Infectious/Communicable Disease

Question 1

Cytomegalovirus (CMV)

Risk factors

Answer 1

• 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

Question 2

Cytomegalovirus (CMV)

Clinical manifestations

Answer 2

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

Question 3

Cytomegalovirus (CMV)

Treatment plan

Answer 3

• 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

Question 4

Cytomegalovirus (CMV)

Testing and Diagnosis

Answer 4

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

Question 5

Cytomegalovirus (CMV)

Impact on fetal development

Answer 5

• 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

Question 6

Cytomegalovirus (CMV)

Prevention

Answer 6

• 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

Question 7

Group B Strepococcus (GBS)

Risk factors and clinical manifestations

Answer 7

• 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

Question 8

Group B Strepococcus (GBS)

Testing and diagnosis

Answer 8

• 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

Question 9

Group B Strepococcus (GBS)

Treatment plan

Answer 9

• 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
  • Unknown GBS & any of following:
    
    • Delivery <37wks
    • ROM >18 hrs
    • Intrapartum temp > 100.4F

Question 10

Group B Strepococcus (GBS)

Impact on maternal health and fetal development

Answer 10

• 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

Question 11

Hepatitis A

Risk factors

Answer 11

• 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

Question 12

Hepatitis A

Testing and diagnosis, treatment plan, and the impact on maternal health and fetal development

Answer 12

• 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

Question 13

Symtoms of acute viral hepatitis

Answer 13

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

Question 14

Hepatitis B

Risk factors and transmission

Answer 14

• 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

Question 15

Hepatitis B

Testing and diagnosis

Answer 15

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

Question 16

Hepatitis B

Treatment plan

Answer 16

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

Question 17

Hepatitis B

Impact on maternal health and fetal development

Answer 17

• 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

Question 18

Hepatitis C

Risk factors

Answer 18

• 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.
• Chronic HCV infection develops in the majority of individuals who are positive for HCV

Question 19

Hepatitis C

Impact on maternal health and fetal development

Answer 19

• 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

Question 20

Hepatitis C

Testing and diagnosis

Answer 20

• 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.

Question 21

Hepatitis C

Treatment plan

Answer 21

• 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

Question 22

Parvovirus B19

Risk factors, clinical manifestations, pathophysiology

Answer 22

• 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

Question 23

Parvovirus B19

Testing and diagnosis

Answer 23

• 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

Question 24

Parvovirus B19

treatment plan, and the impact on maternal health and fetal development

Answer 24

• 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

Question 25

Rubella

Risk factors, clinical manifestations

Answer 25

• Single stranded RNA
• Typically affects children/young adults
• Transmitted person-to-person, respiratory droplets, or via placenta
• Usually mild illness in adults (fetus can get sick)
• 50% have no sx
• Parent sx:
  
  • Non-pruritic rash.
  • Starts on face then trunk then extremities
  • Malaise
  • Fever
  • Conjunctivitis
  • Lymphadenopathy

Question 26

Rubella

Testing and diagnosis, treatment plan

Answer 26

• Parent Diagnosis:
  
  • Positive for IgM specific for rubella indicates exposure or infection
  • (IgG indicates immunity)
• Fetal Diagnosis:
  
  • Viral PCR on CVS or amnio
  • IgM on cordocentesis (must be after 22 wks))
  • Via ultrasonography
  • Common ultrasound findings:
    
    • —Cardia defects
    • —Microcephaly
    • —Early growth retardation
• Maternal Treatment:
• Typically self-limited, no current tx
• Encourage patients who are non-immune to avoid possible exposure to the virus

Question 27

Rubella

Impact on maternal health and fetal development

Answer 27

• Maternal course mild, self limiting
• Congenital Rubella Infection
• Associated with growth restriction, miscarriage, stillbirth and can have significant deleterious effects on the fetus
• 1st tri infection
  
  • 80% transmission to fetus (risk lessens w/increaseing GA)
  • Risk for miscarriage
  • Highest risk for congenital rubella syndrome (CRS)
    
    • Sensorineural hearing loss
    • Cataracts
    • Glaucoma
    • Retinitis
    • Patent ductus arteriosus
    • Cardiac lesions
• Rubella vaccine is live - give 4 weeks prior to conception or post partum (safe to breastfeed)

