Infectious Disease in Pregnancy

Question 1

What determines the risks of transmission of HIV during pregnancy and labour?

Answer 1

High viral load and low CD4 count indicate the likelihood of mother to child transmission. If mother has an undetectable viral load and are on HAART the transmission rate is 0.1%.

Question 2

What counselling should be given to couples where one of them are HIV+ve and they want to get pregnant?

Answer 2

If they wish to get pregnant and the mother is +ve then artificial insemination is encouraged. If other way round, then sperm washing is recommended or donor insemination.

IVF only done in consideration of viral load and CD4 count.

Not all HAART combinations are pregnancy safe so check with doctor.

Question 3

How should a HIV +ve pregnant woman’s HAART treatment be managed antenatally?

Answer 3

If on HAART continue with current treatment – may need slight drug alterations
If mother hasn’t needed HAART then a lower dose should be started at pregnancy
All women should be on HAART by 24 weeks
If on HAART at booking, screen for diabetes and warn increased risk premature labour

Must achieve <50c/ml by 36 weeks otherwise – consider therapeutic drug monitoring, optimise best regimens, genotype and consider intensification.

Question 4

What diseases should also be tested for and vaccinated against in pregnant women who are HIV +ve?

Answer 4

Screen for Hep B and C, varicella zoster and toxoplasmosis antibodies
Offer Hep B, pneumococcal and influenza vaccines
Those commencing HAART at pregnancy should have VL at 2-4 weeks, once a trimester, 36 weeks and at delivery

Question 5

How should HIV +ve women deliver their baby?

Answer 5

Vaginal delivery if >350 CD4 and <50 VL
Obstetric management can follow same guidelines as normal once labour commenced

Caesarean Section indicated to prevent transmission if viral load too high, on zidovudine monotherapy, or if coinfected with Hep C and not on HAART

Question 6

Can HIV+ve women have an amniotomy?

Answer 6

Avoid amniotomy unless delivery imminent

Question 7

How should PROM and PPROM be managed in HIV+ve women?

Answer 7

With PROM always deliver after 34 weeks. If PPROM then steroids and virologic control optimised

Question 8

How should a women who presents with a HIV+ve pregnancy late be managed?

Answer 8

Late presentation = start medication ASAP and antiretroviral infused throughout labour

Question 9

When should CD4 counts be taken for HIV during pregnany?

Answer 9

Minimum of one CD4 count at the beginning of pregnancy and one at delivery

Question 10

Can HIV +ve mothers breast feed?

Answer 10

Infected mothers should avoid breastfeeding – Cabergoline given to supress lactation

Question 11

How should the child of a HIV+ve mother be managed post natally?

Answer 11

Neonatal post-exposure prophylaxis commenced 4 hours after birth and lasts for 4-6 weeks

Pneumocystis pneumonia prophylaxis from 4 weeks for infected neonates (Co-trimazole)

Test kids at 1, 6 and 12 weeks for HIV status and confirmatory test at 18months

Question 12

How should Hepatitis B be managed in pregnancy?

Answer 12

B – Mother may require antivirals if high viral load
If mother HBsAg positive, then give 0.5ml of HB immunoglobulins and vaccinate neonate within 12 hours then again at 1-2 months and 6 months.

Question 13

What antigen status confers the higher risk of hepatitis B transmission?

Answer 13

If mother HBsAg and HBeAg +ve then very high risk of transmission
If only HBsAg +ve then 15% risk.

Question 14

Can mothers who are Hepatitis B positive breastfeed?

Answer 14

Hep B cannot be transmitted when breast feeding

Question 15

What risk does Herpes infection have in pregnancy?

Answer 15

Primary episode in 3rd trimester is the main risk in pregnancy
Recurrent episode in pregnancy is low risk due to antibodies crossing placenta

Question 16

If a woman has a primary infection of Herpes in the 3rd trimester how should this be managed?

