Maternal and Newborn Infectious Disease and Vulvovaginitis Flashcards
Listeria monocytogenes
- Febrile gastroenteritis with gram positive rod bacteremia in a pregnant woman is strongly suggestive of Listeria infection
- Two important virulence mechanisms:
- Listeriolysin O: Creates pores in phagosomes allowing Listeria to escape into the cytoplasm of macrophages
- Actin-based transcellular spread: Uses host actin to spread to connected cells, avoiding the extracellular space.
- Can be treated readily with ampicillin, but unfortunately it often quickly spreads to the fetus and causes fetal death
While a >21-year-old sexually active person with a uterus does not need pap smears, they do need. . .
. . . screening for Chlamydia
Chlamydia may be asymptomatic, but still carries risk of intertility from chronic infection/chronic PID. So, screening should be done in any sexually active person with a vagina or uterus <25 years of age.
In prepubertal girls, the vagina is especially prone to infection due to. . .
. . . neutral pH
Estrogen makes the vagina habitable by lactobacillus, resulting in drop in vaginal pH following puberty.
Vulvovaginitis in pediatric patients
- Usually non-specific
- Most common specific is Group A strep
- Also Shigella flexneri, Haemophilus, Enterobius vermicularis
- Yeast and BV don’t really happen in pre-pubertal children
If no response to vulvovaginitis treatment w/in 24 hours:
- Re-examine
- Exclude pinworms (treated empirically with mebendazole)
- Exclude foreign body
- Empiric treatment with amoxicillin, augmentin, or Keflex x10 days
- Topical hydrocortisone
Treatment for lichen sclerosus
- Topical colbetasol propionate at first, then taper to less potent in 2-4 week intervals
- Lidocaine 5% onitment before urination if necessary.
- Antipruritic at bedtime
- Most pediatric cases resolve with puberty and pediatric cases are NOT associated with cancers
Labial agglutination
- Usually asymptomatic
- Occasionally found with urinary retention, UTIs, or vulvovaginitis
- If asymptomatic: no treatment needed unless persists into puberty
- If symptomatic (difficulty urinating, recurrent UTIs): Topical estrogen cream bid 6 weeks, avoid possible irritants
- If urinary retention: Need to release adhesion, usually under anesthesia. Followed by estrogen cream bid 6 weeks to prevent recurrence.
Urethral prolapse
Common cause of prepubertal bleeding, dysuria, frequency. Usually painless.
Probably related to hypotestrogenic state.
Treat w/ estrogen cream BID after sitz bath. Bleed resolves w/in 1 week, prolapse reduced w/in 2 weeks. Refer to peds urology for excision if indicated due to continued symptoms after medical treatment.
Sarcoma botyroides
True rhabdomyosarcoma of the walls of hollow, mucosa lined structures such as the nasopharynx, common bile duct, urinary bladder of infants and young children or the vagina in females, typically younger than age 8.
self inocluatlino strep vaginitis strep throat
Therapy for mastitis
1st line: Dicloxacillin and continued breastfeeding or pumping
2nd line: Erythromycin, clindamycin and continued breastfeeding or pumping
Methicillin-sensitive Staph aureus is the most common etiology. It is important to emphasize that women can and should continue to breastfeed despite having mastitis, and that their infant is not at risk of infection from mastitic breast milk. The continual forward flow will both help unclog involved ducts and prevent superimposed engorgement, having therapeutic benefit.
Syndrome of breastfeeding mother with itchy areola and infant with white plaques in its orophaynx
Candida!!!
This is a common presentation. Both mom and baby should be treated with antifungals.
What to advise if your patient says “I am planning on using formula to feed my baby until my milk comes in”
There are a few problems with this:
- Milk will not come in unless a woman is actively breastfeeding
- Colostrum, while not milk, is beneficial in its own right for newborns and is usually present by PPD#2.
Contraindications to breast feeding
- Infectious: Hepatitis B, HIV, Tuberculosis, or active herpetic lesion on the breast
- Galactosemia: Infants with galactosemia should NOT be breastfed. They have one of the two common defects in galactose metabolism. Lactose consumption may cause hepatitis or osmotic diuresis, both of which are life threatening for neonates.
___ cervicitis is strongly associated with preterm delivery, where as ___ cervicitis is usually not.
Gonococcal cervicitis is strongly associated with preterm delivery, where as Chlamydial cervicitis is usually not.