Question 28

Toxoplasmosis

risk factors/transmission

Answer 28

Transmission:

• Zoonotic (animal-to-human)
  
  • Cat eats infected small animal → T. gondii lives in the cat’s intestines → oocyst excreted in feces for up to 3 weeks → feces contaminates the litterbox and soil or water if outdoor → people or other mammal eat something contaminated, clean literbox, drink infected water → trophozite released → forms cysts in brain and muscle
• Foodborne (uncooked meat, unwashed veg)
• Congenital (mother-to-child) - only if primary infection during or right before pregnancy
  
  • 30% transmission
• Rare instances: organ transplant and blood transfusion

Question 29

Toxoplasmosis

Clinical manifestations, testing and diagnosis

Answer 29

• 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
• Fetal testing: amnio and PCR to confirm congenital infection after 18 wks.

Question 30

Toxoplasmosis

Treatment plan

Answer 30

Spiramycin

Only available through the FDA

Used in 1st and early 2nd trimester

Pyrimethamine, Sulfadiazine and Leucovorin

Used in 2nd and 3rd trimester

Acutely-infected mothers need to be referred to MFM for co-management.

Infected infants aggressively treated with combo abx X 1 year

Question 31

Toxoplasmosis

Impact on maternal health and fetal development

Answer 31

• Mother usually unaffected unless severely immunocomprimised (ie AIDS)
• Congenital infection more likely when contracted in 3rd tri BUT sx are worse if contracted in 1st tri
• Congenital toxoplasmosis sx:
  
  • Rash
  • Hepatosplenomegaly Ascites
  • Fever
  • Chorioretinitis Periventricular calcifications Ventriculomegaly
  • Seizures
  • Intellectual disability
  • Uveitis

Question 32

What does TORCHS stand for?

Answer 32

T – Toxoplasmosis

O – Other infections

R – Rubella

C – Cytomegalovirus

He – Herpes

S – Syphilis

Question 33

What is hydrops fetalis?

Answer 33

Condition in the fetus characterized by an abnormal collection of fluid in at least two compartments:

• Edema
  
  • Fluid beneath the skin, more than 5 mm
• Ascites
  
  • Fluid in abdomen
• Pleural effusion
  
  • Fluid in the pleural cavity, the fluid-filled space that surrounds the lungs
• Pericardial effusion
  
  • Fluid in the pericardial sac, covering that surrounds the heart

In addition, hydrops fetalis is frequently associated with polyhydramnios and a thickened placenta (>6 cm).

Long term prognosis depends on underlying cause and severity of the heart failure.

If the cause of NIH cannot be determined, the perinatal mortality is approximately 50%

Prognosis is much poorer if diagnosed at less than 24 weeks , pleural effusion is present, or structural abnormalities are present .

Pulmonary hypoplasia is a common cause of death in neonates with plerual effusions.

Fetal hydrops associated with a structural heart defect is associated with an almost 100% mortality rate.

Question 34

Varicella (VZV)

Risk factors, clinical manifestations

Answer 34

• 95% of adults are immune
• Transmission: respiratory droplets, close contact, placenta or ascending lesions from vagina
  
  • Highly contageous
• Symptoms:
  
  • Primary infection manifests as chickenpox
    • Maculopapular pruritic rash
      
      • —face, scalp, trunk
      • —rash → vesicles → pustules → crusts
    • Adults typically have prodromal symptoms:
      
      • —1-2 days before rash
      • Fever, HA, Malaise, Abdominal pain
  • Varicella pneumonia - dangerous, unpredictable medical emergency
    
    • More severe but not more likely in pregnant patients
  • Zoster (Shingles)
    
    • Dormant VZV in sensory ganglion after primary infection reactivated
    • Prodrome: HA, photophobia, malaise, fever, abnormal skin sensations, and excruciating pain
    • Unilateral erythematous vesicular skin rash on trunk or face
    • Pain (rather than itching)
    • Contagious until lesions have dried
    • Most common in elderly and immunocompromised pts

Question 35

Varicella

Testing and diagnosis

Answer 35

• Characteristic lesions
• PCR lesions (if not healed) or sometimes oral secretions
• Single IgM or IgG results cannot be used to confirm infection.
  
