Maternal Infection Flashcards
Define asymptomatic bacteriuria.
Defined as persistent colonisation of the urinary tract by significant numbers of bacteria in women without urinary symptoms.
Define acute cystitis.
Distinguished from asymptomatic bacteriuria by the presence of symptoms such as dysuria, urgency, frequency, nocturia, haematuria and suprapubic discomfort in afebrile women with no evidence of systemic illness.
Define pyelonephritis
Defined as significant bacteriuria in the presence of systemic illness and symptoms such as flank or renal angle pain, pyrexia, rigor, nausea and vomiting.
What is the incidence of UTIs in pregnancy? What increases the risk fo UTIs?
In pregnancy, the overall incidence of UTI is approximately 8%.
Urinary stasis, compromised ureteric valves and vesicoureteric reflux.
Seventy percent of pregnant women develop glycosuria
Sexual activity in women has been established as a significant risk factor for UTI
What are the main risks of a UTI during pregnancy?
Urinary tract infections in pregnant women increase the risk of preterm delivery. They may also increase the risk of other adverse pregnancy outcomes, such as low birth weight and pre-eclampsia.
How do UTIs present in pregnant women?
Lower urinary tract infections present with:
- Dysuria (pain, stinging or burning when passing urine)
- Suprapubic pain or discomfort
- Increased frequency of urination
- Urgency
- Incontinence
- Haematuria
Pyelonephritis presents with:
- Fever (more prominent than in lower urinary tract infections)
- Loin, suprapubic or back pain (this may be bilateral or unilateral)
- Looking and feeling generally unwell
- Vomiting
- Loss of appetite
- Haematuria
- Renal angle tenderness on examination
How should we investigate UTIs in pregnancy?
Nitrites are produced by gram-negative bacteria (such as E. coli). These bacteria break down nitrates, a normal waste product in urine, into nitrites. The nitrites in the urine suggest the presence of bacteria.
Leukocytes refer to white blood cells. There are normally a small number of leukocytes in the urine, but a significant rise can be the result of an infection, or alternative cause of inflammation. Urine dipstick tests examine for leukocyte esterase, a product of leukocytes, which gives an indication to the number of leukocytes in the urine.
Nitrites are a more accurate indication of infection than leukocytes.
During pregnancy, midstream urine (MSU) samples are routinely sent to the microbiology lab to be cultured and to have sensitivity testing.
What organisms usually cause UTIs in pregnancy?
Most common cause of urinary tract infection is Escherichia coli (E. coli). This is a gram-negative, anaerobic, rod-shaped bacteria that is part of the normal lower intestinal microbiome. It is found in faeces, and can easily spread to the bladder.
Other causes:
- Klebsiella pneumoniae (gram-negative anaerobic rod)
- Enterococcus
- Pseudomonas aeruginosa
- Staphylococcus saprophyticus
- Candida albicans (fungal)
How do we manage UTIs is pregnancy?
Urinary tract infection in pregnancy requires 7 days of antibiotics.
The antibiotic options are:
- Nitrofurantoin (avoid in the third trimester)
- Amoxicillin (only after sensitivities are known)
- Cefalexin
Nitrofurantoin needs to be avoided in the third trimester as there is a risk of neonatal haemolysis (destruction of the neonatal red blood cells).
Trimethoprim needs to be avoided in the first trimester as it is works as a folate antagonist. Folate is important in early pregnancy for the normal development of the fetus. Trimethoprim in early pregnancy can cause congenital malformations, particularly neural tube defects (i.e. spina bifida). It is not known to be harmful later in pregnancy, but is generally avoided unless necessary.
Advice:
Increasing oral fluid intake is frequently advocated as a first-line treatment for pregnant women with features of symptomatic urinary infection
What is the prevalence of HIV in pregnancy?
The prevalence of HIV infection in women giving birth in England and Scotland in 2008 was 1/486 (0.2%)
What is the risk of mother to baby transmission of HIV?
Not treated: The risk of mother-to-child transmission of HIV is between 15% and 20% in non-breastfeeding women in Europe and between 25% and 40% in breastfeeding African populations.
Treated: Transmission rates of less than 2% have been reported in studies from resource-rich countries in recent years, owing to effective HAART (leading to low or undetectable plasma viral loads), appropriate management of delivery and avoidance of breastfeeding.
Women should be advised that, in the UK and other resource-rich settings, in the absence of breast feeding, the risk of mother-to-child transmission of HIV in women taking HAART during pregnancy is less than 1%.
What can be done to ensure continued high uptake of HIV screening?
- All pregnant women are recommended to have screening for HIV infection in every pregnancy at their booking antenatal visit. This enables those diagnosed with HIV to take up interventions that can prevent mother-to-child transmission and significantly improve their own health.
- All pregnant women who are HIV positive should be referred promptly for assessment and for their pregnancies to be management within a multidisciplinary team.
