Maternal Infection Flashcards

Question

How should the pregnant woman who develops chickenpox be cared for antenatally?

Answer 1

* Pregnant women who develop a chickenpox rash should immediately contact their general practitioner. * Women should avoid contact with potentially susceptible individuals, e.g. other pregnant women and neonates, until the lesions have crusted over. * Oral aciclovir should be prescribed for pregnant women with chickenpox if they present within 24 hours of the onset of the rash and if they are 20+0 weeks of gestation or beyond. Use of aciclovir before 20+0 weeks should also be considered. * Intravenous aciclovir should be given to all pregnant women with severe chickenpox. * _VZIG has no therapeutic benefit once chickenpox has developed and should therefore not be used in pregnant women who have developed a chickenpox rash._ * Women who develop chickenpox in pregnancy should be referred to a fetal medicine specialist, at 16–20 weeks or 5 weeks after infection, for discussion and detailed ultrasound examination.

Answer 2

The timing and mode of delivery of the pregnant woman with chickenpox must be individualised. When epidural or spinal anaesthesia is undertaken in women with chickenpox, a site free of cutaneous lesions should be chosen for needle placement. If infection occurs within the last 4 weeks of pregnancy, elective delivery should be delayed until 7 days after the onset of the rash (to allow passive transfer of antibodies to fetus)

Answer 3

A neonatologist should be informed of the birth of all babies born to women who have developed chickenpox at any gestation during pregnancy. - Arrange **neonatal ophthalmic examination** after birth. If birth occurs within 7 days of the onset of the rash or the mother develops chickenpox within 7 days of delivery, the neonate should be given VZ Ig and monitored for signs of infection until 28 days after the onset of maternal infection If neonatal infection occurs, treat with acyclovir Women with chickenpox should breastfeed if they wish to and are well enough to do so.

Answer 4

Syphilis is caused by infection with the spirochete bacterium *Treponema pallidum**.*** The number of cases is on the rise in the UK, in part due to the increased levels of immigration from countries where the infection is prevalent.

Answer 5

The course of syphilis is characterised by stages: * Primary and secondary where a person is symptomatic and highly infectious * latent(early/late)where the infection is found at lower levels * tertiary where syphilis reactivates, and serious health complications are common.

Answer 6

since 2009, approx. 1 in 700 postive

Answer 7

* fetal loss rate of 50% * miscarriage * pre -term birth * still birth * congenital syphilis. * Around two-thirds of babies with congenital syphilis will be asymptomatic at birth but most will develop symptoms by 5 weeks of age. * Neonatal disease may manifest as rhinitis, a diffuse maculopapular, desquamative rash with extensive sloughing of the epithelium, particularly on the palms and soles, splenomegaly, anaemia, thrombocytopenia and jaundice. If clinical signs are present at birth, 50% of infants will die in the neonatal period * If untreated, it leads to physical and neurological impairments affecting the child’s bones, teeth, vision and hearing.

Answer 8

* a doctor's recognition of its signs and symptoms * Primary syphilis - painless ulcer (chancre) * Secondary syphilis - skin rash that is characterised by brown sores about the size of a penny. Other symptoms also may occur, such as mild fever, headache and fatigue. * microscopic identification of syphilis bacteria * blood tests. A combination of all three methods is usually used to detect the infection and decide upon its stage and appropriate treatment. SCREENING * Enzyme Immunoassay - detects antibodies to Treponema Pallidum CONFIRMATORY TEST * Treponema pallidum particle agglutination or treponema pallidum hemagglutination

Answer 9

**Ultrasound markers** * Non-immune hydrops fetalis * Fetal growth restriction * Lesions of the head * Lesions of the GI tract

Answer 10

1. Refer to GUM clinic (appropriate contract tracing and determine the stage of infection and complications) 2. Tx only indicated in acute infection or inadequately treated or unclear tx prior to pregnancy 1. 1st line: **IM stat benzylpenicillin** 3. If there are evidence of early infection, then women should be referred to fetal medicine unit by 26 weeks

Answer 11

In the UK, toxoplasmosis affects approximately 2 per 1000 pregnancies

Answer 12

Toxoplasmosis can be acquired when a pregnant woman ingests the parasite: * The parasite spreads in the maternal blood and lymphatic system. * Parasitaemia usually occurs within 3 weeks. * Therefore, placental infection is only a significant risk if the mother acquires the infection during or immediately before pregnancy.

