Maternal Infection and Sepsis Flashcards
How common is sepsis as a cause of maternal death?
Accounts for 10% of maternal deaths
What are some common viral infections that affect pregnant women?
Rubella, measles, influenza, chickenpox, CMV, parovirus, mumps, herpes simplex, HIV
How is rubella transmitted?
By direct contact or respiratory droplet contact
What are the symptoms of rubella?
Fever, rash, lymphadenopathy, polyarthritis
What can maternal rubella infections cause?
Miscarriage, stillbirth, birth defects
What is the triad of congenital rubella syndrome?
Cataract, deafness, cardiac abnormalities
Is rubella common?
No = MMR vaccine has made it rare
How does the stage of pregnancy affect the outcome of rubella?
<8-10 weeks = 90% risk of CRS/multiple defects
11-20 weeks = 10-20% risk of CRS/single defect
16-20 weeks = low chance of deafness
How is rubella diagnosed?
Detection of rubella specific IgG antibody
Blood IgM should be done within 10 days of exposure
What should be considered if there is rubella infection in the early stages of pregnancy?
Termination of pregnancy = high risk of severe birth defects
What is the treatment of rubella?
Supportive = rest, fluids, paracetamol, avoid contact with other pregnant women
What causes measles?
Paramyxovirus = highly contagious but non-teratogenic
What are the symptoms of measles?
Fever, white spots inside mouth, runny nose, cough, red eyes, red blotchy rash that begins on forehead
What are the complications associated with the high fever that can occur in measles?
IUGR, microcephaly, miscarriage, stillbirth, preterm birth
What is associated with a high mortality rate in measles?
High mortality rate if mother develops pneumonia or encephalitis
How is measles treated?
Supportive care
What causes chickenpox?
Varicella zoster virus = DNA virus of herpes family
How is chickenpox transmitted?
Mainly via droplets = primary infection rare during pregnancy
How are women with chickenpox during pregnancy managed?
Check immunity = offer varicella zoster Ig within 10 days of exposure
Avoid other pregnant women = infectious until lesions crust
What is the supportive treatment for chickenpox?
Aciclovir if 20+ weeks gestation = 800mg 5x daily for 7 days
How is severe chickenpox treated?
Admitted to hospital for IV aciclovir
What are the complications associated with severe chickenpox?
Hepatitis, encephalitis, pneumonia
How does gestation impact the outcome of chickenpox?
7-28 weeks = foetal varicella syndrome
4 weeks before delivery = neonatal chickenpox
7 days before delivery = neonatal chickenpox with septicaemia and increased mortality
What causes congenital varicella syndrome?
Transplacental infection with chickenpox during pregnancy
How is congenital varicella syndrome managed?
Referred to foetal medicine specialist = detailed US and foetal MRI
What are the features of congenital varicella syndrome?
Limb hypoplasia, psychomotor retardation, IUGR, chorioretinal scarring, cataracts, microencephaly, cutaneous scarring
What causes CMV?
Human herpes virus family = common cause of congenital infections (0.2-2.2%)
What is CMV the leading cause?
Leading non-genetic cause of sensorineural deafness
What are the foetal risks of CMV infection?
Miscarriage, stillbirth, IUGR, microcephaly, intracranial calcifications, hepatosplenomegaly, thrombocytopenia, chorioretinitis, mental retardation, deafness
What is the risk of congenital CMV infection?
30-40% after primary infection
1-2% after recurrent infection
30% if first trimester infection
47% if third trimester infection
How is congenital CMV diagnosed?
IgG positive in previously seronegative mother
IgM positive with low avidity index
How common are symptoms in congenital CMV?
13% symptomatic at birth
8-23% of asymptomatic go on to have hearing loss
How is CMV managed during pregnancy?
Detailed US every 2-4 weeks
Foetal brain MRI at 28-32 weeks
Foetal blood sample
How is an asymptomatic foetus for CMV managed?
Expectant management until delivery
How are foetuses symptomatic of CMV managed?
Consider in utero treatment
Expectant management until delivery or termination of pregnancy depending on severity
How are mothers with CMV treated?
Valacyclovir and hyper-Ig
What are some features of parovirus infection?
Maternal infection is usually self limited
Foetal infection occurs in 1/3 of cases following maternal infection
What is the characteristic symptom of parovirus?
Rash on face - gives “slapped cheek” appearance
What are the foetal complications of parovirus infection?
Aplastic anaemia, congenital heart failure, hydrops, foetal death
What gestation carries the highest risk of foetal loss due to parovirus infection?
Infections occurring <10 weeks gestation
How is parovirus diagnosed?
Detection of virus specific IgM
How is parovirus infection managed?
Avoid contact with children and pregnant women
Refer to foetal medicine specialist = serial US, foetal MCA doppler
How does parovirus serology guide management?
IgG+/IgM- = likely past infection, reassure
IgG+/IgM + = recent infection, US and MCA doppler, consider foetal sampling and delivery
IgG-/IgM- = no infection, counsel
When would you consider delivery for a parovirus infection?
If near term and hydrops or foetal anaemia are present
What causes mumps?
RNA virus = low incidence due to MMR vaccine
Does mumps tend to have an adverse effect on pregnancy?
No = non-teratogenic and has no ill effects on pregnancy
Can the live MMR vaccine be taken during pregnancy?
