Infectious Diseases in Pregnancy Flashcards
UTIs : #1 pathogen for cystitis / asymptomatic bacturia
E.coli
UTI: Dx
Dx: Get UA, culture, and sensitivity
UTI: Rx
Rx: amoxicillin or augmentin, macrobid, TMP-SMX, cephalexin, fosfomycin x 7d
F/u cx results, get TOC.
Can also give pyridium for dysuria / bladder pain (local anesthetic; can turn urine bright orange).
Risk of UTI in pregnancy
Bigger risk of pyelonephritis
Presentation of pyelo
Fever, CVA tenderness
Management of pyelonephritis
Should be hospitalized, get IV fluids, IV abx (cephalosporin or amp+gent) until afebrile & asx x 48h
Total tx: 10-14d of combined abx.
When to give prophylactic abx for UTI in pregnancy
Prophylactic abx if 2 x [cystitis or asx bacituria] or 1 x pyelonephritis
Bacterial vaginosis presentation
Malodorous discharge / irritation, can be asx.
Organisms that cause BV
Gardnerella, bacteroides, micoplasma (multiple organisms)
Dx of BV
Dx with 3 of: thin, white, homogeneous discharge, “whiff” test with KOH, pH > 4.5, > 20% clue cells.
BV increases the risk for
Increases risk for PPROM, so treat with metronidazole (clinda another option) & get TOC in 1 mo
Rx of BV
Metronidazole or clindamycin
GBS: causes
UTIs, chorio, endomyometritis.
Screen for GBS:
At 35-37 wks with rectovag cx.
Management of +GBS
If positive, get IV PCN G in labor
If unsure, also get PCN G
Amp / cefazolin / clinda are alternatives
Chorioamnionitis presentation
Maternal fever, elevated WBC in mom, fundal tenderness, fetal tachycardia.
Can be fooled: elevated T from prostaglandins, tachycardia from terbutaline, WBC elevated in pregnancy & with labor, or with corticosteroids!
Fundal tenderness + PPROM =
Chorio until proven otherwise
Management of suspected chorio
Do amnio, give IV antibiotics, then speed up delivery time!
Induce / augment if mom & fetus stable, C/S if not
Dx of chorio on amnio
On amnio, see high IL6 and low glucose. WBC not a good marker.
Infections that can affect the fetus
HSV, VZV, Parvovirus B19, CMV, Rubella, HIV, Gonorrhea, Chlamydia, HBV, Syphilis, Toxoplasma gondii
HSV management in pregnancy
If lesions present, C/S to prevent maternal transmission (transmitted in birth canal).
Higher transmission rate if primary infection (IgM, no IgG)
If outbreak in pregnancy, give acyclovir
PPx from 36 wks until delivery
HSV causes ____ in neonate
Causes lesions, sepsis, PNA, herpes encephalitis → devastation.
Give IV acyclovir if infected
VZV
90% adults immune
Can’t vaccinate in pregnancy (live vaccine), but can do before / after
Transplacental spread, a/w congenital malformations (congenital varicella syndrome) if early infection, or postnatal infection (anywhere from benign → disseminated & death) if late in preg
Note: maternal zoster not a/w congenital anomalies
Management of VZV in pregnancy
Give VZIG to mom within 96h if no hx chickenpox and exposed during pregnancy (lessens her outbreak, but doesn’t decrease risk transmission to fetus)
Give VZIG to infant if mom has outbreak within 5d before - 2d after delivery
Parvovirus B19:
Causes erythema infectiosum (fifth dz)
Mild infection, red macular “slapped cheek” rash
Outbreaks in elementary schools, etc. Mild in kids / adults usually
Parvovirus B19 in pregnancy:
1st tri a/w miscarriage
2nd tri a/w fetal hydrops (attacks fetal erythrocytes → hemolytic anemia, hydrops, death)
Management of Parvo in pregnancy
If suspected exposure, check parvovirus IgM/IgG. If IgM +, think acute infection.
If after 20 wks and acute infection put baby on anemia protocol (serial U/S, MCA dopplers, PUBS / transfuse if hydrops)
CMV in mom
Subclinical / mild viral illness in mom, rarely hepatitis / mono-type picture (rarely diagnosed)
CMV in baby
10% exposed develop CMV inclusion disease (hepatosplenomeg, thrombocytopenia, jaundice, cerebral calcs, chorioretinitis, interstital pneumonitis, also MR, high mortality,
sensorineural hearing loss).
CMV tx or ppx
No tx or PPx available.
Rubella in mom
Mom gets mild illness, maculopapular rash, arthralgias, diffuse LAD x 2-4 d
Congenital rubella
Congenital rubella syndrome in baby, esp high transmission in 1st trimester
Deafness, cardiac anomalies, cataracts, MR. “blueberry muffin” baby.
Dx of rubella
Dx with IgM titers
Treatment of rubella
No tx available if acquired
MMR vaccine
Mom can’t get MMR in pregnancy (live vaccine)
HIV management
Get viral load suppressed with HAART, AZT=ZDV intrapartum and afterwards to baby to decrease trans
Do a C/S if VL > 1,000; otherwise can have vaginal or C/S.
Should bottle feed
Gonorrhea screening
Screen in pregnant women @ prenatal visit, again in 3rd trim if at risk, with NAAT or cx
Gonorrhea Rx
IM ceftriaxone, oral cefixime. Also tx with azithromycin / amoxicillin for chlamydia too
Gonorrhea sequelae
Causes PID only in early pregnancy
A/w preterm delivery, PPROM, other infections.
Neonate: mucosal surfaces affected (eyes, oropharynx, external ear, anorectal mucosa). Can also be disseminated (arthritis, meningitis)
Chlamydia
Transmitted in labor.
Often asx, so screen as for GC.
Chlamydia sequelae forn baby
PNA is the big complication.
Rx of chlamydia in prenancy
Remember, no tetracycline / doxy in pregnancy, so give azithromycin, amox, or erythromycin
HBV
From sex, blood exposure
Transplacental transmission; can lead to fulminant liver failure, etc.
Screening for HBV
Screen everybody for HBsAg
Rx of HBV
If positive, give HBIg / HBV vax for baby after delivery.
Syphilis:
T. pallidum
Transmitted transplacentally; usually primary or secondary syph (need spirochetes)
Vertical transmission of syphilis causes:
Intrauterine fetal demise, late abortion, or congenital syndrome (maculopapular rash,
“snuffles”, hepatosplenomeg, hemolysis, jaundice, LAD).
Dx of syphilis
Dx with IgM antitreponemal ab (remember,
IgM don’t cross placenta, so if baby has ‘em they’re infected)
Rx of syphilis
PCN is the only treatment - desensitize and treat with PCN if allergic!!
Later manifestations of syphilis
CN VIII deafness, saber shins, mulberry molar, saddle nose, Hutchinson’s teeth.
Toxoplasma gondii:
Protazoa
Generally subclinical unless immunocompromised , may have vague viral illness
Vertical trans is transplacental, highest if third trimester acquisition
Stay away from cat feces
Neonate symptoms of toxoplasma
Fevers, seizures, chorioretinitis, hepatosplenomegaly, jaundice, hydro / microcephaly.
Dx of toxoplasma
Dx with IgM in neonate, or DNA PCR via amnio to guide decision to terminate.
Rx of toxoplasma
Can treat mom with spiramycin (no teratogenic effects known), but doesn’t cross placenta → no effect on baby.
Use pyrimethamine / sulfadiazine along with folate to prevent bone marrow suppression if
fetal infection has been documented.
