Infections of pregnancy, puerperium and neonate

Question 1

What is the definition of puerperium?

Answer 1

The few weeks following delivery during which the mother’s tissues return to their non-pregnant state (usually 6-8 weeks post partum)

Question 2

A neonate is an infant less than how many weeks old?

Answer 2

Less than 4

Question 3

For what 2 reasons do infections during pregnancy warrant special consideration?

Answer 3

1) Some infections during pregnancy are more severe

2) Some infections during pregnancy can affect the foetus

Question 4

Name 3 infections which during pregnancy tend to be more severe?

Answer 4

1) UTI
2) VZV
3) Entamoeba histolytica

Question 5

What is the route of transmission of infections from mother to baby during pregnancy?

Answer 5

Haematogenous

Question 6

Give 6 pathogens which can be transmitted from mother to baby during pregnancy?

Answer 6

1) Cytomegalovirus (CMV)
2) Parovirus B19
3) Toxoplasmosis
4) Syphilis
5) Varicella zoster virus (VZV)
6) Zika virus

Question 7

Give 6 infections which can be transmitted from mother to baby during delivery?

Answer 7

1) Group B streptococcus
2) Herpes simplex virus (HSV)
3) Gonorrhoea
4) Chlamydia
5) Human immunodeficiency virus
6) Hepatitis B virus

Question 8

Which 2 infections which can be transmitted from mother to baby during delivery are screened for in pregnancy and prophylactic treatment is given to avoid transmission?

Answer 8

1) HIV

2) Hepatitis B

Question 9

Other than foetal toxicity for what 2 other reasons may doses of antimicrobials have to be changed during pregnancy?

Answer 9

1) Handling of drugs differs during pregnancy - eg. increase in GFR results in increased renal excretion of many antimicrobials
2) Serum levels of antimicrobials are generally lower during pregnancy

Question 10

Are pregnant women more at risk of infections?

Answer 10

Yes - physiological and immunological changes during pregnancy pre dispose to some infections

Question 11

Why is the potential of harm to the foetus/neonate a consideration in the prescribing of any anti microbial during pregnancy? 2

Answer 11

1) All anti microbials cross the placenta to some extent

2) Virtually all antimicrobials appear in breast milk of given in therapeutic amounts to breast feeding women

Question 12

Which 2 antimicrobials are considered safe in pregnancy?

Answer 12

1) Penicillins

2) Cephalosporins

Question 13

Which 4 antimicrobials are considered unsafe in pregnancy?

Answer 13

1) Chloramphenicol
2) Tetracycline
3) Fluoroquinolones (eg. ciprofloxacin)
4) Trimethoprim - sulphamethoxazole

Question 14

Name 2 primary viral infections during pregnancy which cause mild symptoms?

Answer 14

1) CMV

2) Zika virus

Question 15

What is meant by primary viral infection?

Answer 15

Infection when you are first exposed to the virus with no existing immunity

Question 16

Name 4 primary viral infections which can be severe during pregnancy?

Answer 16

1) VZV
2) HSV
3) Measles
4) Influenza

Question 17

Name 2 viruses which are tetratogenic?

Answer 17

1) Rubella virus

2) Zika virus

Question 18

What is bacteriuria?

Answer 18

Presence of bacteria in the urine

Question 19

Why is screening for bacteriuria indicated in pregnancy?

Answer 19

Because continuing bacteriuria is associated with premature delivery and increased perinatal mortality

Question 20

What is the definition of asymptomatic bacteriuria?

Answer 20

No symptoms of UTI and 2 samples containing >10^5 same organism

Question 21

Why should bacteriuria be treated in pregnancy?

Answer 21

Can develop into symptomatic UTI if untreated

Question 22

What is the treatment for UTI in pregnancy? 2

Answer 22

1) 7 days relatively non-toxic antibiotic eg. amoxicillin or cephalexin
2) Repeat urine culture post treatment to confirm culture

Question 23

Can trimethoprim be used in pregnancy?

Answer 23

Avoid in the first trimester but can be given in second and third in conjunction with folate

Question 24

Intra-amniotic infections are also known by what 2 other terms?

Answer 24

IAI - abbreviation

Chorioamnionitis (refers to inflammation of umbilical cord, amniotic membranes and placenta)

Question 25

Why are intra-amniotic infections a cause for concern?

Answer 25

They are a major cause of perinatal morbidity and mortality

Question 26

IAIs affect what percentage of pregnancies with term labour?

Answer 26

1-2%

Question 27

IAIs affect what percentage of pregnancies with pre-term labour?

Answer 27

20-25%

Question 28

Name the 5 clinical features of IAIs?

Answer 28

1) maternal fever 2) uterine tenderness 3) malodorous amniotic fluid 4) maternal or foetal tachycardia 5) raised white cell count

Question 29

Why is prolonged rupture of membranes the most common risk factor for IAIs?

Answer 29

Membranes offer a physical barrier to infections, ruptured membranes allow bacteria to ascend through the cervix

Question 30

After prolonged rupture of membranes, what are the 4 other risk factors for IAIs?