Answer 16

If primary infection in 3rd trimester then caesarean is indicated as well as Aciclovir
If couples disconcordant then must use condoms in pregnancy
In primary infection lesions present at delivery then elective C section and high dose Aciclovir to both mother and new-born

Question 17

How can herpes infection affect the neonate?

Answer 17

3 types of neonatal herpes infections
SEM (skin eyes and mouth) treated with antivirals
DIS (disseminated) and CNS (leading to encephalitis) with higher mortality.

Question 18

What risk does chlamydia have in pregnancy?

Answer 18

Chlamydia may increase the risk of premature delivery and low birth weight.

Question 19

How should chlamydia be treated during pregnancy?

Answer 19

Treatment during pregnancy should be with antibiotics but not Doxycycline or ofloxacin as they are contraindicated. Azithromycin or erythromycin should be used instead.

Question 20

What risk does gonorrhoea have in pregnancy?

Answer 20

Gonorrhoea in pregnancy is associated with perinatal mortality, spontaneous abortion, premature labour and early foetal demise. Vertical transmission during pregnancy may cause gonococcal conjunctivitis.

Question 21

How should gonorrhoea be treated during pregnancy?

Answer 21

Treatment is the same as outside pregnancy. After delivery give infants cefotaxime IM and chloramphenicol eye drops within an hour. For active neonatal gonococcal infection given benzylpenicillin IM and 3 hourly chloramphenicol.

Question 22

How should TB exposure or infection be managed in pregnancy?

Answer 22

Vaccinate all new-born in households with TB, born to immigrants from high prevalence areas. Give other vaccines as normal in another arm. Separate actively infected mothers from their babies until 2 weeks of treatment and sputum -ve. Encourage breastfeeding.

Question 23

What is the risk of syphilis during pregnancy?

Answer 23

T Pallidum can cross the placenta and cause congenital syphilis or infect the baby during delivery. If left untreated it can lead to congenital syphilis which is debilitating (saddle shaped nose, deafness and still birth/misscarriage).

Question 24

How are syphilis infections managed in pregnancy?

Answer 24

Tested at their first antenatal clinic.

Treat mother with Benzylpenicillin IM for 3 weeks.

Question 25

Is thrush common in pregnancy?

Answer 25

Candida very common in pregnancy due to high levels of oestrogens

Question 26

How should thrush be managed in pregnancy?

Answer 26

Clotrimazole pessary
Do not given oral azoles in pregnancy
Can use topical antifungals

Question 27

What is the risk of trichomonas vaginalis in pregnancy?

Answer 27

Increased risk of preterm labour and low birth weight. Also predisposes to postpartum sepsis if present at delivery.

Question 28

How is trichomonas vaginalis treated in prengnacy?

Answer 28

Same drugs used to treat but lower dose (can change taste of breast milk). If single dose, then avoid breastfeeding for 12-24 hours.

Question 29

What is the risk of bacterial vaginosis in pregnancy?

Answer 29

Symptomatic BV can increase the risk of pregnancy related complications such as premature birth, miscarriage and chorioamnionitis.

Question 30

How is bacterial vaginosis treated in pregnancy?

Answer 30

Treatment is the same as non-pregnancy unless breast-feeding in which case use lower dose of metronidazole.

Question 31

What are the symptoms of maternal listeria infection in pregnancy?

Answer 31

Maternal symptoms: fever, shivers, myalgia, headache, sore throat, cough, vomiting, diarrhoea vaginitis, miscarriage, prematurity and still birth. Infection usually form food such as milk. Soft cheese and pate.

Question 32

How is listeria infection diagnosed and treated in pregnancy?

Answer 32

Diagnose infection by blood culture.

Treat neonate with ampicillin and gentamicin until 1 week after fever subsides.

Question 33

What are the consequences of listeria infection in pregnancy?

Answer 33

20% of infected foetuses are still born and foetal distress in labour is common.