Infections in Pregnancy

Question 1

Lady 13weeks pregnant presents with possible acute toxoplasmosis. How to test?

Answer 1

chck mum IgG. If negative, ignore.

if IgG positive, check IgM. IgM negative, no recent infection but if sample>6months since conception, try to check recent sample.

If IgM positive, then check IgG avidity. If low avidity, recent infection possible. if high avidity, likely prior to conception (no risk).

if high risk, see if can check amniotic fluid/fetal blood pcr. if negative or unable to check, give spiramycin till delivery. if amniotic fluid/fetal PCR positive, consider sulfadiazine+pyramethamine OR TOP.

Question 2

Paediatric consultant querying congenital CMV in 2 year old girl. How to check?

Answer 2

check mum IgG status. If mum IgG positive, then given child is above 1 year, check child’s IgG status (mum’s IgG would have gone by now). if child IgG negative, then infection excluded. but if child IgG positive, then check Guthrie card. If Guthrie negative, then still cannot exclude (coz Guthrie not sensitive). But if Guthrie positive, then confirmed CMV congenital infection.

Question 3

Query congenital CMV in neonate 2 weeks old (below 3 weeks age). How to check?

Answer 3

Mum’s IgG status. If mum IgG positive

check baby’s urine/saliva culture or NAAT (urine more sensitive)+child IgM

if child IgM positive, confirm with urine/saliva within 3 weeks of birth. if urine/salive negative despite positive IgM, repeat test. if repeat negative=no infection. If repeat urine/saliva positive, confirm with Guthrie.

see full flow chart for rest.

Principle: will always need 2 different samples to confirm congenital CMV. and if using urine/saliva as one of those samples, will always need to check urine/saliva twice (even if sample negative).

Question 4

Query congenital CMV in fetus. How to check?

Answer 4

Check mum’s IgG status. if positive,

do amniotic fluid PCR. if positive - infection confirmed. If negative, then congenital infection highly unlikely.

Question 5

Query congenital CMV in 9 month baby (>3 weeks, but less than 12 months). How to test?

Answer 5

check mum’s IgG status. If mum IgG positive,

CMV in urine or saliva (ok if less than 1 year old)

if negative, repeat and if still negative - say unlikely.

but if CMV urine/saliva positive - check with Guthrie. if Guthrie positive = confirmed. If Guthrie negative, can’t exclude.

Principle: need 2 different tests to be positive if want to confirm congenital CMV.

Question 6

Pregnant woman contact with rubella rash.

For rubella, when in gestation is it most risky to be exposed?

How to manage?

Answer 6

establish baseline immune status: no concerns if 2xrubella vaccine/1 vaccine+1 Ab test>10 IU/ml/2 prev Ab test >10IUml.

If susceptible, send baseline serology for rubella (both IgM and IgG).

if susceptible, repeat sample in 4 weeks. Rubella IgM is not very specific, so if positive repeat in 10-14days using different assay +measure IgG avidity. if confirmed, consider fetal PCR.

• If repeat serology at 4 weeks still negative, then give MMR as per national guidance.

Question 7

Pregnant woman contact with measles rash. When is measles infectious? How to manage?

Question 8

Pregnant woman contact with parvovirus rash. When is parvo infectious?

For parvovirus, when in gestation is it most risky to be exposed?

How to manage?

Answer 8

Most risky if within first 20 weeks.

send baseline serology asap. if IgM positive, IgG negative, then collect another sample ASAP.

if negative baseline then repeat at 1 month. if IgM positive, IgG negative, then collect another sample ASAP. if positive on repeat, then refer to obstetrician.

Question 9

Pregnant woman significant exposure to chickenpox rash. When is chickenpox infectious? How to manage?

Question 10

Pregnant woman exposed to localised herpes zoster ophthalmic rash (exposed on immunocompetent person). when is localised herpes zoster infectious? How to manage?

Answer 10

significant exposure coz in exposed area.

if <20weeks, VZIG within 10days.

if >20weeks, aciclovir 800mg 4x/day from day 7 to day 14, can be given upto 14days since exposure (date of first contact/rash onset)

Question 11

Neonate exposed to measles in sibling. How to manage?

Question 12

Female traveller went to Zika mod-risk area with husband. What contraception precautions to use? for how long?

Question 13

Female traveller went to moderate Zika area without husband. What contraception precautions to use, for how long?

Question 14

Male traveller went to moderate Zika area. Wife pregnant. What contraception precautions to use, for how long?

Question 15

Male traveller went to moderate/high Zika area. Wife not pregnant. What contraception to use? For how long?

Question 16

Pregnant woman went to moderate/high risk Zika area. Symptomatic within 2 weeks of returning. How to manage?

Question 17

Pregnant woman went to high risk Zika area. While out there, symptomatic. symptoms now resolved upon return. How to manage?

Question 18

Pregnant woman went to moderate/high risk Zika area. Completely asymptomatic. How to manage?

Question 19

Pregnant woman went to mod/high risk Zika area. 3 weeks after return, got flu-like symptoms. How to manage?

Answer 19

Worry is only if symptomatic within 2 weeks of trip/during trip.

As new symptoms are now after 2 weeks, she is unlikely to have Zika. No further intervention needed from Zika point of view.

Question 20

Lady went to mod/high risk area for dengue/Zika. When can she donate blood again?

Answer 20

All donors may be accepted six months after their return from an affected area or resolution of symptoms. This may be reduced to four weeks, if they have had neither symptoms nor evidence of infection.

Question 21

Man had sex with wife last week who is now confirmed as having Zika virus. She wasn’t pregnant.

Can he donate?

Answer 21

Must NOT donate if:

The donor has had sex in the last 28 days with someone who has had a confirmed Zika Virus infection in the 6 months preceding the sexual contact.

Can donate again when:

All donors may be accepted six months after their return from an affected area or resolution of symptoms. This may be reduced to four weeks, if they have had neither symptoms nor evidence of infection.

Question 22

Pregnant lady just returned from Zika-endemic area. Wants to test for Zika. How to proceed?

Answer 22

The Zika virus testing service is currently not available for individuals who have had no symptoms suggestive of Zika infection, including private patients. Such individuals include:

• asymptomatic pregnant women who have travelled from Zika-affected countries. She just needs baseline fetal USS and rpt at 20wks (or rpt at 28-30wks if presenting after 20weeks).
• asymptomatic returned male travellers whose partners are currently pregnant. They observe barrier contraception throughout pregnancy.
• asymptomatic returned male and female travellers who are trying to conceive. don’t try to conceive, barrier contraception for 8weeks (female travelled alone), or 6 months (if guy/female whose partner also travelled with her).

Question 23

Man had Zika symptoms while out there in mod/high risk area. Returns to UK. well. Concerned about Zika. How to manage?

Answer 23

Send serum (if within 21 days, send urine also)

Question 24

Man had Zika symptoms while out there in mod/high risk area. Returns to UK. symptomatic. Concerned about Zika. How to manage?

Answer 24

send serum. if within 21 days, send urine also.

Question 25

Lady presents with Zika like symptoms. She hadn’t been abroad, but her husband had been abroad within last 8 weeks. have had sex since. How to test? What if her symptoms had resolved?

Answer 25

test in both situations for possible sexually-transmitted Zika (send serum. if within 21 days, send urine also).

Question 26

person went to mod-high Zika area. returned, initially asymptomatic. but later developed symptoms more than 4 weeks later. Do we test?

Answer 26

Yes if symptomatic. send serum (?send urine too? check with Dr Hussam)