Answer 13

* In first trimester = 10% * In second trimester = 25% * In third trimester \>85%. Most fetuses infected in the third trimester are asymptomatic. **The risk of congenital sequelae and complications in fetus infected in** * Early pregnancy = 85% * Late pregnancy = 10–80%. The classical toxoplasmosis triad: * intracerebral calcification * hydrocephaly * chorioretinitis Implications in pregnancy include: * miscarriage * ascites and hepatosplenomegaly (visible on ultrasound) * chorioretinitis (less common since antiparasitic treatment during pregnancy was introduced; visible on ultrasound) * hydrocephaly (rarely caused by *T. gondii*; visible on ultrasound) * brain tissue calcification (rarely caused by *T. gondii*; visible on ultrasound). Long term fetal effects of toxoplasmosis include: * visual impairment due to persistence of a toxoplasmosis cyst that subsequently ruptures.

Answer 14

* Antibiotics * 1 st line = spiramycin (3-week course of 2-3g OD) * If foetal infection is confirmed discuss the options: * Continuation of pregnancy with more aggressive antibiotic treatment (e.g. sulfadiazine and pyrimethamine) * Treat baby for up to 1 year after delivery (if no TOP). * Adjunct can be prednisolone. * Prevention: avoid eating raw meat, avoid handling cats and cat litter, wear gloves and wash hands when gardening or handling soil

Answer 15

Cytomegalovirus (CMV), a member of the human herpesvirus family, is the most common viral cause of congenital infection, affecting 0.2–2.2% of all live births

Answer 16

The risk of congenital infection appears to vary according to the time during gestation at which primary infection occurs, increasing from around 30% in the first trimester to 47% in the third trimester

Answer 17

The majority of women who acquire CMV infection for the first time (primary infection) will remain asymptomatic However, a minority do experience symptoms similar to those of infectious mononucleosis (glandular fever), including * fever * malaise * myalgia * cervical lymphadenopathy * less commonly, hepatitis and pneumonia, but few suffer long-term sequelae

Answer 18

The features of ***congenital CMV*** are: * Fetal growth restriction * Microcephaly * Hearing loss * Vision loss * Learning disability * Seizures 87% asymptomatic or subclinical infection

Answer 19

IgG avidity testing is often used - a high avidity index (greater than 60%) is highly suggestive of past (more than 3 months) or secondary infection, while a low avidity index (less than 30%) is highly suggestive of a recent primary infection (i.e. within the past 3 months) Maternal serology is still the mainstay for the diagnosis of maternal infection. Virological tests of maternal serum or urine are available, although these correlate poorly with the timing of infection or neonatal outcomes and are, therefore, less useful in the clinical setting Could do amniocentesis PCR

Answer 20

* Simple hygiene-based measures that have been shown to reduce the risk of CMV acquisition include handwashing after contact with urine or saliva, and avoiding sharing utensils, drinks or food with young children. * Refer to **foetal medicine specialist** for regular foetal surveillance * Foetal US examination every 2-4 weeks from diagnosis * ± Foetal MRI at 28-32 weeks gestation o Audiology + ophthalmology F/U * If there is evidence of foetal infection on US discuss the options: * Continuation of pregnancy with expectant management * TOP * Congenital CMV should be confirmed at birth (e.g. urine or oral swab for CMV PCR within 3 weeks of birth) * Offer postnatal antiviral therapy for the baby (e.g. valganciclovir, ganciclovir) for 6 months and start within 4 weeks of life.

Answer 21

50% of women at childbearing age are immune to PVB19 infection and, therefore, 50% are susceptible to infection during pregnancy.

