritis
- Pseudoparalysis (parrot atrophy of newborn)
- Gummatous ulcers
- Periosteal lesions
- Paresis
- Tabes
- Optic atrophy
- Interstitial keratitis
- Sensorineural deafness
- Dental deformities
- Dx clinical
- Tx penicillin
What is Varicella zoster virus (VZV) and how is it transmitted?
- DNA virus, herpes family, highly infectious
- Transmitted via physical contact and aerosol droplets, vertical transmission
- Complicate 3 per 1000 pregnancies in UK
- 90% immunity in UK
What are the features of VZV infection?
Hx:
- Fever
- Malaise
- Pruritic rash (vesicular then crusts over)
O/E:
1. Vesicular rash
What is the incubation period for VZV?
1-3wks, infectious from 48hrs prior to rash forming until vesicles crust over
Dormant period following primary infection where virus remains in nerve root ganglia and may be reactivated as shingles
What investigations should be done if VZV suspected?
Maternal - Bloods:
- Varicella zoster IgM and IgG
Fetal - USS:
- fetal anomaly scan for fetal varicella syndrome
What is the treatment for VZV infection in pregnancy?
- Non-immune mother = give VZIG
- Established chicken pox = Aciclovir if within 24hrs of onset of rash (caution prior to 20wks)
- Maternal infection near term = avoid elective delivery for 5-7 days after rash appears (allows placental transfer of maternal antibodies)
- Neonate requires VZIG if delivered within 7 days before or after onset of maternal rash
List the risks of VZV infection in pregnancy
- Maternal:
- Pneumonia
- Hepatitis
- Encephalitis
- Death (rare) - Fetal:
- Fetal varicella syndrome (if maternal infection before 28/40) - Neonatal:
- Varicella infection of newborn (if maternal infection 1-4wks prior to delivery to 1wk post delivery)
List the features of fetal varicella syndrome
- Skin scarring
- Cataracts
- Chorioretinitis
- Optic atrophy
- Microphthalmia
- Limb deformities
- Neurological abnormalities
What is the prognosis of VZV infection in pregnancy?
After exposure VZIG reduces risk of maternal infection to 50% in the non-immune. No increased risk of miscarriage.
What is rubella and how is it transmitted?
- RNA virus, incubation period 6-21 days
- Infectious from 1wk prior to and 5 days after onset of rash
- Transmission = aerosol, vertical
- 97% women immune in UK
What investigations should be done if rubella is suspected?
Maternal - Bloods:
- Rubella serology IgM and IgG
Fetal - USS:
- Fetal anomaly scan
How is rubella infection in pregnancy treated?
- Symptomatic tx of mother
- In UK may offer TOP if confirmed in first trimester
List the risks of rubella infection in pregnancy
Maternal:
- Miscarriage
- Pneumonia
- Arthropathy
- Encephalitis
- ITP
Fetal:
- Death
- Congenital rubella syndrome
List the features of congenital rubella syndrome
- Deafness
- VSD
- PDA
- Cataracts
- CNS defects
- IUGR
- Hepatosplenomegaly
- Thrombocytopenia
- Rash
What is the prognosis of rubella infection in pregnancy?
- Highest risk of congenital rubella syndrome with infection in first trimester (90%)
- 5-10% risk between 14&16wks
- Low risk after 20wks
What is cytomegalovirus (CMV) and how is it transmitted?
- Common viral infection associated with a severe congenital syndrome in the fetus
- Transmission = sexual contact, blood borne, contact with infected bodily fluids, vertical
- DNA virus, herpes family
- Following primary infection can remain dormant and reactivate
- Incubation period 1-2mths
- 50% immunity in pregnant women
What features would be present on history and examination in CMV?
Hx:
- Often asymptomatic
- ?fever
- Malaise
- Fatigue
O/E:
- Often no clinical signs
- ?lymphadenopathy
What investigations should be done if CMV is suspected?
Maternal - Bloods:
- CMV IgM and IgG
Fetal:
- USS fetal anomaly
- Amniocentesis for CMV PCR (6-9wks after primary infection)
What is the treatment of CMV in pregnancy?
- No treatment to prevent transmission to fetus
- May offer termination of pregnancy if evidence of CNS damage (In UK)
- Neonatal ganciclovir may attenuate audiological complications
List the risks of CMV infection in pregnancy
- Increased risk of miscarriage
2. Congenital CMV
List the features of congenital CMV infection
- IUGR
- Microcephaly
- Intracerebral calcification
- Blindness (chorioretinitis)
- Sensorineural deafness
- Hepatosplenomegaly
- Skin rash
- Pneumonitis
- Intellectual disability
What is the prognosis of CMV infection in pregnancy?
- Rate of transmission to fetus is 40%
- Of these, 10% will develop clinical syndrome
- 90% of babies symptomatic at birth will have later neurodevelopmental problems
What is herpes simplex virus (HSV) and how is it transmitted?
- DNA virus, herpes family
- HSV1 = oral; HSV2 = genital
- Dormant period following infection and can reactivate
- Transmission = Physical contact, sex, vertical
- Transmission to neonate mainly due to direct contact during delivery (41% risk with primary lesions, 2% risk with recurrent lesions)
What features would be present on history and examination in HSV?
Hx:
- Burning sensation
- Pain
- Pruritis
- Dysuria
- May be asymptomatic
O/E:
- Clusters of vesicles with surrounding erythema
- Ulcerated lesions
- Crusts
- ?lymphadenopathy
What investigations should be performed if HSV suspected?
- Usually diagnosed clinically
- Micro = swabs for viral culture / PCR; STI screen
- Bloods = HSV antibody (primary inf in 3rd trimester)
How do we treat HSV infection in pregnancy?
Antenatal = acyclovir in primary infection
Delivery:
- Primary HSV = if within 6wks of likely delivery for LSCS; if >6wks can opt for SVD but give acyclovir intrapartum
- Recurrent = does not necessitate LSCS, if lesions at labour can have LSCS
List the risks of HSV infection in pregnancy
Maternal:
1. Disseminated herpes (encephalitis, hepatitis)
Neonatal:
1. Neonatal HSV - 1 per 60’000 live births, can effect skin/eyes/mouth, CNS or multiple organs
What is the prognosis for HSV infection in pregnancy?
Neonatal mortality 2-50%
