Mod 3-4 Flashcards
After 36 weeks, Rx this abx instead of Macrobid for UTI
Keflex
17 OHCP (Makenna) for PTL is given between ___ - ____ weeks
16-36
not recommended to prevent PTL
bed rest
progesterone PO or IM is only recommended for _____ pregnancies
singleton
abx for intraamniotic infection
gentamycin + ampicillin
population at higher risk for ASB
women w/ sickle cell or sickle cell train
if nitrites are in urine, bacteria is very likely:
e.coli
leukocytes in urine mean the body is:
fighting infection
for women with AS Hemoglobin, check _____ every trimester
urine culture
with pPROM, do NOT:
check cervix
Ffn is indicated during weeks ___-___
24-34
fetal fibronectin is present < ___ weeks and >____ weeks
< 20 weeks; > 37 weeks
both of these are used to predict PTL and used between 24-34 weeks
Partosure and Ffn
cervical length < 15 mm =
high risk for PTB
cervical length 15-29 cm =
intermediate risk for PTB
cervical length >30 mm =
PTB unlikely
ASB is most common in ______ women with _______
Black women w/ sickle cell trait
Risk Factors for \_\_\_\_\_\_\_\_\_\_\_\_: Multiparity GDM sickle cell trait urinary tract congenital anomaly hx recurrent UTI low SES
UTI in Pregnancy
routine screening at ______ weeks gestation is recommended for ASB
12-16
gold standard test for ASB
urine culture
single organism of > _______ cfus /mL is diagnostic for ASB
100,000
pyeolonephritis can occur w/ bacterial counts as low as _________
20,000-50,000
culture urine every trimester for these populations
GDM + sickle cell trait
management for recurrent ASB
Nitrofurantoin 100 mg qHS x 21 days
Abx that concentrates only in urinary tract and causes minimal resistance in Gram(-) organisms
BUT may cause acute pulmonary reaction (rarely) that dissipates on its withdrawal
Nitrofurantoin
Can be caused by chlamydia (culture would be negative)
cystitis
May develop w/o antecedent covert bacteriuria
cystitis
Risk Factors for \_\_\_\_\_\_\_\_\_: Lower socioeconomic status Obesity urinary catheterization Immunosuppression diabetes sickle cell anemia neurogenic bladder Hx before pregnancy of recurrent or persistent UTI UTI associated w/ increased risk of pyelo, PTB, LBW, perinatal mortality Preeclampsia (Especially in 3rd trim)
cystitis
typical sx of \_\_\_\_\_\_\_\_: Typical: Dysuria, Urgency, Frequency Pyuria and Bacteriuria usually found Microscopic or frank hematuria possible Nocturia Suprapubic pain **Frequency and urgency not reliable indicators of UTI
cystitis
If there is a lower UTI with pyuria accompanied by a sterile urine culture - it may be from:
urethritis from chlamydia
treat urethritis from chlamydia with:
azithromycin
cystitis treatments are __-day treatments (90% effective)
3
Treatment for \_\_\_\_\_\_\_\_\_: Amoxicillin 500mg TID Ampicillin 250mg QID Cephalosporin 250mg QID Ciprofloxacin 250mg BID Levofloxacin 200 or 500mg daily Nitrofurantoin 50-100mg QID or 100mg BID TMP/SMZ 160/800mg BID
cystitis
rashes are most common with these diseases
zika, rubella, toxoplasmosis
caused by significant bacteriuria in presence of systemic symptoms
pyelonephritis
pathogens that cause \_\_\_\_\_\_\_\_: E. Coli Klebsiella Enterobacter Proteus gram(+) organisms: GBS or Staph aureus
pyelonephritis
pyelo is most common in ___ trimester
2nd
Risk Factors for \_\_\_\_\_\_\_\_\_\_\_: Nullip Young age Lower socioeconomic status Obesity urinary catheterization
pyelonephritis
Leading cause of septic shock in pregnancy
pyelonephritis
Complications of \_\_\_\_\_\_\_\_\_\_\_: maternal and fetal morbidity maternal sepsis acute renal failure acute respiratory distress PTB LBW FGR C/S
pyelonephritis
Sx of ____________:
Fever
CVA tenderness - unilateral or bilateral
Significant bacteriuria
Flank pain unilateral and right-sided more than half the time
Fever and shaking chills w/ abrupt onset
Aching pain in one or both lumbar regions
Other - chills, myalgia, anorexia, nausea, vomiting, low back pain
Anorexia, nausea, and vomiting may worsen dehydration
Look sick/acutely ill
pyelonephritis
Diagnostics for __________:
Urine sample for dip and culture ***preferred by cath
Many leukocytes, frequently in clumps
Numerous bacteria
Dipstick - nitrites, WBC casts
Blood culture if temp >39, limited clinical utility
Bacteremia - 15-20% of cases
Plasma creatinine - monitor acute kidney injury
pyelonephritis
NitrAtes are _______ in urine
NitrItes are ________ in urine
Nitrates=normal
Nitrites=abnormal, mean infection
__________/_________ to physcian is indicated for pyelonephritis
co-management/referral
Β-agonist tocolysis increases risk X4!! for respiratory insufficiency from pulmonary edema in:
pyelonephritis
Endotoxin-induced hemolysis leading to transient anemia is common in:
pyelonephritis
Management of ___________:
Hospitalize
Obtain urine and possibly blood cultures
Labs: CBC w/ diff, serum creatinine, electrolytes
Repeat in 48 hours
Creatinine also important if giving nephrotoxic drugs
Frequent vitals
Cooling blanket and Tylenol for fevers
Monitor urine output - consider catheter – UO >/=50mL/hr w/ IV fluids
IV antibiotics - change to PO when afebrile
IV- amp & gent, cefazolin or ceftriaxone, or extended-spectrum
Chest x-ray w/ dyspnea or tachypnea
Discharge when afebrile 24 hrs - consider antimicrobial therapy for 7-10 days
Repeat urine culture 1-2 wks after antimicrobial therapy completed
Outpatient tx may be an option w/ carefully selected pts up to 24 wks