- If a woman declines screening, her reasons should be explored sensitively to ensure that she has received accurate information on which to base her decision. Involvement of a senior health professional should be considered. The decision to decline screening should be documented in the maternity notes and screening offered again at around 28 weeks.
What type of HIV test should be used for screening?
Fourth-generation laboratory assays are recommended as the first-line HIV test for antenatal screening.
Where a woman has her HIV screening test at 26 weeks of gestation or later, an urgent request should be made and the result issued by the laboratory with 24 hours.
Rapid HIV tests are recommended for women with unknown HIV status who present in labour and a reactive result should be acted on immediately.
How should we think of managing a patient with HIV in pregnancy?
- MDT Approach
- Antenatal
- Intrapartum
- Postpartum
What is the role of the MDT?
All antenatal care for women who are HIV positive should be managed by a multidisciplinary team, including (as a minimum) an HIV physician, obstetrician, specialist midwife, health advisor and paediatrician.
All women who are newly diagnosed as HIV positive should have an early assessment of their social circumstances.
How should you manage pregnant patient with HIV antenatally?
o Arrange contact with joint HIV physician and obstetric clinic every 1-2 weeks
o Monitor CD4 counts at baseline and at delivery, HIV viral load every 2-4 weeks, at 36 weeks gestation and at delivery.
o ART: all women should be offered ART regardless of whether they were previously taking it!
Additional recommended blood tests for women who are HIV positive include hepatitis C, varicella zoster, measles and toxoplasma.
Women who are HIV positive taking HAART at the time of booking should be screened for gestational diabetes.
Hepatitis B, pneumococcus and influenza immunisation are recommended for all individuals who are HIV positive; these immunisations can be safely administered in pregnancy.
Women who are HIV positive should be screened for genital infections at booking (or after multidisciplinary team referral if diagnosed HIV positive in pregnancy) and again at 28 weeks. Any infection detected should be treated according to UK national guidelines.
How should you manage pregnant patient with HIV in the intrapartum period?
o Mode of delivery depends on viral load at 36 weeks gestation:
- < 50 copies/mL → reassure that vaginal delivery is appropriate
- >50 copies/mL or co-existent hepatitis C or ZDV monotherapy → recommend elective C-section with intrapartum IV zidovudine @38 weeks.
Delivery by elective caesarean section for obstetric indications or maternal request should be delayed until after 39 completed weeks of gestation in women with plasma viral loads of less than 50 copies/ml, to reduce the risk of transient tachypnoea of the newborn.
Delivery by elective caesarean section at 38 weeks to prevent labour and/or ruptured membranes is recommended for:
o Cord should be clamped as soon as possible and the baby should be bathed immediately after birth.
How should you manage pregnant patient with HIV in the postpartum period?
o Advise women not to breastfeed
Beware: this advice is only relevant for women in the UK, and is different for women living in under-resourced countries
o Treat all newborns with ART within 4 hours of birth
If low-risk of transmission → zidovudine monotherapy for 2-4 weeks
If high-risk of transmission → triple ART (zidovudine, lamivudine and nevirapine) for 4 weeks
o Confirm or deny diagnosis of HIV in the neonate with direct viral amplification by PCR (normally carried out at birth, on discharge, 6 weeks and 12 weeks) a confirmatory HIV antibody test is performed at around 18 months of age.
How should a patient be counselled on a pregnancy with HIV?
How common is primary VZV infection in pregnancy?
primary VZV infection in pregnancy is uncommon; it is estimated to complicate 3 in every 1000 pregnancies
What are the complications of VZV infection in pregnancy?
Maternal: varicella pneumonitis, hepatitis, or encephalitis
Fetal
- 1-2% Teratogenicity – only in early pregnancy infection (<20 wks) → Fetal varicella syndrome - 1% of pregnancies
- Infection within 4 weeks of delivery (worst if within 5 days after or 2 days before maternal infection) → severe neonatal varicella infection
What is congenital varicella syndrome?
Congenital varicella syndrome occurs in around 1% of cases of chickenpox in pregnancy.
It occurs when infection occurs in the first 28 weeks of gestation. The typical features include:
- Fetal growth restriction
- Microcephaly, hydrocephalus and learning disability
- Scars and significant skin changes located in specific dermatomes
- Limb hypoplasia (underdeveloped limbs)
- Cataracts and inflammation in the eye (chorioretinitis)
How can we prevent varicella infection in pregnancy?
- Vaccination
- Varicella vaccination prepregnancy or postpartum is an option that should be considered for women who are found to be seronegative for VZV IgG.
- Women who are vaccinated postpartum can be reassured that it is safe to breastfeed.
- Advice
- Women who have not had chickenpox, or are known to be seronegative for chickenpox, should be advised to avoid contact with chickenpox and shingles during pregnancy and to inform healthcare workers of a potential exposure without delay.
How should we manage patients who have been exposed to varicella but have not developed an infection?
- If the pregnant woman is not immune to VZV and she has had a significant exposure, she should be offered VZIG as soon as possible.