Earliest signs of chorioamnionitis
- Maternal fever
- Uterine tenderness
- Elevated fetal heart rate at baseline
Standard regimen for chorioamnionitis
Ampicillin plus gentamicin
WITH
Immediate delivery (induction of vaginal labor unless C section is otherwise indicated – chorioamnionitis itself is not an independent indication for C section)
Most common etiologies of chorioamnionitis
- Group B Streptococci (aka Streptococcus agalacticae)
- Gram negative enterics (E. coli, Salmonella, Shigella, Serattia, Klebsiella, Enterobacter, Proteus, etc)
Diagnosing chorioamnionitis
While treatment should be started empirically when it is suspected clinically, official diagnosis requires amniocentesis and amniotic fluid gram stain
Signs of chorioamnionitis in the absence of rupture of membranes is suggestive of infection with. . .
. . . Listeria monocytogenes
Listeria causes chorioamnionitis via transplacental spread as opposed to spread from the vaginal canal and cervix (how the enterics and GBS get there)
This should prompt a dietary history looking for evidence of unpasteurized dairy product consumption
Infection and antenatal steroids
Chorioamnionitis is a hard contraindication to antenatal steroids
When a patient presents with PPROM, but vaginal fluid tests positive for phosphatidyl glycerol, you should. . .
. . . begin induction of labor
There is no reason to wait expectantly since the infant’s lungs are mature already. Beginning labor now will minimize the mother’s risk of infection.
Fetal parvovirus infection
- Parvovirus B19 crosses the placental membrane and infects fetal erythrocyre precursors, producing fetal anemia
- This leads to hydrops fetalis
- The earliest sign of fetal hydrops is polyhydramnios(Excess amniotic fluid), which presents on exam asuterine size greater than predicted by dates with difficult to palpate fetal parts
- Diagnosis is made by serology (IgM)
- If < 20 days since exposure, may be false negative
- False positives may also occur, so if positive re-test in 1-2 weeks to confirm
- If maternal infection is detected, weekly fetal ultrasounds and MAC dopplars are performed for 10 weeks to detect hydrops or elevated MCA flow, and if found the patient is referred for fetal intrauterine transfusion
Why do we give occular erythromycin to newborns?
To prevent gonococcal conjunctavitis
Interestingly, occular erythromycin does not reduce rates of Chlamydial conjunctavitis. This may be because Chlamydia is an intracellular organism while gonococci are extracellular – so superficial antibiotics cannot sufficiently manage the infection.
Rather, if an infant does develop Chlamydial conjunctavitis, they would be treated with oral erythromycin for 14 days.
Chlamydial endocervical infection during pregnancy
NOT associated with PROM or preterm labor
However, we do treat it anyway since it IS associated with neonatal conjunctavitis and pneumonia.
Treatment for pregnant patients is 7 days of erythromycin or amoxicillin, OR a one time oral dose of azithromycin. Note that the standard treatment for a non-pregnant patient is doxycycline, but tetracyclines are contraindicated in pregnancy.
Why are tetracyclines contrainidcated in pregnancy?
Permanent staining of the neonatal teeth
The viral load goal for an HIV-infected mother during pregnancy to reduce risk of vertical transmission
< 1000 copies per milliliter
Special precautions to prevent vertical transmission of HIV during pregnancy
- Scheduled Cesarean delivery prior to labor or ROM (if patient arrives in labor already, allow labor to continue as the window of preventing vaginal transmission has already passed)
- Intrapartum IV zidovudine
- No breast feeding
- Feeding of oral zidovudine syrup to the neonate
- Maintaining copy number < 1000 / mL throughout pregnancy via strictly adherent HAART
How do you treat syphilis in a pregnant patient who is penicillin allergic?
Desensitize them to penicillin and use it anyway!!!
There is no alternative to penicillin to treat syphilis in a pregnant patient
First-line for chorioamnionitis
Ampicillin plus gentamicin
First-line for mastitis
Dicloxacillin
CMV IgM often cross-reacts with. . .
. . . EBV
Utility of CMV IgG affinity assays
If other tests are inconsistent or equivocal, the high affinity IgG can suggest chronic or resolved infection with CMV
Signs of fetal CMV on ultrasound
- Ventriculomegaly (brain)
- Ventricular calcifications
If all maternal serology fails to provide a definitive picture of whether or not there may be fetal CMV infection, one definitive method is to. . .
. . . perform amniocentesis and measure the amniotic fluid CMV viral load
Risk factors for chorioamnionitis
- Prolonged labor
- ROM for > 18 hours
- Multiple vaginal exams
- GBS +
- Presence of intrauterine pressure catheter
- Amniocentesis
- Any STI in pregnancy
Fever in a laboring patient is ___ until proven otherwise.