No clinical improvement in 72 hrs and persistent fevers - consider/eval for urinary tract obstruction or other complications
Recurrence 30-40% - may need suppressive therapy for rest of pregnancy
pyelonephritis
Labs for ____________:
CBC w/ diff, serum creatinine, electrolytes
Repeat in 48 hours
pyelonephritis
~50% of those that give birth prematurely do not have an identified _________
risk factor
Risk Factors for \_\_\_\_\_\_\_\_\_\_\_: ---Maternal Factors Age<17 and >35 African-American ethnicity Genetic variants Low prepregnancy body weight BMI<19.8 Low socioeconomic status Short interpregnancy interval <18 months Stress - depression, anxiety, PTSD Smoking in pregnancy Substance abuse - cocaine, crack, heroin, tobacco ---Fetal factors Congenital anomalies Fetal growth restriction Infection Isoimmunization w/ hydrops Maternal medical and reproductive history Previous preterm birth - MOST SIGNIFICANT RISK FACTOR Prior cervical surgery - cone, D&C Mullerian tract abnormalities Short cervical length measured on TVUS ---Current pregnancy factors Cervical insufficiency - short cervix Infections during pregnancy Intrauterine infection Polyhydramnios Multifetal gestation Maternal disorders - PIH, HELLP, placenta previa Pyelonephritis Vaginal bleeding during more than one trimester
PTL
There is conflictin evidence that these are risk factors for \_\_\_\_\_\_\_\_\_\_\_: Asymptomatic bacteriuria lower UTIs genital tract infections periodontal disease vaginal bleeding
PTL
Differential Dx for \_\_\_\_\_\_\_\_\_: Many! Physiologic changes of pregnancy and normal discomforts like backache and pelvic pressure Braxton hicks ctx Dehydration Lax vaginal tone Round ligament pain Infection Abruption Trauma Appendicitis, cholecystitis, pyelonephritis
PTL
Detected in cervicovaginal secretions in those w/normal pregnancies w/intact membranes before 20 weeks and at term
Reflects stromal remodeling of the cervix before labor
Fetal fibronectin
fFN is abnormal between ___-___ weeks
** could mean inflammation/uterine activity
24-34
screening ___________ patients for fFN does not improve outcomes
asymptomatic
Even when used w/ TVUS cervical length universal screening for _____ has poor predictive value
fFN
In symptomatic patients, fFN has ______ positive predictive value, _____ negative predictive value
poor positive predictive value
better negative predictive value
best predicts who will NOT give birth w/in the next 7-14 days
fFN
______ screening for cervical length is not affected by obesity, cervix position, or shadowing from fetal presenting part
TVUS
TVUS is __________ as routine screening for PTL]
**SMFM - screening for women w/ prior PTB
ACOG - only says to “consider screening”
NOT indicated
Suggested to be done along with fFN for symptomatic women
TVUS
TVUS in symptomatic patients: if cervix < ___ mm - send fFN
29
Not a good predictor of PTL alone to guide treatment - use in combo with other things
TVUS
perform TVUS if cervix < ___ cm dilated
2
perform TVUS if cervix __-__ cm dilated with no change in 30-60 min
2-3
if TVUS shows cervical length is intermediate (16-29 mm) but fFN is negative, midwife should:
send patient home
considered ineffective strategies for dealing with PTL
IV hydration and Bedrest
indicated for women with hx of PTB
17-OHP-C weekly IM injections
17-OHP-C weekly IM injections is recommended over __________
vaginal progesterone
17-OHP-C not evidence-based for __________ gestations
multiple
when patient is taking progesterone for hx of PTL and cervical length ___ or less mm, midwife should:
refer to OB
current singleton pregnancy with prior singleton PTB, give 17 OHP-C starting at __ weeks until ___ weeks, **regardless of cervical length
16-24
history of PTB– start checking _________ at 16 weeks
cervical length
with NO history of PTB, ____________ progesterone works just as well as cerclage
vaginal
tocolytics generally not recommended after _____ weeks
33
tocolytics not recommended in women with _____ because it does not improve neonatal outcomes
PPROM
limit use of tocolytics to ____ hours to allow for corticosteroid administration
48
do not use tocolytics beyond ___ weeks even to allow for corticosteroids
34
medications that have best clinical efficacy as tocolytics with lower incidence of toxicity and maternal S/E
Procardia (nifedipine)
Indocin (indomethacin)
no longer recommended for acute tocolysis
terbutaline
tocolytic that should be reserved for clinical situation where nifedipine and indomethacin are contraindicated or fetal/newborn neuroprotection is the goal
Mag Sulfate
tocolytics are risk for pulmonary edema and are ineffective in ____________
multiple gestations
Contraindications for \_\_\_\_\_\_\_\_\_\_\_\_: ruptured membranes nonreassuring fetal status intraamniotic infection preeclampsia IUFD lethal fetal anomaly maternal bleeding w/ hemodynamic instability chorio
Tocolytics
give for fetal lung maturation prior to 34 weeks (consider up to 36.6 weeks)
corticosteroids (bethamethasone and dexamethasone)
give 12 mg IM q24 hours x2
bethamethasone
give 6 mg IM q12 hours x4
dexamethasone
give one course of corticosteroids when risk of PTB in ___ days if patient is less than ____ weeks
7; 34
If no previous course of corticosteroids, midwife may consider one course if imminent risk at less than _____ weeks
36.6
may repeat corticosteroid course when previous course was given ___ days earlier and at risk of PTB at < ____ weeks
7; 34
Do we give regularly scheduled repeat course of corticosteroids?
