Keeler: Perinatal Infections including GBS Flashcards
Rubella
1st trimester maternal infection Triad = deafness + cataracts + CHD Check immunity all OB pts Advise OB pt to avoid kids w/ rashes Vaccinate (MMR) post-partum Don’t get PG within 3 months of MMR vaccine
This is a preventable problem!!
Toxoplasmosis
Parasite Toxoplasma gondii
Soil, cat feces
Prior infection confers immunity
Baby: eyes, brain, CP……
Sorry, dude, YOU get to change the litter box
Advise all OB pts – handwashing, cats, raw meats
Varicella
If exposure, test for immunity (IgG Ab)
If not immune = VZIG
Risk to mom = varicella pneumonia
This, too, is preventable!
“Fifth Disease”
Parvovirus B19 Exposure – child w/ “slapped cheek” rash Test for IgG immunity If non-immune, monitor for IgM turning + If +, MFM consult to monitor for hydrops, CHF
Herpes
Mom can give HSV (I or II) to baby
Ask about hx and current lesions – both oral and genital !!!!
Test lesion only if never confirmed before
Blood test for antibodies = worthless
Ask about lesions as labor approaches
Worst outcome = if PRIMARY outbreak at time of vaginal delivery
Cesarean section if lesion within 1 week of labor – or if lesion after 39 weeks
?? Role of tocolytics to defer labor (never after 39 weeks)
HIV
HIV can cross the placenta
Safe to use anti-retroviral Rx during Pg – can prevent baby from acquiring the virus
Check all NOB patients – w/ “routine” labs!
This, too, is PREVENTABLE!!
Cytomegalovirus
In Herpesvirus “family” – latency
Contact w/ urine or saliva of young children
Handwashing
Don’t share utensils
Baby: IUGR, hearing/vision loss, mental disability, coordination lack, seizures, death
No vaccine; antibody testing, MFM consult
“TORCH”
T = toxoplasmosis O = other (syphilis, varicella, PVB19) R = rubella C = cytomegaolvirus H = herpes
Limiting? – HIV, enteroviruses, lyme dis
The Story of GBS
GBS = Group B beta-hemolytic streptococcus
10 + % of women are “colonized”
Only real adult issue = occasional UTI
GBS – the baby
Birth through “colonized” environment……. Pneumonia Sepsis Meningitis High fatality %
This is almost 100% preventable!
GBS protocol
Culture @ 36 weeks – vag/rectal
No results? - “rapid” test in L&D
Antimicrobial prophylaxis w/ ampicillin or substitute (clindamycin)
Try for 2 doses during labor, prior to delivery; keep giving it as long as labor lasts
Stop with delivery
chorioamnionitis Risk factors
prolonged labor prolonged membrane rupture **multiple digital vaginal examinations (especially with ruptured membranes) nulliparity previous IAI meconium-stained amniotic fluid internal fetal or uterine monitoring presence of genital tract pathogens - sexually transmitted infections - group B streptococcus - bacterial vaginosis Alcohol Tobacco Preterm labor or premature rupture of membranes (PROM)
chorioamnionitis Presentation – usually during labor
Fever (usually > 100.0 deg F) 100.4 “rule”?
Uterine tenderness
Maternal tachycardia (>100/min)
Fetal tachycardia (>160/min)
Purulent or foul amniotic fluid
Maternal leukocytosis (defined as white blood cell [WBC] count >15,000)
- 70 to 90 percent of cases
Chorio causes risks
Increased risk of labor abnormalities - uterine atony - postpartum hemorrhage - endometritis Dysfunctional myometrial contractility due to inflammation If undergo cesarean delivery - wound infection - endomyometritis - venous thrombosis
- Life-threatening gram-negative septicemia
- Fever + tachycardia (of mom and/or baby) = warning signs – YOU go to bedside!
Chorio – treatment
The uterine environment is, in effect, an “abscess”.
Thus, treatment is “drainage” = DELIVERY
If labor well-advanced and progressing, and if mom/baby are stable – strive for vaginal delivery
Ampicillin – 2 gm IV Q4H
Gentamicin – calculated by Pharmacy
Clindamycin – 900 mg IV Q8H
This is the time-tested “Triple Antibiotic” regimen.
