Infectiosu Diseases During Pregnancy Flashcards
TORCH’S infections
Toxoplasmosis Other (parvovirus, VZV, COVID, GBS, Etc.) Rubella CMV Herpes Simplex HIV Syphilis
need to screen all of these
Toxoplasmosis review
Obligate intracellular protozoan that has 2 forms of life
- trophozoites = invasive
- cyst/oocyte = latent form
Acquired via
- raw meat (MOST COMMON)
- goat milk and unpasteurized dairy
- cat feeces (only definitive host)
- organ transplantation
Clinical features
- in immunocompetent = asymptomatic in 90%. 10% = mononucleosis w/ bilateral cervical adenopathy (but presents with a (-) heterophile antibody test
- in immunocompromised = bad mono illness with ocular or cerebral toxoplasmosis, encephalitis, pneumonitis
Congenital infection:
- more likely to get It later in gestation but is more dangerous earlier in gestation
- currently recommendations is to NOT screen for this bug unless you have clinical suspicion
Diagnosis = IgM/IgGtests and PCR sample from amnotic fluid in pregnancy
- (-) in IgG and IgM = susceptible but no infection
- (-) IgG w/ (+) IgM = recent infection
- (+) IgG w/ (-) IgM = past infection and immune
Treatment = pyrimethamine, sulfadiazine
- leucovorin as last line
- if before 18week gestation = spiramycin
Ultrasound findings of fetal toxoplasmosis infections
Ventriculomegaly. Microcephaly, intracranial calcifications, IUGR, hepatosplenomegaly
Neonatal findings of toxoplasmosis
Rash
Hepatosplenomegaly
Ascites
Fever
Periventricular calcifications
Ventriculomegaly
Seizures
Syphilis review
Gram (-) spiral shaped bacteria that is spread via sexual contact, blood transfusion
Humans are only natural host and if congenital are pasted by maternal blood
- CANNOT be transmitted in breast milk
- frequency of passing it on increases as gestation advances
Ultrasound can detect severely affected fetus
- shows place to eagle, IUGR, microcephaly, Hepatosplenomegaly, hydrops
Congenital syphills symptoms
Early
- maculopapular rash
- snuffles
- hepatosplenomegaly
- jaundice
- lymphadenopathy
- osteochondritis
- iritis
Late
- Hutchinson (notched teeth)
- interstital keratitis
- deafness
- saber shins
- hydrocephalus
- clutter joints
- optic nerve atrophy
Varicella review
Highly contagious (infection rates 60-90%)
Primary infection = fever, malaise and maculopapular rash that becomes vesicular and crust off (chicken pox)
- lasts 6-10 days and once all vesicular lesions crust off you are not infections anymore
Secondary infection = vesicular erythematous skin rashes that usually follow a dermatome pattern (lays dormant in the sensory/dorsal root ganglia)
in pregnancy, risk of fetal transmission = 1/2%
- ONLY seen in 1st and 2nd trimester
Treatment for acute varicella in pregnant patients
Supportive care and isolation for mild disease
If IgG (-) for varicella = MUST give VZIG within 96 hrs of exposure
Oral acyclovir (800mg P.O 5xday) for severe varicella
- **this doesnt prevent congenital varicella however
- also need hospitalize usually if this bad
Varicella ultrasound findings
Hydrops
Hyperechogenic foci in liver and bowels
Cardiac and limb malformations
Microcephaly
Fetal growth restriction
Congenital varicella findings
Infection earlier in pregnancy produces worse symptoms
Skeletal malformations
Skin scarring
Chorioretinitis
Microcephaly
Cataracts
high neonatal death rate especially within 5 days of delivery and 48hrs after delivery
Parvovirus review
Single strand DNA virus that is exposed to almost everyone at any point
- *50% of women are immune**
- 8% of susceptible pregnant women will become infected if exposed (risk highest in women with school-aged children or work in school settings)
Symptoms of infections
- reticular rash on trunk and peripheral arthropathies
- flu-like syndrome
- low grade fever
- malaise
- headache
- sore throat
- arthralgia
- if underlying hemoglobinopathies = aplastic crisis (kills RBC precursors via direct cytotoxic effects) **
follow the same IgG and IgM titers as toxoplasmosis. However if recently exposed patient is IgM negative = need to repeat titers in 3-4 weeks and look for any IgG titer increases
Parvovirus congential infections
- *NOTE: majority of fetus will have NO adverse effects**
- however there is a risk for spontaneous abortion, stillbirth and non-immune hydrops fetalis(rates increase if infected <20 weeks)
Is confirmed with amniotic fluid PCR showing serology
- weekly MCA Doppler is needed with hydrops evaluation
Treatment = in utero transfusion and treat hydrops (high mortality of hydrops is present)
Rubella review
Single strand RNA virus that is transmitted by respiratory droplets
Maternal transmission = hematogenous spread
- risk of transmission goes up the earlier in pregnancy (highest risk in <8 weeks)
- is known to cause ischemia and damage to placental blood vessels
Symptoms
- widespread non pruritic erythematous maculopapular rash with postauricular adenopathy
- conjunctivitis
- mild flu-like symptoms
Diagnosis
- maternal = IgM/IgG levels
- fetal = PUBS for IgM after 20 weeks and culture of tissue/amniotic fluid
MMR vaccine for rubella
95% seroconversion rate
Contraindications in pregnancy!
