Infections in Pregnancy/Congenital Infections Flashcards
CMV
Herpes virus, transmitted by personal contact.
40% vertical transmission.
Effect on baby:
- IUGR
- Oligohydramnios
- Pneumonia
- Thrombocytopenia
- Hearing, vision and learning impairment
NB baby is often asymptomatic at birth (85%) but can go on to develop sensorineural hearing loss (10-15% risk)
Investigations during pregnancy
- USS - intracranial and hepatic calcification
- Serology - recent infection shoes high IgM titres with low IgG avidity
- Confirm infection by amniocentesis 6/52 after maternal infection
Management during pregnancy
- Surveillance for USS abnormalities
- Foetal blood sampling at 32wg, for platelets
- Offer TOP
Management after birth:
- Babies with CNS involvement - can give oral valganciclovir for 6/12
- Monitor for sensorineural hearing loss
Rubella
- Infection in early pregnancy is associated with multiple abnormalities whereas infection >20 weeks is low risk.
Triad of symptoms:
- Cardiac abnormalities (mainly PDA)
- Deafness
- Cataracts
There can also be:
- Blueberry rash
- Thrombocytopenia
Investigations
- ALL women are screened at their booking appointment
- Refer to foetal medicine + TOP offered if mother gets Rubella <20wg
- If after 20wg, no measures needed
- Women may need vaccination after end of pregnancy
- Do not give live vaccine during pregnancy
Toxoplasmosis
Earlier maternal infection gives more severe foetal infection
Investigations during pregnancy
- Maternal testing for IgM
- if IgM +ve, do avidity testing, as IgM can remain high for 1y
- USS - hydrocephalus + intracranial calcification
Management during pregnancy
- Spiramycin started as soon as maternal infection is diagnosed
Management of neonates
- Pyrimethamine + sulfadiazine + calcium folinic acid
HSV
- Vertical transmission can occur if vesicles are present
- Clinical diagnosis in pregnancy
Management during pregnancy
- C-section if delivery is within 6 weeks of primary attack
- Daily aciclovir closer to term
Presentation in neonate:
- Blistering rash
- Meningoencephalitis
Management in neonates:
- Aciclovir to exposed neonates
Varicella zoster
- Effect on foetus depends on timing of infection
Effect on baby in early pregnancy
- Eye and CNS damage
- Skin scarring
- Limb Hypoplasia
Effect on baby in late pregnancy
- Severe neonatal infection can occur if infection is 5 days either side of delivery
Management during pregnnacy
- If mum has been in contact with an infected person, determine the significance of the contact (face-to-face, 15 mins, same room)
- Do serological testing to check immunity, if she is unsure
If she’s not immune:
- VZIG to prevent - within 10 days of contact
- Aciclovir to treat - within 24h of rash onset
REFER TO FOETAL MEDICINE 5 WEEKS AFTER INFECTION (detailed USS ± amniocentesis)
Delivery
- Avoid delivery until 7 days after all lesions have cleared
Management of neonates
- Infants should be given VZIG if the rash was present 7 days before or 7 days after delivery
- Aciclovir if symptoms develop
Parvovirus B19
Effect on foetus
- Anaemia
- thrombocytopenia
- There can be hydrops fetalis
- 10% foetal death, before 20wg
Investigations during pregnancy
- If mum is exposed or symptomatic, IgM testing and foetal surveillance
- Detect foetal anaemia on USS (increased blood flow in MCA on Doppler and oedema from cardiac failure)
Management during pregnancy
- Regular scanning for anaemia
- In-utero transfusion for hydrops
Hepatitis B
RISK TO BABY: vertical transmission, 90% babies become chronic carriers
- Routinely screened for in pregnancy
Positive screen result:
- Repeat test to make sure
- MDT with gastroenterology/Hepatology for treatment
- If viral load >10^7, tx with tenofovir
Neonatal care
- After delivery, give baby vaccine and IVIG within 4h
(reduces risk of infection by 90%)
HIV
RISK TO BABY - VERTICAL TRANSMISSION
Routinely screened for in pregnancy
If HIV is diagnosed in pregnancy:
- Do HIV resistance testing
- Start women on triple therapy before 24wg
- If she is presenting at >28wg, just start her straight on triple therapy
Antenatal care:
- Normal routine scans for baby
- Monitor viral loads, LFTs regularly
Delivery
- If viral load undetectable at birth, can do vaginal delivery
- If there is detectable viral load, recommend C-section
After delivery
- Start baby on PEP within 4h of delivery
- Test maternal viral load
- If viral load undetectable, give baby zidovudine
- If viral load detectable, give baby triple therapy + co-trimoxazole
- Tell mum not to breastfeed
- Follow up mum after 6-8 weeks
Special considerations
- Mental health support for mum
- Full STI screen
Group B Strep
RISK TO BABY: EOS
- Group B Strep = Strep galactiae
Risk factors for Group B Strep:
- Previous baby with GBS (50% risk)
- Preterm labour
- ROM > 24h
- Maternal fever
- UTI with GBS on culture
Management of known GBS carrier
- Benzylpenicillin throughout delivery
- IOL after ROM, to minimise baby contact time
- NB abx are not needed if it is a C-section
If patient had previous GBS baby, explain there is a 50% risk in this pregnancy and offer swabs 35-37wg.
Management of baby
- Baby well at birth - send home if baby has been well for 24h with safety-netting
- Baby unwell at birth - admit, give benpen + gent
Syphilis
- Routinely screened for at booking
- Vertical transmission can occur at any stage
- MDT management with GUM and obstetric lead for ID
- Tx with benzylpenicillin and monitor for foetal distress from 28wg
Listeriosis
- Grame +ve bacillus
- Causes non-specific febrile illness
- Can be fatal to foetus
Bacterial vaginosis
- Overgrowth of anaerobes eg. Gardnerella vaginalis
- Increased risk of preterm labour and miscarriage
- Treat with oral clindamycin
HSV in pregnancy
RISK TO BABY - CONGENITAL HSV INFECTION (3 patterns):
- Localised to skin/eye/mouth
- Localised CNS disease (encephalitis only)
- Disseminated disease with multi-organ involvement
FIRST EPISODE HSV
- give 400mg aciclovir TDS for the episode
- Then give 400mg aciclovir TDS from 36wg until delivery
- If first episode is in 3rd trimester, give aciclovir until delivery and recommend C-section
RECURRENT EPISODE HSV
- Give 400mg aciclovir TDS but no other measures needed and vaginal delivery is fine
ACTIVE LESIONS DURING LABOUR
IV aciclovir + recommend C-section
NEONATAL CARE
Vaginal delivery
- Give IV aciclovir if the herpes infection was within 6 weeks of delivery
- Take swabs from skin, eyes, throat and mouth
C-section
- No special measures
- Tell parents to practice good hand hygiene
- Safety netting
Hepatitis C
- Only screen high-risk women e.g. IVDU, intranasal drug use
- Repeat test for positive result
- Refer baby to specialist for treatment
Malaria in pregnancy
Medical emergency
- Need to confirm diagnosis with thick and thin blood films
- Admit all women
Treatment
UNCOMPLICATED MALARIA (<2% RBCs parasitised)
- Falciparum: quinine + clindamycin (monitor because quinine can cause hypoglycaemia)
- Non-falciparum: chloroquine
COMPLICATED MALARIA (>5% RBCs parasitised, or severe clinical picture) - IV artesunate
Do blood films in the neonate, and then weekly for 28 days