Answer 22

15 min in the same room, or face-to-face contact with someone that has the virus

Answer 23

The main effect of parvovirus infection is fetal anaemia. The most common presentation of fetal infections is by non-immune hydrops, diagnosed on an ultrasound scan. Hydrops can develop up to 12 weeks, and possibly 18 weeks, after maternal infection. Therefore, detailed ultrasound examination for signs of fetal hydrops should be undertaken for at least 12 weeks from the date of the exposure, or proven maternal infection. More reliable tests for congenital malformations include: * detection of B19 DNA in maternal or fetal serum or tissues * identification of characteristic intranuclear inclusions demonstrated on histological samples or microscopy * more recently, viral DNA amplifications using PCR in maternal and fetal serum or tissues and in the placenta, has proved to be the most sensitive and accurate diagnostic.

Answer 24

* main effect of parvovirus infection is fetal anaemia - caused by PV infection of the erythroid progenitor cells in the fetal bone marrow and liver → faulty red cell production → shorter life span → anaemia * The risk of transmission is increased between 9-20 weeks of gestation. → intrauterine death or hydrops fetalis * Transplacental transmission risk is about 30%, depending on gestation. * Overall fetal loss rate for those with maternal infection is 5-10%. Complication of severe HF → maternal pre-eclampsia-like syndrome (TRIAD of Hydrops fetalis + placental oedema + oedema in the mother) also protienuria and hypertension

Answer 25

A detailed history of the timing of contact and any maternal symptoms suggestive of recent parvovirus B19 infection should be taken. The management of proven parvovirus B19 infection has become more active with the demonstration that intrauterine transfusion of the fetus improves the outcome – several reports describe intravascular transfusion for treatment of parvovirus related fetal anaemia with a survival rate of more than 80%.

Answer 26

* The risk to the fetus of primary rubella in the first 16 weeks of gestation is substantial. * Rubella infection prior to the estimated date of conception or after 20 weeks of gestation carries no documented risk. * Primary rubella contracted between 16 and 20 weeks of gestation carries a minimal risk of deafness only. * The possible long-term outcomes of infections acquired prenatally are: * sensorineural deafness * diabetes mellitus * thyroid disease * growth hormone deficiency * vascular effects * encephalitis.

Answer 27

Management depends on point in gestation and individual circumstances. Due to the low, but definite, risk to the fetus of maternal rubella reinfection in the first 16 weeks of pregnancy, there may be circumstances when further fetal investigation by genome detection is carried out, to ascertain if fetal infection has occurred. A range of possible approaches has been explored, but they are all invasive, e.g. amniocentesis and fetal blood sampling. They, therefore, carry a risk of an adverse outcome.

Answer 28

The risk of infection is increased in: * pregnant women * neonates * the elderly * the immunosuppressed. * It may be difficult to diagnose listeriosis as it presents as a spectrum of disease and can mimic other infections. Food sources of infection include: * soft cheese * milk * shrimps * rice salad * uncooked chicken. Maternal infection can lead to placental infection and, in turn, fetal septicaemia. The fetus may also be colonised during passage through the birth canal.

Answer 29

The classic pathology of listeriosis is abscess formation, although maternal infection may be asymptomatic. Listeriosis can present as: * infectious mononucleosis-like syndrome (malaise, chills, fever, pharyngitis, lymphadenopathy, monocytosis) * influenza-like syndrome (fever, headaches, upper respiratory syndromes) * typhoid-like syndrome (high spiking temperature, back pain) * febrile gastroenteritis (fever, musculoskeletal symptoms, nausea, vomiting, diarrhoea).

Answer 30

* Early onset listeriosis, within 2 days of birth, presents with signs of septicaemia and meningitis. * Infected neonates are often delivered preterm, and would usually have acquired the infection from the placenta. * Late onset listeriosis, which presents after 5 days with meningitis, is usually a result of infection during delivery.

Answer 31

*L. monocytogenes tested* in the mother by blood culture, rectovaginal culture and Gram staining. As the fetus will excrete *L. monocytogenes* in urine, the amniotic fluid will become infected. An amniocentesis sample can therefore be cultured, and the bacteria Gram stained.

Answer 32

* Listeriosis can lead to maternal septicaemia or meningitis. Occasionally, the onset on labour may induce a fever. * The impact on the fetus may be seen in the days/weeks following infection. Potential implications include **fetal death in utero.** * Congenital infection is often fatal, but the long-term morbidity is currently unknown. * It has been suggested that fetal infection may lead to an increased risk of developmental delays, but other studies report no effects.