No
fetal adverse effects of \_\_\_\_\_\_\_\_\_\_\_\_: ***if taken longer than 48 hours: oligohydramnios in utero constriction of ductus arteriosus necrotizing enterocolitis in premies patent ductus arteriosus in NB
Indomethacin (Indocin (NSAID)
maternal adverse effects of \_\_\_\_\_\_\_\_\_\_: pulmonary edema cardiac dysrythmia myocardial ischemia SOB chest pain hyperglycemia hypokalemia palpitations hypotension tachycardia tremor
terbutaline (beta blocker)
use Mag Sulfate in patients ____-_____ weeks
24-34 weeks
avoid use of Mag Sulfate with _________
calcium channel blockers (Nifedipine/Procardia)
Mag Sulfate can leach ________ out of mom and baby which leads to fractures
calcium
less than ___% of women w/ clinical PTL go on to give birth within 7 days
10
Current suggested guidelines to diagnose \_\_\_\_\_: >/=6 ctx/hr Cervical dilation >3cm 80% effaced ROM Bleeding
PTL
MOA:
binds to β-2 adrenergic receptors → chain rxn → decreased intracellular calcium → myometrial receptors blocked
*receptors can become desensitized w/prolonged use → decreased effectiveness
beta blockers
terbutaline
ritodrine
MOA:
Directly blocks calcium ion influx through cell membrane and release of intracellular calcium from the sarcoplasmic reticulum → inhibited myometrial contraction
calcium channel blocker (Nifedipine)
MOA:
COX inhibitor reduces prostaglandin production by cost
NSAIDs Indomethacin
probably competes w/ calcium at cell membrane which reduces calcium available for myometrial ctx
Mag Sulfate
fetal adverse effects of __________:
Tachycardia
neonatal hypoglycemia
beta blockers (terb)
Contraindications for __________:
tachycardia sensitive cardiac disease
poorly controlled HTN and/or
diabetes
beta blockers (terb)
terbutaline may cause PP _________
hemmorrhage
BBW: Not for tocolysis for >72 hours d/t maternal cardiac complications; PO NOT recommended due to lack of proven effectiveness
terbutaline
ACOG says this can be used for short term inpatient us but it no longer recommended for acute tocolysis
terbutaline
maternal adverse effects of \_\_\_\_\_\_\_\_\_\_: peripheral vasodilator transient nausea flushing headache palpitations hypotension dizziness tachycardia
calcium channel blockers (Nifedipine)
fetal adverse side effects are secondary to maternal hypotension for this medicatio
calcium channel blockers (Nifedipine)
Contraindications of \_\_\_\_\_\_\_\_\_\_\_\_: preload-dependent cardiac disorder left ventricular dysfunction CHF hemodynamic instability
Calcium Channel Blockers
Do not use concurrently w/ terbutaline or mag sulfate
calcium channel blockers (Nifedipine)
maternal adverse effects of ____________:
nausea, vomiting, reflux, gastritis, platelet dysfunction
NSAIDs (Indomethacin)
Contraindications of \_\_\_\_\_\_\_\_\_\_\_\_: platelet dysfunction bleeding diathesis, hepatic dysfxn GI ulcerative disease, asthma if sensitive to aspirin
NSAIDs (Indomethacin)
- Not reccommended for more than 48 hrs of continuous use
* Not reccommended for >/=32 wks
NSAIDs (Indomethacin)
maternal adverse effects of \_\_\_\_\_\_\_\_\_\_\_: flushing nausea blurred vision headache lethargy muscle weakness hypotension ~~ Rarely: pulm edema, resp or cardiac arrest
Mag Sulfate
fetal effects of ____________:
neuroprotective
↓FHR variability
↓neonatal tone
Mag Sulfate
Contraindications of ____________:
impaired renal function
myasthenia gravis
cardiac conduction defects
Mag Sulfate
Do not use concurrently w/ nifedipine
Mag Sulfate
Toxicity - loss of ________ reflexes, UO < ____ mL/hr, resp rate < __/min
patellar; 30; 12
toxicity of Mag increases w/ serum creatinine > ___mg/dL
1.0
possible risks of \_\_\_\_\_\_\_\_\_\_\_: Neonatal hypoglycemia Adverse effects on neurodevelopment Increased cerebral palsy incidence Late gestation (>34 weeks) - higher neonatal and perinatal mortality in the overall population w/ increased use of steroids. potential adverse effects on neurodevelopmental outcomes found in animal studies showing a reduction in brain growth at later gestations