  • Rash + positive IgM → diagnistic varicella.
  • A positive IgM suggests primary infection but doesnt exclude reinfection/reactivation of latent
  • IgM is considerably less sensitive then PCR testing of skin lesions.
  • IgM may not be reliable; and false negative IgM common
• Congenital varicella syndrome ultrasound markers:
  
  • Combo of limb hypoplasia, skin lesions, microphthalmos, and abnormal positioning of limbs.
  • Nonimmune hydrops findings include: hepatosplenomegaly, ascites, pleural effusion, pericardial effusion, and liver calcification
  • VZV DNA testing in placental villi, fetal blood or amniotic fluid and for VZV IgM in fetal blood may be done
  • Presence of VZV DNA does not necessarily correlate with fetal disease

Question 36

Varicella

Treatment plan

Answer 36

• Administer varicella immunoglobulin (VZIG) ASAP post exposure
  
  • May be effective as late as 96 hours after exposure
  • 125 units per 10 kg, with a max of 625 units.
• Supportive care: calamine lotion, antipyretics, and if necessary, systemic antipruritics.
• Acyclovir (800 mg PO 5x/day) or valacyclovir (1 g PO 3x/day)
  
  • Give to everyone - if instituted within 24 hours of rash emergence → decreased duration
• Maternal varicella pneumonia - 5% maternal mortality and presents 3 to 5 days following the rash
  
  • IV acyclovir q 8 hours.
• If varicella occurs within 5 days before and 2 days after delivery, give VZIG to newborn and isolate from the patient until all vesicles have crusted over to prevent VZV transmission.
• If possible, delay delivery 5 to 7 days following the onset of maternal illness to potentially prevent neonatal VZV (20% to 30% mortality)

Question 37

Varicella

Impact on maternal health and fetal development

Answer 37

Maternal complications:

• Secondary skin bacterial infections, CNS manifestations, such as meningoencephalitis or cerebellar ataxia, and pneumonia or pneumonitis, either viral or bacterial.
• Less common: hepatitis, hemorrhagic complications, thrombocytopenia, and nephritis
• HZ ophthalmicus when ophthalmic division of trigeminal nerve is involved can → chronic ocular complications, reduced vision, and blindness

Risks of Fetal/Neonatal Infection

• Congenital Varicella Syndrome (CVS)
  
  • VZV during 5th - 20th wk. Only 2% risk, but 30% mortality
  • Severe forms can be fatal
  • Signs:
    
    1. Skin lesions
    2. Microcephaly
    3. Skin scarring
    4. Chorioretinitis
    5. Limb hypoplasia
    6. Developmental delay
• Neonatal Varicella
  
  • VZV near term (ie 5 days before birth - 2 days after)
  • If placental transfer, sx by 10 days old
  • May cause severe or fatal illness in newborn
  • Death from VZV much more likely if parent develops rash btw 4 - 5 days before and 2 days after delivery (no time for antibodies)
  • Try to delay delivery if possible
  • VZIG either IM or IV after delivery
• Zoster in infancy or early childhood
  
  • Extremely rare
  • Increased in frequency in neonates whose mothers had gestational varicella
  • Mild and not painful

Question 38

Chlamydia

Risk factors, clinical manifestations

Answer 38

• Highest rates: adolescents and young adults. Rate for African Americans 8x > Caucasians
• Mostly asymptomatic
• May have:
  
  • Vaginal discharge
  • Postcoital bleeding
  • Dysuria
  • Vague lower abdominal pain
  • Mucopurulent cervical discharge
  • Tenderness on bimanual exam
  • Numerous WBCs on wet mount, but not diagnostic

Question 39

Chlamydia

Testing and diagnosis, treatment plan

Answer 39

• Testing:
  
  • Screen at 1st prenatal visit.
  • NAATs, rapid test, culture on urine or vaginal swab
  • Retest any high risk in 3rd tri
  • Age < 25 years
  • New sexual partners or multiple partners
  • Women who test positive at 1st prenatal visit should be retested 3–6 months later, preferably in the 3rd tri
• Treatment:
  
  • Azithromycin 1 gram PO single dose OR
  • Amoxicillin 500mg PO TID x7days
  • 5-10% of pts do not respond to tx, TOC need to be done in 2-3wks s/p tx (or 3-4 wks per Gabbe)
  • Abstain from sexual contact until 7 days after completion of antibiotic therapy.