Answer 33

Typical treatment is intravenous administration of ampicillin plus gentamycin. In order to prevent infection, pregnant women should be encouraged to avoid soft cheeses, and not to re-heat leftover food.

Answer 34

Infection may be localised to the skin, eyes or mouth (best prognosis), or cause encephalitis or disseminated infection Neurological morbidity is higher in local CNS disease even with appropriate treatment. Untreated/delayed treatment in newborns can result in intellectual disability and death. Infection with HSV-2 has a poorer prognosis than HSV-1.

Answer 35

Maternal complications are generally similar to those occurring in the non-pregnant state; however, the incidence of disseminated HSV, although rare, is probably increased. In most reported cases, this condition occurs in the second or third trimester.

Answer 36

Female partners of men with genital herpes who themselves have no history of genital herpes should be strongly advised not to have sex at the time of lesional recurrence. Use of condoms throughout pregnancy may diminish the risk of acquisition Pregnant women should be advised of the risk of acquiring HSV-1 as a result or orogenital contact

Answer 37

* All pregnant women with first-episode genital herpes should be referred to genitourinary physicians * A recurrent episode of genital herpes occurring during the pregnancy is not an indication for delivery by caesarean section. There is insufficient evidence as to whether daily acyclovir 400 mg tds from 36 weeks reduces the incidence of neonatal herpes.

Answer 38

1. Early recognition and treatment of neonatal HSV infection are important to reduce the mortality and the incidence of serious neurological sequelae in surviving children. 2. Delivery should have swabs taken for viral culture from the eyes, oropharynx and any mucocutaneous lesions 3. Neonates with suspected herpes infection (with or without central nervous system signs or symptoms) should have a lumbar puncture in order to obtain specimens of cerebrospinal fluid for PCR and/or culture and should be treated with intravenous aciclovir.

Answer 39

Streptococcus agalactiae (Lancefield Group B beta-haemolytic streptococcus) is a normal commensal of the female genital tract and can be found in the bowel flora of 20–40% of adults.

Answer 40

Early-onset GBS disease is generally defined as an infection appearing within 7 days of a baby being born, although 90% of cases occur within 24 hours

Answer 41

Infection predominantly occurs after a baby is exposed to maternal GBS during childbirth but the risk of the infant contracting the disease is increased if the mother has one or more of the following factors: * previous infant with early-onset GBS disease * GBS bacteriuria in current pregnancy or GBS colonisation at term * prolonged rupture of membranes (an interval of 18 hours or more between rupture and delivery) * preterm labour at less than 37 weeks of gestation * maternal temperature higher than 38°C.

Answer 42

The incidence of early onset GBS disease in the UK and Ireland has significantly increased to 0.57/1000 births in 2015

Answer 43

A number of reasons are given by the national screening committee for this, which include: * women carrying GBS don’t always have affected babies * 17–25% of women who screen positive for GBS at 35–37 weeks will be negative for GBS at delivery * many of the babies severely affected by GBS are those born prematurely and before the recommended timing for screening.

Answer 44

* Can be offered to patients who have previously had GBS detected in a previous pregnancy, irrespective of their current carrier status, if this would then affect their decision whether to have intra-partum antibiotic prophylaxis or not. * This screening should be carried out at 35–37 weeks of gestation, or 3–5 weeks prior to an anticipated delivery date, and should take the form of a swab from the lower vagina and the rectum.

Answer 45

**Intrapartum-antibiotic prophylaxis (IAP)** are recommended if: * GBS is detected incidentally in the vagina or the urine in the current pregnancy * a woman had a previous baby with neonatal GBS disease * a woman chooses to following GBS detection in a previous pregnancy, with or without choosing to have screening in this pregnancy * a woman goes into pre-term (\<37 weeks’ gestation) labour * a woman has an intrapartum pyrexia (38ºC or greater) - though antibiotic cover should be broad and include coverage for GBS. **IAP - IV Benzylpenicillin 3 g** as a loading dose, followed by **1.5g** every 4 hrs until deliver Also should start 4 hrs prior to delivery. * If non-severe penicillin allergy - **IV Cefuroxime 1.5 g** loading dose followed by **750 mg** every 8 hrs until delivery * if the patient has a severe penicillin allergy – **intravenous vancomycin 1 g** every 12 hours until delivery. Abx not recommend if elective C-section