Corticosteroids
avoid calcium channel blockers in _________ disease
liver
calcium channel blockers can cause ____ tension
hypo
Maternal risks of ___________:
Intraamniotic infection (15-25%)
Postpartum infection ( 15-20%)
Abruptio placentae complications (2-5%)
PPROM
Fetal Risks of \_\_\_\_\_\_\_\_\_\_: Respiratory distress- most common Sepsis Intraventricular hemorrhage Necrotizing enterocolitis With intrauterine inflammation- increase risk of neurodevelopmental impairment
PPROM
treatment options for PPROM @ < 24 weeks
expectant management or IOL
may be considered as early as 20.0 weeks in PPROM
antibiotics
these treatments are not recommended in PPROM if pregnancy is not viable
Mag Sulfate for fetal neuroprotection, corticosteroids, tocolysis or GBS prophylaxis
treatment for PPROM @ 24.0-33.6 weeks
expectant management
recommended treatment to prolong latency with PPROM (if no contraindications)
antibiotics
treatments for __________:
Antibiotics
Single course corticosteroids
GBS prophylaxis as indicated
PPROM 24.0-36.6 weeks
Estimated that ___-___ % of term deliveries are complicated by a clinically apparent intraamniotic infection. Increases after 40 weeks completed gestation
2-5
Risk Factors for \_\_\_\_\_\_\_\_\_: Prolonged ROM Long labors Manipulative vaginal or intrauterine procedures Frequent Cervical exams Dehydration
Intra-Amniotic Infection
Categories of __________:
Isolated Maternal Fever
Suspected
Confirmed
Intra-Amniotic Infection
category of intra-amniotic infection based on clinical criteria which include maternal intrapartum fever, and one or more of the following maternal leukocytosis, purulent cervical drainage, or fetal tachycardia.
suspected
category of Intra-Amniotic Infection based on a positive amniotic fluid test result (gram stain, glucose level, or culture results consistent with infection) or placental pathology demonstrating histologic evidence of placental infection or inflammation
confirmed
category of Intra-Amniotic Infection either a single oral temp of 39 C or greater, or an oral temperature of 38 - 38.9 C that persists then the temperature is repeated after 30 min.
isolated maternal fever
diagnosis of _______________________ is made
- when maternal temperature is greater than or equal to 39.0 C OR
- when maternal temp is 28- 28.9 C and one additional clinical risk factor is present.
suspected intraamniotic infection
Maternal complications of \_\_\_\_\_\_\_\_\_\_\_\_: Maternal morbidity Dysfunctional labor (requiring increased intervention) PP uterine atony with hemorrhage Endometritis Peritonitis Sepsis ARDS Rarely death
intraamniotic infection
Neonatal complications of \_\_\_\_\_\_\_\_\_\_\_\_: Neonatal pneumonia Meningitis Sepsis Death
intraamniotic infection
Administration of __________ antibiotics is recommended whenever an intraamniotic infection is suspected or confirmed
intrapartum
intraamniotic infection is rarely an indication for:
C section
maternal temp elevation greater than 38 C (100.4 F) in women who use epidural analgesia during labor. Occurs in a subset of laboring women after epidural administration and is noninfectious in origin
epidural fever
epidural fever will not improve if given _________
Tylenol
epidural fever will somewhat improve if given ______________ but will impact chorio
corticosteroids
polymicrobial clinical syndrome resulting from replacement of the normal hydrogen peroxide producing Lactobacillus sp. in the vagina with high concentrations of anaerobic bacteria (e.g., Prevotella sp. and Mobiluncus sp.), G. vaginalis, Ureaplasma, Mycoplasma, and numerous fastidious or uncultivated anaerobes.