Answer 30

1) Amniocentesis 2) Cordocentesis 3) Cervical cleavage 4) Multiple vaginal examinations

Question 31

What is cervical cleavage and why is it a risk factor for IAIs?

Answer 31

Ribbon like structure put into the cervix like a purse string for someone with an incompetent cervix who has suffered multiple miscarriages - as it is a man made structure it increases the risk of infection

Question 32

Which pathogen can cause IAI by haematogenous infection?

Answer 32

Listeria monocytogenes

Question 33

What are the 2 pathogeneses of IAIs?

Answer 33

1) Bacteria present in the vagina cause infection by ascending through the cervix 2) Haematogenous infection (although this is rare)

Question 34

What are the 3 main causative organisms of intra-amniotic infections?

Answer 34

1) Group B streptococcus 2) Enterococci 3) Escherichia coli

Question 35

What is the management for IAIs?

Answer 35

Antimicrobials and delivery of the foetus (Anti microbials should be administered at time of infection - although risk of harm from anti-microbial , foetus at greater risk from infection)

Question 36

What is puerperal endometritis and what percentage of pregnancies does it affect?

Answer 36

Infection of the womb during puerperium, affects around 5% of pregnancies

Question 37

Is puerperal sepsis still a relevant problem today?

Answer 37

Yes, it remains a major cause of maternal death

Question 38

What are the 4 risk factors for puerperal endometritis?

Answer 38

1) Caesarean section 2) Prolonged labour 3) Prolonged rupture of membranes 4) Multiple vaginal examinations

Question 39

What are the 5 clinical features of puerperal endometritis?

Answer 39

1) Fever 2) Uterine tenderness 3) Purulent, foul-smelling lochia (normal discharge after childbirth) 4) Increased white cell count 5) General malaise, abdominal pain

Question 40

What are the 3 causative organisms of puerperal endometritis?

Answer 40

1) Escherichia coli 2) Beta-haemolytic streptococci 3) Anaerobes

Question 41

What is the treatment for puerperal endometritis?

Answer 41

Broad spectrum IV anti microbials - continued until the patient has been apyrexial for 48 hours

Question 42

How is a diagnosis of puerperal endometritis made?

Answer 42

Vaginal endometrial swabs - although the role of these is controversial, in a patient with systemic symptoms a blood culture may be more useful

Question 43

What is the pathogenesis of puerperal mastitis?

Answer 43

Infection gains access via cracked/fissured nipples

Question 44

What are the 3 clinical features of puerperal mastitis?

Answer 44

1) Mean onset = 5.5 weeks post delivery 2) Abrupt onset fever, chills and breast soreness 3) Redness, warmth and tenderness of affected breast

Question 45

What is the most common causative organism of puerperal mastitis?

Answer 45

Staphylococcus aureus

Question 46

A breast with a blocked duct can present the same as in puerperal mastitis, how can they be distinguished?

Answer 46

Blocked duct - wont be any of the systemic symptoms and will be no purulent discharge from the nipple

Question 47

How is a diagnosis of puerperal mastitis made? 2

Answer 47

1) Clinical | 2) Culture of the pus

Question 48

What is the management of puerperal mastitis? 4

Answer 48

1) Continue nursing 2) Optomise nursing technique and breast care (also key to prevention) 3) Anti-staphylococci antibiotics (eg. flucoxacillin) 4) Incision/ drainage if abscess present

Question 49

In addition to puerperal mastitis and puerperal endometritis, what are the 3 other causes of puerperal sepsis?

Answer 49

1) Pneumonia 2) IV catheter related infection 3) Wound infection eg. c section

Question 50

What is sepsis?

Answer 50

A syndrome resulting from invasion of pathogenic bacteria into the blood

Question 51

Name a common and serious neonatal complication of neonatal sepsis?

Answer 51

Neonatal meningitis

Question 52

Depending on the causative organism, neonatal sepsis can be early or late onset, when does early onset infection present?

Answer 52

Within 2 weeks of birth

Question 53

The clinical features of neonatal sepsis may be subtle and atypical, name 7 possible clinical features of neonatal sepsis?

Answer 53

1) Temperature (hypothermia or pyrexia) 2) Respiratory (dyspnoea, apnoeas, cyanosis) 3) Cardiovascular (tachycardia, bradycardia, hypotension) 4) Hepatic (cardiomegaly, jaundice) 5) GI (anorexia, vomiting, abdominal distension, diarrhoea) 6) Haematological (bleeding disorders) 7) Central nervous system (lethargy, irritability, seizures)

Question 54

Give the 3 most common causative organisms of neonatal sepsis/ meningitis?

Answer 54

1) Group B streptococcus 2) Escherichia coli 3) Listeria monocytogenes The latter is not particularly common but is worth remembering

Question 55

How is a diagnosis of neonatal sepsis/ meningitis made? 3

Answer 55

1) Blood culture 2) Urine culture 3) CSF culture

Question 56

What is the management of neonatal sepsis/meningitis?

Answer 56

Broad spectrum antimicrobials active against the common causes eg. amoxicillin plus gentamicin