Question 40

Chlamydia

Impact on maternal health and fetal development

Answer 40

• Impact on Pregnancy:
  
  • May cause localized infection of urethra, endocervix and rectum
  • May cause peri-hepatitis and pneumonia
• Impact on Newborn:
  
  • May cause Opthalmia Neonatorum and pneumonia
    
    • May have perforation of the globes of the eye and blindness

Question 41

Gonorrhea

Risk factors, clinical manifestations, testing and dx

Answer 41

• 2nd most common STD
• Most common among age 15 - 19
• Signs and Symptoms:
  
  • May be asymptomatic
  • Vaginal mucopurulent discharge
  • Lower abdominal pain/tenderness
  • Fever
  • Dysuria/urinary frequency
  • Tenderness in the area of Bartholin’s or Skene’s glands
• Diagnosis:
  
  • NAAT
  • Culture of endocervix and vagina
  • Urine culture
  • Prenatal assessment- 1st and 3rd trimester for HR patients (<25 yrs highest risk)

Question 42

Gonorrhea

Impact on maternal health and fetal development

Answer 42

May cause PROM and/or PTD

May pass to newborn → Opthalmia Neonatorum & sepsis

Question 43

Syphilis

risk factors, clinical manifestations

Answer 43

• More common in males than females (1.5:1)
• 30x more common in blacks than in whites
• 20-24 year olds at greatest risk
• Primary
  
  • Raised painless chancre 10-90 days after infection, goes away in 3-6 wks
• Secondary
  
  • Macropapular rash on palms of hands and soles of feet and mucous membranes, usually 2-6 months after. Spontaneously resolves in 2-6 wks.
  • Only 1/3 of un-tx primary cases progress to 2nd
  • Most contageous at this stage
• Tertiary—neurosyphilis, cardiac lesions (ie aortic aneurysm)

Question 44

Syphilis

Impact on maternal health and fetal development

Answer 44

Ultrasonography findings

• —Placentomegaly
• —IUGR
• —Microcephaly
• —Hepatosplenomegaly
• —Hydrops

Congenital syphilis

• transplacental, can happen at any stage of infection (almost 100% in early stage) and any GA
• Often associated with infections of the bone, brain, heart, lungs, and abdominal organs
• Leading cause of stillbirth and neonatal death in the developing world
• Early Clinical Manifestations:
  
  • Macupapular rash
  • Snuffles (Syphilis rhinitis)
  • Mucous patches
  • Hepatosplenomegaly
  • Jaundice
  • Pneumonia
  • Lymphadenopathy
  • Osteochondritis
  • Chorioretinitis
  • Iritis
• Late Clinical Manifestations:
  
  • Hutchinson teeth
  • Mulberry molars
  • Intestational keratitis
  • Deafness
  • Saddle nose
  • Rhagades
  • Saber shins
  • Mental retardation
  • Hydrocephalus
  • Generalized paresis
  • Optic nerve atrophy
  • Clutton joints

Question 45

Syphilis

testing and diagnosis, treatment plan, and the impact on maternal health and fetal development

Question 46

HSV

(active 1º and 2º infections, past hx of infection)

Transmission to baby, impact on maternal health and fetal development

Answer 46

Neonatal herpes transmission:

• Transmission to rarely through placenta, usually through birth
  
  • Recommend C/S for active genital lesions or prodromal symptoms such as vulvar pain or burning at delivery
  • Suppressive therapy for anyone who has had a vaginal outbreak during pregnancy starting at 36 weeks
• 80% of infected infants are born to parents with no reported hx of HSV
• Primary HSV @ delivery- 30-60%
• Recurrent HSV lesion @ delivery- 1-3%
• H/O recurrent HSV, but NO lesions @ delivery- 1-3%

Clinical manifestations:

• Skin, eye, mouth disease
• Localized CNS disease
• Disseminated state involving multiple organs
• Non-specific symptoms such as irritability, fever, poor feeding or lethargy

Neonatal Herpetic Infection Complications:

