Infectious/Communicable Disease Flashcards
1
Q
Cytomegalovirus (CMV)
Risk factors
A
- Double stranded DNA herpes virus
- Most common cause of congenital infection in developed country
- Transmitted via all body fluids, sex, vertical
- Usually urine or saliva
- Remains latent in host cells after initial infection → latent virus can reactivate → recurrent infection
- Risk factors:
- Low- to-middle incomes
- Black and Hispanic women - both higher seroprevalence of CMV and birth prevalence of congenital CMV
- Day care workers and small children
- Vertical transmission
- 30 - 40 % after primary infection
2
Q
Cytomegalovirus (CMV)
Clinical manifestations
A
Adult signs/sx:
- Usually asymptomatic
- Occasionally can mimick mononucleosis or flu
- Fever
- Sore throat
- Aching muscles
- Fatigue
- Cervical lymphadenopathy
Fetal signs:
- Presence in fetal blood or amniotic fluid (not indicator of severity)
- Ultrasound findings:
- Intracranial calcifications
- Microcephaly
- Hydrocephaly
- IUGR
- Hydrops
- Poly or oligohydramnios
- Echogenic bowel or liver
- Ascites
- Ventriculomegaly
3
Q
Cytomegalovirus (CMV)
Treatment plan
A
- No vaccines or safe treatments
- Depending on gestational age, pregnancy termination may be an option in the presence of congenital CMV or fetal anomalies.
- Consultation/collaboration if primary infection or fetal anomalies for amniocentesis, serial ultrasounds, or available treatments
4
Q
Cytomegalovirus (CMV)
Testing and Diagnosis
A
Laboratory testing recommended only when:
- Pt presents with a mononucleosis-type illness
- Fetal anomaly is detected
- Maternal request
Diagnosis:
- Presence of CMV-specific IgM and a four-fold increase in IgG titers in maternal serology.
- PCR and viral cx are expensive
- Amniocentesis for fetal testing
5
Q
Cytomegalovirus (CMV)
Impact on fetal development
A
- Leading cause of congential hearing loss
- Transmission risk highest in 3rd tri, but infection in 1st tri associated with worse outcomes
- Infection <20 weeks GA, infants may exhibit serious sequelae such as:
- low platelets
- enlarged liver and spleen
- jaundice
- petechiae
- sensorineural hearing loss
- developmental delays
- seizures
- ~30% of severely infected infants die
- 95% infants with congenital CMV infection exhibit no obvious clinical findings at birth
- Neonatal infection usually asymptomatic/not associated with sequelae
6
Q
Cytomegalovirus (CMV)
Prevention
A
- Wear gloves and wash hands after changing diapers.
- Wash hands after feeding a young child, wiping a young child’s nose or drool, or handling a child’s toys.
- Avoid sharing cups/utensils with a young child,
- contact with tears or saliva when kissing a child, putting a pacifier in her own mouth, or sharing a toothbrush with a young child.
- Clean toys, countertops, and other surfaces that come in contact with a child’s urine or saliva.
- Practice safe sex, including limiting the number of partners and correct use of condoms
7
Q
Group B Strepococcus (GBS)
Risk factors and clinical manifestations
A
- 10-30% of pregnant patients colonized with GBS in vagina or rectum
- May be colonized without any signs or symptoms
- Neonates can acquire the organism by vertical transmission in utero or during the birth process
- Transmission rate 50% with vaginal delivery, but only 1–2% of the infected neonates develop GBS disease
- Risk factors for early-onset GBS disease:
- Intrapartum GBS colonization
- Gestational age <37 completed weeks
- PROM
- Intra-amniotic infection
- Young maternal age
- Black race
8
Q
Group B Strepococcus (GBS)
Testing and diagnosis
A
- Universal screening for GBS colonization at 35–37 weeks’ gestation with the use of a single swab
- Swab the lower vagina (vaginal introitus), then the rectum, inserting the swab through the anal sphincter.
- Patient can self-collect following appropriate instruction
- Cervical, perianal, perirectal, or perineal specimens are not acceptable and a speculum should not be used for culture collection
- Exception: GBS UTI in pregnancy or previous baby with GBS disease
9
Q
Group B Strepococcus (GBS)
Treatment plan
A
- Intrapartum Penicillin G q 4 hours until delivery is prophylaxis of choice.
- Prophylaxis indications:
- Previous infant with GBS dz
- GBS UTI with current pregnancy
- GBS cx during current pregnancy
- Unless planned C/S and no labor or ROM
- GBS cx during current pregnancy
- Unknown GBS & any of following:
- Delivery <37wks
- ROM >18 hrs
- Intrapartum temp > 100.4F
10
Q
Group B Strepococcus (GBS)
Impact on maternal health and fetal development
A
- Usually no impact on pregnancy, danger is generally intra/postpartum
- Parent
- Rare: sepsis, UTI, chorioamnionitis, post-partum endometritis
- Neonate
-
Early onset sepsis (within 7 days of birth)
- Vertical transmission
- Severe pneumonia and septecemia
-
Late onset sepsis (7 days - 3 months)
- Vertical and horizonal transmission
- Bacteremia, meningitis, and pneumonia
-
Early onset sepsis (within 7 days of birth)
11
Q
Hepatitis A
Risk factors
A
- small RNA virus
- transmitted by the fecal–oral route,
- person-to-person contact or
- consumption of contaminated food or water
- Typically self-limited and does not result in chronic infection.