Bacterial Vaginosis
Sx of ___________:
Vaginal irritation and itching
Dyspareunia
Gray or white discharge
Fishy odor that is often most noticeable after vaginal penetration during sexual activity
75% are asymptomatic
Speculum–appears thin white/gray homogenous discharge + irritated vaginal mucosa and introitus and possibly cervicitis
Bacterial Vaginosis
Diff Diagnosis for ____________:
Vulvovaginal candidiasis
Bacterial Vaginosis
Diagnostics for ____________:
- Gram stain with use of Nugent scoring system is the gold standard for diagnosis (rarely available)
- Saline and KOH slides to determine pH
- Whiff test
Bacterial Vaginosis
Components of _____________:
- Presenece of a thin homogenous discharge that adheres to vaginal walls
- Presence of clue cells on the normal saline prepared slide
- pH of the vainga or vaginal dischare is 4.5 or higher
- Positive Whiff test which signals the release of an amine fishy odor when vaginal discharge contacts alkaline KOH
Amsel’s Criteria
BV is diagnosed when 3 of the 4 ______________ are present
Amsel’s Criteria
BV is associated with an increase instance of _________
Preterm Birth
Preventions for ____________:
Routine probiotics especially Lactobacillus crispatus can be helpful in establishing a normal vaginal flora and reducing recurrence
Abstain from vaginal intercourse during treatment
Wash all objects before they touch the vagina
Use condoms
Bacterial Vaginosis
Approximately 50-80% of adults have this infection. It is the most common viral infection in newborns in the U.S. with approximately 30,000 new cases occurring each year.
Cytomegalovirus (CMV)
in the herpes virus family that shares a characteristic ability to establish lifelong latency. After initial infection, which may cause few symptoms, this virus becomes latent, residing in cells without causing detectable damage or illness.
Cytomegalovirus (CMV)
Transmission routes for ____________:
- direct contact with saliva or urine, especially from babies and young children - commonly found in daycares
- sexual contact
- breast milk to nursing infants
- transplanted organs and blood transfusions
Cytomegalovirus (CMV)
Sx of \_\_\_\_\_\_\_\_\_\_\_\_: Fever Sore throat Fatigue Swollen glands
Cytomegalovirus (CMV)
Occassionally, ______ can cause Epstein-Barr or Hepatitis
Cytomegalovirus (CMV)
Babies born with ____________ can have hearing loss (most common) brain, liver, spleen, lung, and growth problems
Cytomegalovirus (CMV)
Differential Dx for _______________:
Other human herpes virus
Other viral diseases complicating pregnancy
Cytomegalovirus (CMV)
Preferred testing for CMV in newborns:
saliva or urine
Testing for CMV in adults:
blood
For babies with signs of congenital CMV infection at birth, treatment with _______________ may improve hearing and developmental outcomes
antivirals–primarily valganciclovir
There is limited information on the effectiveness of ____________ to treat infants with hearing loss alone.
antivirals–primarily valganciclovir
the most common serologic test for measuring CMV antibodies (IgG + IgM)
ELISA
A positive test for CMV ______ indicates that a person was infected with CMV at some time during their life but does not indicate when a person was infected.
***only applies for persons ≥12 months of age when maternal antibodies are no longer present.
IgG
Measurement of CMV IgG in paired samples taken 1 - 3 months apart can be used to diagnose ________ infection
primary
seroconversion (1st sample IgG negative, 2nd sample IgG positive) for CMV is clear evidence for ________________ infection
RECENT primary
The presence of CMV _____ cannot be used by itself to diagnose primary CMV infection because it can also be present during secondary CMV infection
IgM
CMV IgM positive results in combination with low IgG avidity results are considered reliable evidence for _________ infection
primary
Following primary CMV infection, IgG antibodies have _____ binding strength (avidity) then over 2-4 months mature to _____ binding strength (avidity)
LOW then HIGH
standard laboratory test for diagnosing congenital CMV infection
polymerase chain reaction
(PCR) on saliva
_______ is usually collected and tested for confirmation after the CMV saliva PCR because most CMV seropositive mothers shed CMV virus in their breast milk which can cause a false-positive CMV result on saliva collected shortly after the baby has breastfed.
urine
collect a saliva sample from baby to test for CMV at least __ hour(s) after breastfeeding and within ____ weeks of birth
1 hour within 3 weeks of birth
testing of newborns for CMV is not routinely performed, though some states perform targeted CMV testing of newborns who fail the ___________
hearing screen
most CMV infections in pregnancy women are __________
asymptomatic
most newborns will not be infected by ________ (only 20% will)
CMV
Management of CMV in pregnancy if pregnant woman has CMV AND fetus has evidence of IUGR or anomaly
refer to OB
most maternal _____ infections do not result in fetal infection
CMV
the later the gestation, the _____ likely CMV is to affect infant
LESS
Prevention of ____________:
handwashing
avoid kissing
CMV infection
percentage of women colonized with GBS in pregnancy
25%
The rate of GBS in newborns are decreasing and is less than _____% per 1,000 newborns in term infants.