• Seizures
• Psychomotor retardation
• Blindness
• Learning disabilities
• Death

Question 47

HSV

(active 1º and 2º infections, past hx of infection)

Treatment plan

Answer 47

• Primary outbreak:
  
  • —Acyclovir: 400mg PO TID x 7-10 days
  • —Valacyclovir: 1g PO BID x7-10 days
  • Famcyclovir: 250 mg PO TID x 7-10 days
• Symptomatic recurrent episode:
  
  • —Acyclovir: 800 mg PO BID x 5 days or TID x 2 days
  • —Valacylcovir 500mg PO BID x 3 days or 1g PO QD x 5 days
• Daily suppression:
  
  • —Acyclovir 400mg PO BID from 36 wks until delivery
  • —Valacyclovir 500-1000 mg PO QD from 36wks until delivery

Question 48

HSV

(active 1º and 2º infections, past hx of infection)

clinical manifestations, testing and diagnosis

Answer 48

• Culture (turn around time is 72-96 hrs)
• PCR assays- faster and very/most sensitive
• Serology to test for antibodies- may be able to differentiate between HSV-1 and HSV-2, depending on lab
  
  • IgG and IgM can help determine whether the episode is primary or recurrent as well as identify the infection subtype to better characterize the risk of vertical trans- mission.
  • Antibodies 2–12 weeks after infection, and cannot be used alone to diagnose acute infection.

Question 49

Trichomonas

Impact on maternal health/fetal development

Answer 49

• Associated with adverse pregnancy outcomes including:
  
  • Premature ROM
  • PTB
  • LBW
• Vertical transmission in about 5% of pregnancies.
  
  • Most cases of neonatal infection resolve within 1 month after birth without tx.
• Treatment for T. vaginalis during pregnancy may be associated with an increase in the rate of PTB).
  
  • Current consensus- symptomatic patients and their partners should be treated to relieve suffering, though it remains unclear if this course of action prevents or promotes PTB

Question 50

Bacterial vaginosis

Impact on maternal health and fetal development

Answer 50

• Maternal implications
  
  • —Chorioamnionitis
  • —Endometritis
  • —C-section wound infection
• Neonatal implications
  
  • —Preterm labor/delivery
  • —PPROM
  • SAB

Question 51

Bacterial vaginosis

Trreatment

Answer 51

• Treat all symptomatic pregnant women regardless of risk factors
• —High risk asymptomatic pregnant women should be treated according to some experts.
• —Treatment of asymptomatic low risk pregnant patients is inconclusive
• BV and chorioamnionitis may increase the risk of perinatal transmission of HIV → extra important to tx HIV infected patients
• Medications:
  
  • —Metronidazole 500 mg PO BID x7 days
  • —Clindamycin 300mg PO BID x7 days
  • —Vaginal administration has lower efficacy and is not recommended during pregnancy

Question 52

HIV

risk factors, testing and diagnosis, treatment plan

Answer 52

• Risk factors:
  
  • Women usually aquire by heterosexual contact
  • Black Americans 65% of new cases
• Testing:
  
  • HIV 1 and 2 antibody assay at 1st prenatal visit and in 3rd trimester for anyone at increased risk
    
    • if positive → confirmation of infection with an HIV-1/HIV-2 antibody differentiation immunoassay and HIV-1 nucleic acid test
• Treatment:
  
  • Combination care with at least 3 drugs from at least 2 classes of ARVs
  • If CD4 < 200 → need prophylaxis against OI’s
  • Viral load check q trimester if on stable, effective regimen

Question 53

HIV

Impact on maternal health and fetal development

Answer 53

• Most perinatal HIV transmission occurs within the intrapartum period
  
  • effective cART or scheduled C/S in patients without viral suppression (VL > 1,000) substantially reduces transmission
• Early/sustained control associated with decreased HIV transmission → initiate cART as early in pregnancy as possible for all women not treated preconceptionally
• Breast feeding not recommended in the US (benefits of BF do not outweigh risks of transmission)
• Test infant:
  
  • 14 to 21 days of life
  • 1 to 2 months
  • 4 to 6 months
  • 2 positive tests on different specimens, (excluding cord blood), required to dx HIV infection; 1 positive test is a presumptive diagnosis.
  • Presumptively excluded: 2 negative tests at age 14 days or older and age 1 month or older.
  • Defnitive exclusion in a non-breastfed infant is based on 2 negative tests at age 1 month or older and at age 4 months or older