- Risk factors:
- Exposure to contaminated food or water
- Substandard hygiene or sanitation
- Illegal drug use
- Having children in day care.
- Recently emigrated from or recently traveled to high-risk countries
12
Q
Hepatitis A
Testing and diagnosis, treatment plan, and the impact on maternal health and fetal development
A
- Minimal risk associated with HAV in pregnancy
- Vertical transmission negligible because parental anti-HAV IgG antibodies cross the placenta and protect the infant after birth
- Dx by serological testing
- IgM anti-HAV antibodies - appear early in the disease process and persist for several months.
- IgG antibodies - predominate during the convalescent period, persist and provide immunity for life against reinfection. IgG antibodies will also be present after vaccination.
- Treatment:
- Post-exposure vaccine if known contact
- Supportive therapy
- limit physical activity (avoid liver trauma)
- healthy diet
- avoid alcohol and hepatotoxic meds
- Give baby HAV immune globulin within 48 hrs
13
Q
Symtoms of acute viral hepatitis
A
May include:
- Jaundice
- Malaise
- Fatigue
- Anorexia
- N/V
- RUQ pain
- Hepatic transaminases and bilirubin moderately to markedly elevated
- Liver biopsy shows extensive hepatocellular injury with prominent inflammatory infiltration
14
Q
Hepatitis B
Risk factors and transmission
A
- small DNA virus
- 40-45% of ALL cases of hepatitis
- 85-90% cases have complete resolution: asymptomatic and immune
- 10-15% cases develop a chronic HBV (usually no sx)
- 15-30% continued viral replication → hepato-cellular damage/carcinoma
- Transmission: HIGHLY CONTAGIOUS
- Direct blood-to-blood contact
- Unprotected sex
- Unsterile needles
- Perinatal – vertical and intrapartum (mostly intrapartum or when aquired during 3rd tri)
- Risk factors:
- Injectable drug use
- Sexual contact with at-risk and/or multiple partners
- Asian women have highest infection rates
- Health-care workers
- Hemodialysis patients
- Travelers to high-risk areas
15
Q
Hepatitis B
Testing and diagnosis
A
Antigens
- HBsAg
- surface marker on HBV.
- Indicates INFECTIOUS (acute or chronic if present > 6 months)
- May be negative if previously infected/cleared the virus
- HBcAg
- only released within infected hepatocytes.
- HBeAg
- indicates viral replication during acute and chronic infection
Antibodies
- anti-HBs
- recovery from B virus or immunity
- Also develops in response to immunization
- anti-HBc
- response to Hep B infection
- positive for life
- anti-HBe
- response to replicating HBeANTIGEN.
- indicates clearance of virus or response to antiviral therapy
- IgM anti-HBc
- acute infection with Hep B. Usually within past 6 months
16
Q
Hepatitis B
Treatment plan
A
HBV vaccine series and HBV immune globulin (HBIG) within 12 hours of birth if parent** **HBsAg-positive
Supportive care
- Test viral load between weeks 30-34 and provide counseling regarding risk of infection
- Determine acute vs chronic
GI consult may perform following based on disease state
- Co-mgmt with OB and GI to follow disease process and liver involvement
- Liver Biopsy; will grade stage of disease if chronic
- Hepatic US
- Evaluation of liver enzymes
- Offer immunization to susceptible patients
Comprehensive care
- Offer HIV and other STI testing
- Offer Hepatitis A vaccine to prevent further liver injury
- Education on safe sexual practices
- Education on abstinence of alcohol and substances that may lead to liver damage
- Caution when prescribing medication excreted by the liver
- Offer testing for household members and sexual contacts
17
Q
Hepatitis B
Impact on maternal health and fetal development
A
- Report positive HBsAg screen to state and local hepatitis prevention programs
- Refer to a liver disease specialist
- Chronic HBV can have flare during pregnancy - monitor liver panel and viral load periodically
- Perinatal transmission with amniocentesis low/minimal, but avoid if possible
- Breastfeeding is safe as long as not on antiviral meds, and the infant has received HBIG and vaccine.
- abstain from breastfeeding with bleeding nipples until healed
18
Q
Hepatitis C
Risk factors
A
- RNA virus
- Most common blood borne infection in US + leading cause of chronic liver disease
- Risk factors:
- Hx of IV drug use
- Hx of blood transfusion received before 1992
- Hx of body tattoos or body piercings
- Health-care workers, especially those experiencing
- needlestick injury
- Multiple sexual partners
- Hx prior STI
- HIV infection
- Mostly asymptomatic (clinical sx in ~25% of exposed)
- Onset is 2–24 weeks after exposure and may include:
- Fatigue
- Joint pain
- Jaundice
- Myalgia
- Generalized pruritis.