Associated mortality rate for GBS disease in a full term infant is ___-___%
0.5%
4 - 6%
Risk Factors for \_\_\_\_\_\_\_\_\_ transmission: African American Positive culture bacteriuria in pregnancy Previous infant with sepsis Previous chorioamnionitis PPROM ROM greater than 18 hours Maternal fever in labor Preterm birth/low birth weight
GBS
Maternal Sx of \_\_\_\_\_\_: Febrile mother Significant and persistent fetal tachycardia Odor to amniotic fluid Uterine tenderness (late sign)
GBS
Newborn Sx of \_\_\_\_\_\_\_: Fever Pallor and poor tone Respiratory distress Slow irregular pulse Difficulty feeding
GBS
Differential Dx for ___________:
Streptococcus B carrier state complicating pregnancy
Strep of the newborn due to streptococcus, Group B
GBS
Diagnositics for __________:
- culture at 35-37 weeks gestation
- Positive in urine culture during pregnancy
- Previous infant with GBS disease
- CBC
- Cultures at birth when there no GBS results are amnion/placenta, infants axilla, groin or ear fold
GBS
can be harmless or it can lead to infections such as UTI, pneumonia, or sepsis in mother
GBS infection
Sx of newborn ________:
- newborn sepsis
- pneumonia
- (less frequently) meningitis (more commonly seen in late-onset disease)
GBS infection
Reasons for __________ with GBS:
- IP fever greater than 100.4
- Positive GBS in preterm labor or PROM
- Signs of Chorioammnionitis
- Transfer of care or birth location due to symptoms
- GBS positive mom with abnormal FHR pattern
- Symptomatic infant
Referral
Preventitions for ________:
–Probiotic therapy with Lactobacilli during pregnancy:
Yogurt with live active cultures
Naturally fermented live culture foods such as Kombucha, kimchi, kefir
Culturelle tablets
–Herbal remedies such as:
Astragalus root tea, tincture or capsule to build immunity
Echinacea for 2-3 weeks only
Tea of lemon balm and oregano, 2-3 cuts daily
Raw garlic no more than 1 clove per weeks 2-3 weeks before birth
–Chlorhexidine vagina wash
–Waterbirth
GBS
Without immunization shortly after birth, as many as ___% of infants born to Hep B infected mother will become infected
90%
Transmission of _________:
Blood or Body Fluids
**Vertical transmission can occur during pregnancy
Hep B
Risk Factors for _________:
- Health care professionals
- Hemodialysis patients
- IV drug use
- Sexual contacts, multiple sex partners
- STIs
- Household contacts
- Employment in prison system or facility for developmentally delayed
- International travelers or immigrants from high-prevalence area
Hep B Infection
Sx of \_\_\_\_\_\_\_\_\_: Malaise and lethargy Fever and chills RUQ pain Jaundice Nausea and vomiting ***At least half of all initial are asymptomatic
Hep B Infection
Differential Dx for \_\_\_\_\_\_\_\_: Hepatitis A Hepatitis C Cholestasis of pregnancy Cholelithiasis
Hep B Infection
Diagnostics for __________:
screen in ALL pregnant women
Liver functions test - elevation in acute phase
HBsAg - detected 1-12 weeks postinfection
Hep B
HBsAg is detected __-__ weeks after infection
1-12
Positive HBsAg means:
current or chronic infection of Hep B
Positive HBsAB/ anti-HBs means:
Hep B immunity (after infection or vaccination)
Recovered after Hep B
Negative HBsAg means:
susceptibility to Hep B
Negative HBsAB/ anti-HBs means:
infection of Hep B
Postive HBcAb (hepatitis core antibody)/ anti-HBc means:
past or present infection of Hep B
chronic Hep B infection
Postive IgM Antibody to Hep B Core Antigen/ IgM anti-HBc means:
Acute Hep B infection
appears positive 6-14 weeks after Hep B infection and disappears with 6 months of acute disease
IgM Antibody to Hep B Core Antigen/ IgM anti-HBc
mothers and infants can have _______ or ________ Hep B infections
acute or chronic
Management of ______________:
-Adequate rest
-Herbs for immune support
Milk thistle tea
Dandelion tea tincture or capsule
Turmeric
Green tea
-Provide education on transmission
-Postpartum follow up for referral to GI
-Preterm birth is increased with hepatitis B infections!
-Refer to infectious disease and specialties
-Pediatric consultation when maternal infection present
Hep B Infections
_________ risk is increased with Hep B infections in pregnancy
Preterm birth
Prevention of ___________:
Administration of immunization series for at-risk uninfected women
Refrain from sharing household items such as toothbrushes and razors
Other family members should be tested and vaccinated if non-immune
Cover cuts and skin lesions
Use of condoms/ safe sex
Abstinence from alcohol consumption
Wash hands before eating and after toileting
Avoid contact with blood or body fluids
Avoid undercooked food in endemic areas
Hep B
Hepatitis anti-virals that can be given during pregnancy:
Hep A + Hep B (NOT Hep C!!!)
Breastfeeding is not contraindicated during _________ unless taking antiviral therapy
Hep B or Hep C infection
If screening HBsAg is POSITIVE, order these tests:
HBeAg (Hep B e-antigen)
HBV DNA concentration
ALT
If HBeAg is POSITIVE or…
HBV DNA concentration > 20,000 or…
ALT > 19
then midwife should:
refer to specialist immediately!