- not in breastfeeding though
- should also avoid getting pregnant 4 weeks after vaccination
Ultrasound findings in congenital rubella
IUGR
Microcephaly
Supravalvular pulmonary stenosis
Hydrops
Congential rubella signs
Sensorineural deafness
Cataracts
PDA
Microcephaly
Blueberry muffin rash
Cytomegalovirus review
Double stranded DNA herpes virus
Endemic in the US with 80% of adults infected by age 40
Risk factors: Daycare workers Multiple sex partners Low socioeconomic status First pregnancy <15 yrs
DONT screen in pregnancy even for high risk
Symptoms
- most are asymptomatic with mild flu symptoms if present
Diagnosis
- primary infection = IgM (+) and IgG (-)
- *possess low IgG avidity**. Transmission risk = 40%
- reactivation infection = IgM and IgG (+)
- *possess high IgG avidity**. Transmission risk = 1%
In utero = amniotic fluid PCR is positive
Herpes Simplex virus (HSV) review
DsDNA virus transmitted by urine, saliva, Semen and blood
- *is the most common painful genital ulcer disease worldwide**
- 2nd most common STI worldwide (#1 is HPV)
Clinical presentation
- exposure to onset = 4 days after incubation
- typically shows vesicles, tissues and itching of infected areas
New brown infections = disseminated herpes in the temporal lobes, skin and mucous membranes
HSV counseling
> 85% of patients infected are unaware they are
- asymptomatic shedding > majority of HSV infections
Greatest risk of spreading = 1st 12 months after getting HSV-2
- must get the infected patient on suppressive therapy for the 1st year of diagnosis
Dont let infected patients have sex with partners if they are symptomatic
Primary genital symptoms
Very painful vesicles/ulcers, burning, itching, dysuria, urinary retention, lymphadenopathy
Antibodies typically appear between weeks 2-12 after symptoms
Viral shedding is possible until vesicles/ulcers are crusted (usually 10-12 days from onset)
HSV in pregnancy
MUST start suppressive therapy after 36 weeks of gestation
- 75% decreases in outbreaks
- 40% reduction in C-sections
Indications for C-sections in HSV patients
- active genital lesions on genitalia (if on back/buttock or thigh = cover with teasers and your okay)
- active prodromal symptoms (vulvar pain, irritation or burning at delivery)
- *if the lesions are resolved usually need to wait > 6 weeks out just to make sure**
Pregnancy with influenza
While not dangerous to the fetus for infection, pregnant patients have a more severe symptoms which leads to increase risk of spontaneous abortion, preterm delivery and low birth weight
- *also during 1st trimester makes fetus even more susceptible to infections/abnormalities
- **this is because of the hyperthermia that occurs with the flu
- *you need to get the vaccine IM in pregnancy patients
- MUST be inactivated vaccine though and ASAP**
If they have active infection = give Oseltamivir
HIV in pregnancy
40% of HIV postive women are identified in pregnancy
- MUST screen as soon as possible in pregnancy (repeat in 3rd trimester in high risk factors/areas
- should also encourage partners to get screened as well
Risk factors for perinatal transmission
- no antiretroviral therapy
- no prenatal care
- presence of AIDS (low CD4 and high viral load)
- maternal illicit drug use
- preterm delivery
- breast feeding
Mother can transmit of HIV either antepartum, intrapartum and post partum
- 70-80% occurs during the delivery process
viral load is the most importiant risk factor for transmission
Delivery recommendations with HIV
If on no medications and labs:
- offer C-section at 38 weeks without amniocentesis
- start mother on ZDV regimen
If the mother is on ARV and viral load is > 1000
- offer C-section at 38 weeks without amniocentesis
- continue therapy
If the viral load is <1000
- NO C-section and you can do normal vaginal birth
- give ZDV intrapartum and neonatal
If the viral load is > 1000 right before labor
- may allow labor or CS if needed
Group B Streptococcus
30% of women are colonized naturally
- 40-50% of colonize women’s will pass on to neonate (higher risk if ACOG risk factors are present)
If neonate is infected = 30% mortality
Risk factors
- prematurity
- prolonged ROM
- intrapartum fever
- previous affected child
- age is <20
- heavy maternal colonization
- low levels of GBS antibodies
- African Americans
- late prenatal colonization or heavy bacterial load
Screening = ALL pregnant women 36 weeks need to be screened UNLESS:
- GBS bacteriuria is picked up or previous child had invasive GBS infection = screen earlier and give prophalzis treatment immediately
CDC recommendations for GBS screening
No prophylaxis antibiotics if
- positive screen in prior pregnancy (have to rescreen first)
- elective cesarean without labor or ruptured membranes
- negative cultures regardless of risk factors
Give prophylaxis if
- tests postive
- bacteriuria > 10^3 CFU for GBS
- previous pregnancy with disseminated GBS
**negative GBS screen is valid for 5 weeks!!*
Treatment for GBS
No allergies to penicillin = penicillin G IV every 4 hrs until delivery
Allergies to penicillin w/ NO anaphylaxis symptoms with penicillin or cephalosporin noted = cefazolin 2g IV and then 1g IV every 8hrs
Allergies to penicillin w/ anaphylaxis history to penicillin or cephalosporin
- isolate susceptible to clindamycin = give clindamycin IV
- isolate NOT susceptible to clindamycin = give vancomycin 1g IV every 12 hrs
Coronavirus pregnancy considerations
Pregnancy= increased risk of issues in the pregnant patient, but doesnt not increase risk directly to the fetus (does indirectly increase damage to the fetus though)
COVID maternal screening must include for mental health issues
**DONT withhold COVID 19 mRNA vaccines based the patient being pregnant only
Treatment of COVID in pregnancy
Continuous fetal monitoring, give steroids and lovenox x2 weeks