- llness is generally mild/often be ignored or mistaken for transient viral illness.
- Onset is 2–24 weeks after exposure and may include:
- Chronic HCV infection develops in the majority of individuals who are positive for HCV
19
Q
Hepatitis C
Impact on maternal health and fetal development
A
- Parental:
- higher risk for cholestasis
- Premature rupture of membranes
- Preterm birth
- Congenital malformations
- Placental abruption,
- GDM
- overall perinatal mortality
- Fetus:
- more likely to be LBW or admitted to a NICU
- Risk of perinatal transmission depends on HCV viral load, HIV status, and ALT levels
- undetectable HCV RNA → unlikely to transmit HCV to their infants
- increased risk with higher viral titers (>100,000 copies/mL)
- HIV infection (2-3x higher transmission risk)
- Highter if ALT levels were elevated in the year preceding the pregnancy
- Transmission may be increased with invasive fetal monitoring, amniocentesis, and ROM > 6 hours
20
Q
Hepatitis C
Testing and diagnosis
A
- Only test at-risk women: ie IV drug use
- Screen (ELISA) for antibody to HCV.→ positive → hepatitis C viral RNA testing to check for current infection and their viral load.
- Antibodies appear 6–10 weeks after the onset of illness and are present in more than 97% of infected persons within 6 months after exposure
- hepatitis C viral RNA positive within 1–3 weeks after exposure.
21
Q
Hepatitis C
Treatment plan
A
- No tx for HCV in pregnancy other than expectant management
- Rever to liver specialist
- Counsel to abstain from alcohol and potentially hepatotoxic meds
- Give vaccinations for hepatitis A and B
- Vaginal birth and breastfeeding are not contraindicated.
- HCV in breast milk at very low levels but is inactivated in the infant’s GI tract
- Abstain from breastfeeding with cracked or bleeding nipples until healed
22
Q
Parvovirus B19
Risk factors, clinical manifestations, pathophysiology
A
- Aka fifths disease or slapped cheek disease
- Single stranded DNA, preferentially infects rapidly dividing cells
- Mostly found in children
- Transmission mostly respiratory, also oral and blood
- crosses placenta
- 50% adults immune from prior exposure
- *Animal parvoviruses can’t infect humans
- Mostly asymptomatic.
- If present, likely to be mild/nonspecific
- fever, arthralagia, stuffy nose, headache, and nausea, occurring approximately 1–2 weeks after exposure.
- Bright facial exanthema, or rash on cheeks, giving “slapped cheek” appearance in 3rd week. Also may have lacy red rash on trunk and extremities
- If present, likely to be mild/nonspecific
23
Q
Parvovirus B19
Testing and diagnosis
A
- Test if pt exposed, develops sx, or when abnormal ultrasound findings suggest congenital infection.
- serum ELISA testing for IgG and IgM antibodies.
- IgG + but IgM - → immunity
- If both negative, and the test was performed after the incubation period → patient not immune and has not been infected.
- If both antibodies are positive → patient has been infected in the previous 7–120 days
24
Q
Parvovirus B19
treatment plan, and the impact on maternal health and fetal development
A
- No treatment or vaccine
- Good handwashing
- Majority of patients who become infected with parvovirus B19 have no adverse pregnancy outcome,
- Replicates rapidly in RBCs and is a potent inhibitor of erythropoiesis → anemia and hydrops
- ~ 3-5% of infected women experience miscarriage, severe fetal anemia, or nonimmune hydrops fetalis
- especially if infected in first 20 wks
- if fetal hydrops and ascites seen on US think parvo
29
Q
Toxoplasmosis
Clinical manifestations, testing and diagnosis
A
- Parent Signs and Symptoms :
- May be asymptomatic
- May have similar sx as mononucelosis:
- Fatigue
- Malaise
- Sore throat
- Fever
- Swollen lymph nodes in your neck and armpits
- Swollen tonsils
- Headache
- Skin rash
- Rarely vision changes
- Patient Diagnosis:
- Presence of IgM-specific antibody
- Very high IgG antibody titer
- Fetal Indicators for maternal serum testing:
- Abnormal ultrasound
- Hydrocephaly
- CNS abnormalities (intracranial calcifications, ventriculomegaly)
- Hepatosplenomegaly/ascites
- Plural effusion
- Symmetric FGR
- Nonimmune hydrops
- Abnormal ultrasound
- Fetal testing: amnio and PCR to confirm congenital infection after 18 wks.
56
Q
Asymptomatic Bacteriuria vs Acute Cystitis
treatment plan
A
- 3 day course of antibiotics seems as effective as a 7 - 10 day course (according to Gabbe)
- use longer course for recurrent
- If sensitivities are available use them to make antibiotic choice
- Nitrofurantoin (Macrobid) - effective against most common pathogens except proteus. Has minimal effect on vaginal/bowel flora
- Ampicillin, amoxicillin, cephalexin (keflex), amoxicillin-clavulanic acid (Augmentin) - more likely to cause diarrhea and monilial vulvovaginitis
- Augmentin or Bactrim for empiric tx of suspected resistant infections