Fever in a laboring patient is chorioamnionitis until proven otherwise.
Clinical diagnostic criteria for chorioamnionitis
- Fever
- Maternal tachycardia
- Fetal tachycardia
- Leukocytosis (relative to pregnancy reference range)
- Fundal tenderness
Endometritis 3 weeks post-C section is an indication for. . .
. . . dilation and curretage
There is very likely retained placental tissue which is fostering infection
Complications of pyelonephritis
Sepsis
ARDS
Congenital toxoplasmosis
- Triad of chorioretinitis, hydrocephalus, diffuse intracranial calcifications
- Often w/ blueberry muffin rash (petechiae, purpura)
- Diagnosis: T. gondii IgM or DNA PCR
- Treatment: Pyrimethamine, sulfadiazine, and folinic acid
- Prevention: Avoid cat faeces, undercooked meat
- Mnemonic: Four C’s of congenital toxo; Cerebral califications, Chorioretinitis, hydro-Cephalus, Convulsions
Early and Late Onset Congenital Syphilis
- Early (<2 years): Jaundice and hepatosplenomegaly, diffuse nontender lymphadenopathy, maculopapular rash, sniffles/rhinorhea, skeletal abnormalities
- Late (>2 years): Frontal bossing (large forehead), perioral fissures, “Hutchinson teeth” (widely spaced, characteristic of syphilis), interstitial keratitis, sensorineural hearing loss
- Diagnosis: VDRL or RPR, darkfield microscopy, PCR
- Treatment: Penicillin (even if allergic)
- Prevention: Treatment of mother in early pregnancy
- Hutchinson’s triad: Hutchinson teeth, interstitial keratitis, sensorineural hearing loss
Congenital Listeriosis
- Spontaneous abortion or permature birth, meningitis, sepsis, granulomatosis infantiseptica (vesicular and pustular skin lesions)
- Diagnosis: Bacterial culture
- Treatment: Ampicillin and gentamicin
- Prevention: Avoid unpasteurized dairy products, soft cheeses, and cold deli meats
Congenital VZV
- IUGR, premature birth, chorioretinitis, cataracts, encephalitis, pneumonia, CNS abnormalities, hypoplastic limbs
- Diagnosis: Direct fluorescent antigen test, PCR for VZV DNA, serology for IgM
- Treatment: VZVIG, acyclovir, breastfeeding
- Prevention: Active immunization of mother before pregnancy, passive immunization with VZVIG
Congenital Rubella
- IUGR, congenital sensorineural deafness, cataracts, heart defects, CNS abnormalities
- Blueberry muffin rash (petechiae and purpura)
- Diagnosis: Serology for IgM, PCR for DNA
- Treatment: Supportive care only
- Prevention: Active immunization of mother before pregnancy, second immunization following delivery if titers remain negative/low
- Mnemonic: 3C’s: Cataracts, cochlear defects, cardiac defects
Congenital CMV
- IUGR, jaundice, hepatosplenomegaly, chorioretinitis, sensorineural deafness, periventricular calcifications, microcephaly, seizures
- Blueberry muffin rash (petechiae and purpura)
- Diagnosis: Viral culture, PCR for CMV DNA
- Treatment: Ganciclovir and valganciclovir, supporive care
- Prevention: Frequent hand washing, avoid potentially contaminated places (schools, pediatric clinics)
Congenital HSV
- Premature birth, IUGR, skin/eye/mouth involvement with vesicular lesions and keratoconjunctavitis, meningoencephalitis, sepsis
- Diagnosis: Viral culture, PCR for HSV DNA
- Treatment: Acyclovir, supportive care
- Prevention: Cesarean delivery if lesions present in maternal vaginal canal, suppressive therapy during active pregnancy during infection and again starting at 36 wks with valaciclovir.
Maternal HBV
- Can be treated during pregnancy with tenofovir, particularly from 28 weeks to delivery (beginning of third trimester)
- Presence of HBe Antigen indicates high risk of transmission, since new viral particles are being produced
- To prevent neonatal infection:
- Tenofovir from week 28 to delivery
- Baby should receive HBIG for passive immunization and active hepatitis B vaccine for life-long immunity
- Breastfeeding is SAFE
- If baby is infected, there is risk for neonatal cirrhosis and hepatocellular carcinoma
Wound infection need to be. . .