Question 54

Coxsackie virus

Patho/transmission, impact on pregnancy

Answer 54

• Causes hand, foot, and mouth disease
• Enterovirus transmitted through the fecal-oral route
• Several serotypes exist, and adult infection typically results in a self-limited febrile illness that requires no treatment
• During pregnancy has been associated with liver failure (non-life threatening), miscarriage, and an increased rate of insulin-dependent diabetes in offspring, although a causative relationship has not been established

Question 55

Asymptomatic Bacteriuria vs Acute Cystitis

risk factors, clinical manifestations, testing and diagnosis

Answer 55

• Asymptomatic bacteriuria 5-10% of pregnancies (often predates pregnancy)
• Acute cystitis about 1 %
• 1/3 will develop pyelonephritis if untreated
• Common organisms: e. coli, klebsiella, proteus
• Urine culture at 1st prenatal visit for everyone
  
  • Positive is > 100,000 colonies/mL
• Acute cystitis sx:
  
  • frequency
  • dysuria,
  • urgency
  • suprapubic pain
  • hesitancy
  • dribbling
  • Gross hematuria may be present, leukocyte esterase and nitrate usually positive
  • High fever and systemic symptoms are uncommon

Question 56

Asymptomatic Bacteriuria vs Acute Cystitis

treatment plan

Answer 56

• 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

Question 57

Pyelonephritis

risk factors, clinical manifestations

Answer 57

• Incidence is 1-2% in pregnancy
• Usually undiagnosed UTI or inadequate tx
• Normal pregnacy changes: progesterone inhibits ureter peristalsis + gravid uterus compresses uterers → urinary stasis → increased risk of infection
• 75-80% of cases occur on right side
• E. coli is prominent pathogen
• klebsiella and proteus in recurrent infection
• Symptoms:
  
  • Fever
  • Chills
  • Flank pain and tenderness
  • Urinary frequency or urgency
  • Hematuria
  • Dysuria
  • May have signs of preterm labor, septic shock, and acute respiratory distress syndrome (ARDS).
  • Urinalysis is usually positive for WBC casts, RBCs, and bacteria

Question 58

Pyelonephritis

Treatment plan

Answer 58

• Outpatient if mild disease, hemodynamically stable, and no evidence of PTL
  
  • amoxicillin-clavulanic acid 875 mg BID or double-strength trimethoprim-sulfamethoxazole BID x 7 to 10 days.
• Alternatively, a visiting home nurse may administer a parenteral agent such as intravenous (IV) or intramuscular (IM) ceftriaxone 2 g once daily.
• Although an excellent drug for lower tract infections, nitrofurantoin monohydrate does not consistently achieve the serum and renal parenchymal concentrations necessary for successful treatment of more serious infections.
• Patients who appear to be moderately to severely ill or who show any signs of preterm labor should be hospitalized for IV antibiotic therapy
• Take macrobid suppression once better due to recurrence risk and screen for bacteriuria q visit

Question 59

Describe maternal alterations in immune response during pregnancy

• Review cell-mediated and humoral response to infection
• Describe the normal changes that occur in the WBC count during pregnancy

Answer 59

• T helper and cytotoxic T cells are suppressed
  
  • thought to be why autoimmune diseases like MS, rheumatoid arthritis (etc) go into remission
• Humoral (B-cells) dont really change
  
  • IgA - present in breastmilk
  • IgG - crosses placenta, present in breastmilk
    
    • can potentially harm fetus (ie parental Graves disease → neonatal hypothyroid in 1% of cases, another example: Rh issues)
• WBCs can be 5,000 - 15,000 normally in pregnancy
  
  • Mostly neutrophils
  • Can get as high as 30,000 in labor without infection

Question 60

Infections that cross the placenta

Answer 60

1. Toxoplasmosis
2. Rubella
3. Parvo
4. CMV
5. VZV
6. Listeriosis
7. Syphilis

Question 61

Infections that do not cross the placenta

Answer 61

1. GBS
2. Hepatitis A, B, C
3. GC/CT
4. HIV
5. Flu