- VZIG is effective when given up to 10 days after contact (in the case of continuous exposures, this is defined as 10 days from the appearance of the rash in the index case).
- Should be managed as potentially infectious from 8–28 days after exposure if they receive VZIG and from 8–21 days after exposure if they do not receive VZIG
- Should be advised to stay away from pregnant women and neonates
- A second dose of VZIG may be required if a further exposure is reported and 3 weeks have elapsed since the last dose.
How should the pregnant woman who develops chickenpox be cared for antenatally?
- 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.
When and how should the woman with chickenpox be delivered?
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)
What is the management of varicella zoster postnatally?
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.
Summarise the management of VZV contact in pregnancy.
What causes syphilis? How has the incidence changed?
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.
Describe the course of syphilis.
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.
How common is it for women to screen positive for syphilis?
since 2009, approx. 1 in 700 postive
What are the complications of syphilis in pregnancy?
- 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.
How do we diagnose syphilis in the mother?
- 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
How do we diagnose syphilis in the fetus?
Ultrasound markers
- Non-immune hydrops fetalis
- Fetal growth restriction
- Lesions of the head
- Lesions of the GI tract
How do we manage syphilis infection in pregnancy?
- Refer to GUM clinic (appropriate contract tracing and determine the stage of infection and complications)
- Tx only indicated in acute infection or inadequately treated or unclear tx prior to pregnancy
- 1st line: IM stat benzylpenicillin
- If there are evidence of early infection, then women should be referred to fetal medicine unit by 26 weeks
How common is toxoplasmosis infection in pregnancy?
In the UK, toxoplasmosis affects approximately 2 per 1000 pregnancies
How does a women get infected with toxoplasmosis?
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.
When can T.gondii be transmitted from mum to fetus? What are the consequences?
- 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.
How can we diagnose Toxoplasmosis?
How do we manage Toxoplasmosis infection in prgenancy?
- 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
What is Cytomegalovirus and how common is congenital infection?
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
How does the risk of congenital CMV infection vary over trimesters?
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
How does CMV infection present in pregnancy?
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
What are features of congenital CMV?
The features of congenital CMV are:
- Fetal growth restriction
- Microcephaly
- Hearing loss
- Vision loss
- Learning disability
- Seizures
87% asymptomatic or subclinical infection
How can we diagnose CMV infection in pregnancy?
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
How do we manage CMV infection during and after pregnancy?
- 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.
What percentage of women are susceptible to HPV B19 infection during pregnancy?
50% of women at childbearing age are immune to PVB19 infection and, therefore, 50% are susceptible to infection during pregnancy.
how do we classify significant exposure to PVB19?
15 min in the same room, or face-to-face contact with someone that has the virus
How can we diagnose PV B19?
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.
What are the consequences of PVB19 infection on neonates? What are the chances of transmission PVB19?
- 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
How can we manage PVB19 infection?
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%.
How can we investigate suspected rubella infection in pregnancy?
What are the implications for the neonate in congenital rubella? When are the consequences likely to be serious?
- 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.
How do we manage rubella?
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.
Describe the aetiology of listeria infection.
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.
How does listeria infection present in the mother?
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).
How would listeria present in the fetus?
- 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.
How can we diagnose listeria infection during pregnancy?
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.
What are the consequences of listeria infection during pregnancy?
- 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.
How should we manage Listeria infection during pregnancy?
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.
What are the implications of HSV infection in a neonate?
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.
What are the implications of HSV infection in the mother?
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.
How can we prevent herpes infection during pregnancy?
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
How should we manage HSV infection in pregnancy?
- 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.
What is the management of neonatal herpes?
- Early recognition and treatment of neonatal HSV infection are important to reduce the mortality and the incidence of serious neurological sequelae in surviving children.
- Delivery should have swabs taken for viral culture from the eyes, oropharynx and any mucocutaneous lesions
- 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.
Where is Group B Streptococcus usually found commensally?
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.
What is early onset GBS disease?
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
What causes GBS disease? What increases the risk?
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.
What is the incidence of early onset GBS disease?
The incidence of early onset GBS disease in the UK and Ireland has significantly increased to 0.57/1000 births in 2015
Why do we not screen for GBS antenatally?
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.
Who can screening for GBS be offered to?
- 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.
How do we manage GBS in the intrapartum period?
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
What is the neonatal management of maternal GBS?
- 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
What are concerning neonatal signs? How does early and late onset GBS present?
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.
How do we diagnose Hep A infection in pregnancy?
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.
How should we manage Hepatitis A infection in pregnancy?
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.
How do we diagnose Hep B?
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.
What are the implications of Hep B infection for the mother and neonate?
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.
How do we manage Hepatitis B infection in pregnancy?
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)
How do we diagnose Hep C infection?
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.
What are the implications of Hep C infection?
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.
How do we manage Hepatitis C infection in pregnancy?
• 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).
How do we manage Hepatitis C infection in pregnancy?
• 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).