If HBeAg is NEGATIVE or…
HBV DNA concentration < 20,000 or…
ALT < 19
then midwife should:
refer to specialist after delivery
If HBsAg is NEGATIVE but patient is “at-risk”, the midwife should:
- consider vaccination during pregnancy
- repeat HBsAg at delivery
Transmission of _______:
Blood
Vertical transmission can occur during pregnancy
Hep C
Sx of \_\_\_\_\_\_\_\_\_\_\_\_: Malaise and lethargy Fever and Chills RUQ pain Jaundice Nausea and vomiting Asymptomatic
Hep C
Risk Factors for \_\_\_\_\_\_\_\_\_: -IV drug use - ever -Sexual contacts -HIV positive women -Hemodialysis patients -Blood or organ recipient before 1992 -Evidence of liver disease -Body tattoos non sterile -Ingestion of raw shellfish -International travel -Day care workers -Immigrants from: Asia Africa Pacific Islands Haiti Middle East Eastern Europe Central/South America Rural Mexico
Hep C
Diagnostics for \_\_\_\_\_\_\_\_: Screening for ALL pregnant patients (guidelines just changed) Liver function tests Antibody test ***If Positive, consider RNA test)
Hep C
Anti-HCV (Hep C Antibody) is reliable ___-___ weeks after initial infection
5-6
Management of _________:
Refer (to specialists) with acute disease
Collaborate for NB care
Consult with Peds prior to birth
Hep C Infection
Administer Hep Bantiviral therapy to pregnant women with high _________
viral loads
Prevention of \_\_\_\_\_\_\_\_\_\_\_: Refrain from sharing household items Cover cuts and skin lesions Use of condoms Emphasize abstinence from alcohol consumption Vaginal birth is recommended
Hep C Infection
RNA retrovirus (RNA virus that replicates via production of DNA that is inserted into the host cell genome)
HIV
Transmission of __________:
Breastfeeding - exposes infant to the virus
Infected blood and bodily secretions
Risk of acquisition is increased if woman has STDs such as herpes, gonorrhea, or genital ulcers
HIV
Early screening for _______ allows early diagnosis and administration of ARV medication which can decrease the incidence of perinatal transmission of
HIV
Sx of early stage \_\_\_\_\_\_\_\_\_: First stage- Acute retroviral syndrome (within the first few weeks after infection) Fever Malaise Skin rash Nausea Diarrhea Headache Sore throat Lymphadenopathy (similar to mono symptoms)
HIV
Sx of 2nd stage _______:
asymptomatic during a period of clinical latency can be up to 8 years or longer
HIV
Sx of 3rd stage \_\_\_\_\_\_\_\_: Fever Weight loss Diarrhea Cough Shortness of breath Opportunistic infections Intense illnesses and infections more severe than would be expected for age or health status
HIV
Active AIDS when CD4 cell count falls below ___ and symptoms of advanced infection appears
200
Sx of late stage \_\_\_\_\_\_: CD4 count < 200 Oral candidiasis Shingles Abnormal Pap tests and STIs More susceptible to cancer Opportunistic infections
HIV
Diagnostics for \_\_\_\_\_\_: Rapid test ELISA test Western blot test Antiretroviral ARV drug resistance testing
HIV
Refer pregnant woman with:
HIV infection
Greatest risk for vertical transmission of _____ is during birth
HIV
Can deliver vaginally if HIV viral load is < _____
1000
Prevention of \_\_\_\_\_\_\_: Abstinence or consistent condom use No sharing of needles Smoking cessation Do not breastfeed
HIV
causes 66% of all cervical cancers
HSV Types 16 and 18
causes 90% of genital warts
HSV Types 6 and 11
preferred HSV tests for persons who seek medical treatment for genital ulcers or other mucocutaneous lesions
cell culture and PCR
HSV PCR sensitivty declines as:
lesions dissipate
HSV treatment for positive pregnancy women should be started at ____ weeks
36
risk for HSV transmission is highest for infants whose mothers contract it in:
late pregnancy
newborns whose mothers acquired HSV late in pregnancy should receive:
acyclovir
pregnant person with high viral load can be considered for ______ therapy
HBIG
women who acquire HSV late in pregnancy should be co-managed with:
MFM + infectious dx specialist
asymptomatic viral shedding is more common with HSV Type __ and mostly happens during first ___ months after contraction
2; 12
HSV-2 increases risk of contracting:
HIV
listeriosis infections symptoms are often:
asymptomatic or nonspecific
Sx of \_\_\_\_\_\_\_\_\_: **often asymptomatic flu-like illness with fever myalgia, Backache headache often preceded by diarrhea or other gastrointestinal symptoms
Listeriosis
Diagnostics for _________:
Primarily by blood culture
Placental cultures should be obtained in the event of delivery
***Stool cultures should not be used
Listeriosis
can cause miscarriage, stillbirth, or preterm labor
Listeriosis
Fetal effects of ___________:
Fetal and neonatal infections can be severe, resulting in fetal loss, preterm labor, neonatal sepsis, meningitis, and death
Can cause lifelong health problems for the baby, including intellectual disability, paralysis, seizures, blindness, or problems with the brain, kidneys, or heart
Listeriosis
Antimicrobial regimen of choice is high-dose intravenous ampicillin (at least 6 g/day) X at least 14 days.Frequently, gentamicin is added to the treatment regimen because it has demonstrated synergism with ampicillin
Listeriosis
To prevent ________, women should avoid:
Hot dogs, lunch meats, cold cuts (when served chilled or at room temperature; heat to internal temperature of 74°C [165°F] or steaming hot)
Refrigerated pâté and meat spreads
Refrigerated smoked seafood
Raw (unpasteurized) milk
Unpasteurized soft cheeses such as feta, queso blanco, queso fresco, Brie, queso panela, Camembert, and blue-veined cheeses
Unwashed raw produce such as fruits and vegetables (when eating raw fruits and vegetables, skin should be washed thoroughly in running tap water, even if it will be peeled or cut)
Listeriosis
Parvovirus also known as:
Fifth Disease
Transmission of _________:
Respiratory droplets
Blood and blood-derived products
‘vertically’ from pregnant woman to fetus
Parvovirus
Sx of \_\_\_\_\_\_\_\_: The characteristic rash is often described as ‘slapped cheeks’ (Lacy red rash on the cheeks, legs, belly and neck) Arthralgia Arthritis Fever **Can be asymptomatic
Parvovirus
Diagnostics for _________:
Direct evidence of infection is obtained by detection of B19V-DNA using PCR
B19V specific IgM antibodies become detectable in serum 7–10 days after infection, sharply peak at 10–14 days, and then decline within 2 or 3 months.