. . . opened and drained, in addition to systemic antibiotics
Ddx for cervicitis
- Gonococci
- Chlamydia
- Trichomonas (not true cervicitis, actually vaginitis, but mimics the clinical picture)
- HSV (usually HSV-2, rarely HSV-1)
A patient presents with signs and symptoms of cervicitis, but refuses a pelvic exam. What can you do for diagnosis?
Urine NAAT (at least for gonococci and chlamydia)
Diagnosing disseminated gonococcemia
Usually diagnosed by culture of gonococci from the papules present at distant sites
Gonococcal infections of the neonate present ___ days following birth
Chlamydial infections of the neonate present ___ days following birth
Gonococcal infections of the neonate present 2-5 days following birth
Chlamydial infections of the neonate present 5-14 days following birth
Gonococcal pharyngitis
May be seen when N. gonorrheae is transmitted via oral sex.
Gonorrhea’s pili are capable of adhering to throat mucosa as well as cervical.
Cervical motion tenderness
Exquisite pain experienced when the cervix is manipulated digitally
Suggestive of salpingitis
When the diagnosis of PID is in doubt, it may be confirmed by. . .
. . . laporoscopy demonstrating purulent material at the fimbriae of the Fallopian tubes
Standard inpatient and outpatient PID antibiotic regimens
Outpatient: One shot IM ceftriaxone, oral doxycycline 2x/day for 14 days, +/- metronidazole 2x/day for 14 days
Inpatient: IV cefotetan OR doxycycline continued until 24 hours post improvement, then discharge on oral doxycycline 2x/day for 14 days
Tubo-ovarian abscess
Possible complication/sequellae of salpingitis
Does not require surgical drainage, but often requires metronidazole or clindamycin in addition to standard salpingitis regimen due to the high prevalence of gram negatives.
Think of these as being largely composed of bacteroides
Contraception methods and PID
IUDs increase the risk of PID (you are giving the microbes a pathway into the uterus)
Oral hormonal therapies decrease the risk of PID (progestin thickens cervical mucous)
Salpingitis is virtually always. . .
. . . polymicrobial
Chlamydia or gonorrheae may pave the way, but normal vaginal flora follow
Why is it typically better to treat BV with oral metronidazole rather than intravaginal metronidazole?
Two reasons:
- Less invasive for the patient
- Intravaginal metronidazole has low bioavailability at the locations that often serve as reservoires of Gardnerella: Skene’s glands and the urethra
Classic findings of trichomoniasis
- Erythematous vagina
- Frothy yellow-green discharge
- Punctuations of the cervix (strawberry cervix)
Treatment for chancroid (H. ducreyi)
- Oral azithromycin
- IM ceftriaxone
Treating syphilis
If < 1 year infection: Single dose penicillin
If > 1 year infection: Three courses of penicillin
If non-pregnant, tetracycline or doxycycline may be used if penicillin allergic. Obviously, these are contraindicated in pregnancy.
Neurosyphilis requires IV penicillin regardless of allergy state.
Best treatment for uncomplicated cystitis
Oral bactrim for 3 days
Urethritis
Presents with symptoms identical to cystitis, but causative organisms are C. trachomatis, N. gonorrheae, and Trichomonas instead of the typical lower urinary tract pathogens.
Should be suspected when a patient presents with classic signs of LUTS, but urinalysis is negative and standard antibiotics do not improve symptoms. Next step is to culture a swave of the urethra for these organisms.
Contraindications to levonorgestrel IUD
- Hx of recent STI
- Behavior that is high risk for STIs
- Abnormal uterine size or shape
Indications for intrapartum penicillin
- 35-37 wk screen positive for GBS
- Previous delivery complicated by early onset neonatal GBS infection
- GBS UTI or other GBS infection of mom during the pregnancy
Candidiasis of the nipple
Candida will not always be visible the way it is with thrush, but it will be very uncomfortable and painful
Any nipple pain in the early postpartum period should prompt inspection of the infant’s oral cavity as well.
Treat w/ topical clotrimazole. It is not unreasonable to add an antibiotic or substitute for mupirocin due to concern over possible Staph aureus infection of the nipple, which may lead to breast abscesses
Indication for Cesarean delivery in patients with HIV
If >1000 copies per mL, we recommend Cesarean delivery
Otherwise, we can just give intrapartum ziduvodine and counsel not to breastfeed.
Of course, if they are already in labor or have already ruptured, the benefit of Cesarean is already lost, so we can let them delivery vaginally.