If vaginal birth – D/C antibiotics after, unless clear evidence for continuing infection
If C/S – debatable
Chorio - laboratory
Yes, get cultures (aerobic & anaerobic):
Of fluid at birth or C/S (micro labs love fluid! – send a tube of fluid, not a swab sample)
Of membranes and placenta
BUT – several days for results
BUT – may help later
Send placenta, cord, membranes to Pathology – micro can verify your dx (and, your lawyer will thank you)
Apgar scoring- general
Time-honored neonatal scoring system to try to predict:
- Need for infant resuscitation
- Long term outcome
Weak correlation, esp with long term outcome
Lot of factors influence the score
Subjective in many respects
apgar points
2 points for each:
Heart rate (0, <100, >100)
Respiratory effort (0, weak cry, strong cry)
Muscle tone (limp, weak flexion, active)
Reflex (sole stim) (0, grimace, strong cry)
Color (pale/blue, pink w/ blue extrem, pink)
normal apgar
Normal is 7+ @ 1 minute and 9-10 @ 5 min (if a question, add a 10 minute score also)
In Colorado, altitude affects the score!
Few babies qualify for a “10”. Most have “acrocyanosis” = blue-tinted feet/hands.
Cerebral palsy causes
“Birth asphyxia” was thought to be THE cause
This is WRONG
HYPOXIA/ACIDEMIA DURING LABOR IS “CAUSE” OF ONLY 5-10% OF CP CASES
Infections Strokes Anomalies Exposures Trauma Etc etc
apparent real cause of cerebral palsy
Acidemia
Hypoxia leads to (lactic) acidemia
“Metabolic acidosis”
This appears to be the “damaging” agent
YOU now have a SAFE HARBOR! (re: cerebral palsy and asphyxia)
The umbilical cord contains FETAL BLOOD
(2) umbilical arteries = lower O2 concentration – blood here comes from the fetus
(1) umbilical vein = higher O2 concentration – blood here comes from the placenta
- Umbilical ARTERIAL blood sample = reflective of fetal environment………….
Fetal (arterial) pH (and PO2 and PCO2) can be measured objectively. Just the pH is good enough:
If pH is normal, clearly establishes that baby was NOT hypoxic/acidemic at birth.
Normal umbilical arterial pH is ≥ 7.00
* One (ONE!!) ml of cord blood can save you untold grief. Take the sample – every time.
Home Birth
This is a very risky “choice”
It’s a Third World birth right here in the US !!
All about the “mom’s experience”
Little regard for the baby
(Some in this group are also in the “non-vaccination” group)
Third World - barriers
Poverty Resources Training Personnel are few and far-between Cultural norms Women empowerment Girls as a commodity WATER WATER WATER (etc.)
Obstructed labor (3rd world)
Prolonged labor for hours/days (!) at 10 cms
C/S can be hours away!
Baby usually doesn’t survive
Infection
Hemorrhage
Rupture of uterus
* Pressure on bladder → FISTULA (urinary)
Fistula- 3rd world
No access to repair
Affected women are “banished” – ostracized
? Some actually murdered
US teams go to, e.g., Niger (Sub-Sarahan)
Anesthesiologist, Uro-Gyn or Urologist, Gyn’s
Fistula + Cultural norms
Young females, aged 11-12 are “eligible” for marriage. “Sold into marriage” by their father “I needed the money to feed my family” Before pelvic bone structure is “adult” Result = obstructed labor and fistula
Hemorrhage – a simple measure
10 Units of oxytocin given IM into anterior thigh immediately after baby is born *
Risk of hemorrhage is reduced!!!!!
Cheap and simple. Easy training.
- Caution: here, we give oxytocin into IV bottle after the PLACENTA is delivered – more rapid onset than IM. (Don’t “trap” the placenta.)
Hemorrhage – another simple measure
Cytotec® (misoprostol)
“Synthetic prostaglandin”
Given rectally or sublingually after placenta is delivered
Cheap, easy, no syringe needed
“Wants” from Third World women
CLEAN WATER
VACCINES
CONTRACEPTION