IgG antibodies gradually increase from 14 days after infection and reach a plateau level after 4 weeks of gradual increase
Parvovirus
Both fetal cord blood and amniotic fluid samples are suitable for diagnosis of:
Parvovirus
Risk of fetal complications of ________ is believed greatest when infection occurs in the first 22 wks
Parvovirus
vertical transmission of _______ occurs 1–3 weeks after maternal infection, suggesting that fetal infection occurs during the maternal peak viral load
Parvovirus
Fetal effects of _________:
Fetal infection may resolve spontaneously without any sequelae, or lead to severe consequences such as
nonimmune hydrops fetalis (NIHF) due to severe fetal anemia, (highest frequency during 8–20 weeks of gestation)
thrombocytopenia,
hyperechogenic bowel,
myocarditis,
possibly central nervous system damage
encephalopathy,
cerebral migratory abnormalities
neonatal encephalitis
Intrauterine fetal demise (IUFD) (occurs mostly 20-24 weeks of gestation)
Parvovirus
a potent inhibitor of erythropoiesis
Parvovirus
if partner has been exposed to Zika, midwife should advise:
use condoms or abstinence
Midwifery Management of _________:
weekly ultrasounds
if hydrops/anemia develops, immediate referral
Parvovirus
Prevention of ___________:
Regular washing of hands with soap and hot water
Careful disposal of tissues or other items that carry bodily fluids
Covering your mouth when sneezing, coughing, etc.
Limited exposure to those who have Fifth disease
Parvovirus
Transmission of _______:
nasal secretions
Rubella
Rubella transmission peaks in:
late winter/Spring
Sx of \_\_\_\_\_\_\_\_\_\_: Fever Maculopapular rash, beginning on the face and spreading to the trunk and extremities Arthralgias Arthritis Head and neck lymphadenopathy Conjunctivitis May be asymptomatic or very mild symptoms
Rubella
Rubella infection in pregnant woman is:
very mild
Fetal effects of __________:
Congenital rubella syndrome- Worse the earlier in the pregnancy the exposure occurs
Eye defects- cataracts and congenital glaucoma
Congenital heart defects- patent ductus arteriosus and pulmonary artery stenosis
Sensorineural deafness- the most common single defect
Central nervous system defects- microcephaly, developmental delay, mental retardation, and meningoencephalitis
Pigmentary retinopathy
Neonatal purpura
Hepatosplenomegaly and jaundice
Radiolucent bone disease
Neonates born with congenital rubella may she the virus for many months and thus be a threat to other infants and susceptible adults who contact them
Extended syndrome- progressive panencephalitis and type 1 diabetes
Rubella
Management of __________:
Droplet precautions for 7 days after the onset of the rash
Referral is warranted due to the high risk in the fetus
Rubella
Prevention of ____________:
Vaccination- at least 1 month prior to pregnancy; do not give during pregnancy but can give postpartum even when breastfeeding
Prenatal serological screening for rubella is indicated for all pregnant women
Rubella
Sx of \_\_\_\_\_\_\_\_\_\_\_: Most Maternal infections are subclinical Fatigue Fever Headache Muscle pain Maculopapular rash Posterior cervical lymphadenopathy --If host is immunocompromised, reaction can be severe Encephalitis Retinochoroiditis Mass lesions
Toxoplasmosis
GBS screening: ____ - _____ weeks
36.0 - 37.6
Fetal effects of ___________:
Associated with severe neonatal infections
-Neonates usually have generalized disease:
Low birthweight
Hepatosplenomegaly
Jaundice
Anemia
Possibility of primary neurological disease with intracranial calcifications with hydrocephaly or microcephaly
Many develop chorioretinitis and exhibit learning disabilities
The classic triad (chorioretinitis, intracranial calcifications, and hydrocephalus) is often accompanied by convulsions
Toxoplasmosis
Toxoplasmosis Severity of fetal infection depends on gestational age at the time of maternal infection
Risks for fetal infection _________ with pregnancy duration
The severity of fetal infection is _________ in early pregnancy
increase; increased
False positives occur in presence of blood, or semen, alkaline antiseptics, or BV
Nitrazine
False negative with prolonged membrane rupture or minimal residual fluid
Nitrazine