Answer 46

* If women who are known to have GBS decline IAP, or have not had adequate IAP, then their baby should be monitored for _12 hours post-birth_ * Term babies who are clinically well at birth and whose mothers have clinically indicated IAP more than 4 hours before delivery do not require any special observations. * If neonatal infection: IV penicillin and gentamicin

Answer 47

*Concerning neonatal signs and symptoms include*: * temperature \<36ºC or \>38ºC * high respiratory rate * change in skin colour * poor tone * difficulties with feeding * abnormal behaviour, including inconsolable crying, or listlessness. *Early onset GBS disease presents with*: * sepsis * pneumonia * meningitis. *Late onset GBS disease presents with*: * meningitis (more common than early onset disease) * pneumonia * sepsis * focal Infections (e.g. osteomyelitis, septic arthritis, cellulites, and lymphadenitis). Mortality is greater for late onset disease than early onset disease.

Answer 48

The specific routine diagnosis of acute hepatitis A is made by finding anti-HAV IgM in the serum of patients. A second option is the detection of the virus and/or antigen in the faeces.

Answer 49

Prevention: * Good hand hygiene * Hepatitis A vaccine - for people at increased risk * For post-exposure prophylaxis of non-vaccinated people, the passive administration of Ig can modify the symptoms of infection, provided it is given within 2 weeks of exposure.

Answer 50

About 30% of infected people have no signs or symptoms, and signs and symptoms are less common in children than adults. Signs and symptoms include: * jaundice * fatigue * abdominal pain * loss of appetite * nausea and vomiting * joint pain.

Answer 51

Mother: * death from cirrhosis of the liver * liver cancer Neonate HBV is usually passed to the baby at birth. The possible long-term effects are: * liver cirrhosis * hepatocellular carcinoma.

Answer 52

Screening: The aim of screening is to * prevent fetal abnormalities by identifying women early in pregnancy so that treatment can be initiated to reduce transmission of infection from mother to child, * to prevent adverse outcomes in the infant. • **Antenatal** o **Refer to hepatologist** o Offer tenofovir to women with high HBV viral load (HBV DNA \>107 IU/ml) * Start in the 3rd trimester and stop 4-12 weeks after delivery unless the mother meets criteria for long-term treatment * Monitor HBV viral load every 2 months and LFTs monthly • **Postnatal** o Offer **hepatitis B Ig** and **hepatitis B immunisation** to the newborn * HBV Ig – given within 24 hours of delivery * Hep B vaccine **extra doses** compared to routine schedule: at birth, 4 weeks, 12 months o Confirm or deny diagnosis of hepatitis B in the neonate with **blood test for serology** (normally carried out at 12 months following completion of immunisation schedule) o **Encourage breastfeeding (carries no risk of transmission)**

Answer 53

General signs and symptoms include: * jaundice * fatigue * dark urine * abdominal pain * loss of appetite * nausea. 80% of people infected with hepatitis C have no signs or symptoms Diagnosis of HCV transmission is generally made by polymerase chain reaction (PCR) for HCV RNA sequences in plasma.

Answer 54

Maternal: * Liver damage * Coagulopathies and thrombocytopenia * Portal hypertension → Oesophageal haemorrhage Neonate: HCV transmission occurs in approximately one in 20 births. HCV infection is transmitted at birth and detection of infant infection only becomes reliable after 3 months.

Answer 55

• **Antenatal** o **Refer to hepatologist** o Beware: the usual treatments for HCV, interferon and ribavirin, are contraindicated in pregnancy and should be deferred to the postpartum period • No specific precautions on mode of delivery, or postnatal care, are recommended (there is no strong evidence that suggests such precautions reduce rates of vertical transmission).

Answer 56

• **Antenatal** o **Refer to hepatologist** o Beware: the usual treatments for HCV, interferon and ribavirin, are contraindicated in pregnancy and should be deferred to the postpartum period • No specific precautions on mode of delivery, or postnatal care, are recommended (there is no strong evidence that suggests such precautions reduce rates of vertical transmission).