No
Does influenza infection affect the course of pregnancy?
No = course remains unaffected
Is the influenza vaccine contraindicated during pregnancy?
No = also safe to take when breastfeeding
What are some complications associated with influenza infection?
Virulent infection = miscarriage, preterm labour
1st trimester infection = no teratogenic effect
How is influenza treated?
Antivirals and monitor for complications
What is herpes simplex infection?
Genital tract infection due to HSV-2 = transmitted by sexual contact
What type of herpes simplex infection is associated with high risk of foetal infection?
Primary genital HSV infection
How is recurrent or primary HSV infection in 1st/2nd trimester treated?
Aciclovir 400mg 3x daily
Vaginal delivery
How is primary HSV in the third trimester treated?
Treat infection with antivirals
Recommend C-section
How common is vertical transmission of HIV?
About 14-25% = higher in premature birth and prolonged membrane rupture
What are the foetal risks associated with HIV?
IUGR, miscarriage, perinatal mortality
What other infections should be screened for if mother is HIV positive?
Other STIs, CMV, TB and toxoplasmosis
What is the initial management for HIV?
Partner notification and assess viral load/CD4+
HAART treatment and prophylactic antibiotics
What type of delivery is recommended for HIV positive mothers?
Elective C-section = reduces vertical transmission risk by 50%
Zidovudine infusion 4hrs prior to C-section
When may a vaginal delivery be considered in an HIV positive woman?
If viral load <50 and on HAART
How is Zika virus spread?
Primary infection happens through mosquito bite = no vaccine
What can Zika virus cause in pregnant woman?
Serious foetal birth defects
How does Zika virus present?
Majority have minimal symptoms
In those with significant symptoms, virus causes mild 2-7 days illness
What are the birth defects associated with Zika virus?
Microcephaly, brain defects, hearing/vision problems, limited ROM at joints, seizure/too much tone restricting body movement, swallowing abnormalities, developmental delay
What causes covid-19?
SARS-Cov-2 coronavirus
Where does covid-19 tend to effect?
Mostly a respiratory disease = mouth, nose and eyes are routes of infection
How is covid-19 transmitted?
Droplets = 5-10mcm size, spread about 1m
Aerosol = <5 mcm size, wide spread, can remain airborne for longer
Fomites (e.g mobile phones)
How does covid-19 impact pregnancy?
Pregnant women don’t seem to be at higher risk
No evidence of increased risk of severe disease, ITU admission or death
How common is vertical transmission of covid-19?
Rate of 2.5-4% = mode of birth doesn’t affect transmission risk
What is sepsis?
Life threatening organ dysfunction caused by body’s response to infection
What are the signs of sepsis?
Respiratory rate >22 and heart rate >100 High or low temperature = >38c or <35C Hypotension = systolic BP <90mmHg Cap refill >2s and oxygen saturation <94% on air Skin clamminess and rash/mottled skin Confusion or agitation
What may help the early recognition of sepsis?
Plotting clinical observations on a MOEWS chart
What is a red flag for sepsis?
Reduced or altered consciousness in a pregnant/postpartum woman
What is the treatment for sepsis?
Sepsis 6 = give high flow oxygen, measure hourly urine output, give IV antibiotics and fluids, take blood for cultures, check haemoglobin and lactate
How quickly should the sepsis 6 be delivered?
Within 1 hour
What causes toxoplasmosis?
Toxoplasmosis gondii = found in raw/uncooked meat or infected cat faeces
How can toxoplasmosis spread to the foetus?
Via transplacental transmission
What are the foetal complications of toxoplasmosis?
Hydrocephalus, chorioretinitis, cerebral calcifications, microcephaly, mental retardation
What is the treatment of toxoplasmosis?
Self limiting and doesn’t usually require treatment
Acute infection can be treated with spiramycin
What causes listeriosis?
Listeria monocytogenes = intracellular gram positive bacillus
Where is listeria monocytogenes found?
In soil and vegetation = infection causes by eating infected foods or through contact with infected miscarried animal products
What are the maternal symptoms the listeriosis?
Flu-like illness or like food poisoning = headache, diarrhoea, nausea, abdominal pain
What is the outcome of liseriosis?
Neonatal death due to septicaemia occurs in 10%
Overall perinatal mortality is 50%
What are the obstetric complications of listeriosis?
Late miscarriage, preterm labour, stillbirth
What is the treatment for listeriosis?
Ampicillin and gentamicin
Trimethoprim and sulfamethoxazole if penicillin allergy
How can listeriosis be prevented?
Pregnant women should avoid unpasteurised milk, soft cheese and refrigerated smoked seafood
What are some features of group B strep infections?
Safe most of the time
Can rarely cause sepsis, pneumonia or meningitis
When would you give penicillin for group B strep infection?
If positive swab or urine sample
Previous baby affected by group B strep
When would you add broad spectrum antibiotics to penicillin when treating group B strep infection?
If chorioamnitis or risk factors for complications present
What are the risk factors for complications from group B strep infection?
Preterm birth. prolonged rupture of membrane, raised temperature
How are mild UTI symptoms treated?
7 days of oral antibiotics
Respond to microbiology results as required
How are systemic UTI symptoms or sepsis treated?
Admit for IV antibiotics
Request microbiology and possibly US
