OB: PERINATAL INFECTIONS

Question 1

Elements of torch syndrome

Answer 1

TORCH syndrome comprises hemolytic anemia, thrombocytopenia, hepatosplenomegaly, and brain calcifications. The hemolytic anemia results in extramedullary hematopoiesis (specifically of the liver and spleen), leading to hepatosplenomegaly and neonatal jaundice.

Question 2

What leads to torch syndrome?

Answer 2

The infections that cause TORCH syndrome are those in the original mnemonic—Toxoplasmosis, Other (early syphilis), Rubella, Cytomegalovirus, and Herpes simplex virus. TORCH syndrome are extremely rare.
INFECTION BELOW 20 WGA

Question 3

When is a fetus at risk for TORCH?

Answer 3

hey are so rare because, to develop TORCH syndrome, the mother must become exposed and infected for the first time during pregnancy, before 20 weeks’ gestation.

Question 4

What is the most common outcome of TORCH syndrome?

Answer 4

the most common outcome is stillbirth or spontaneous abortion.

Question 5

What other viruses aside from the TORCH infections can have significant impact on developing fetus?

Answer 5

parvovirus B19, varicella-zoster virus, Zika virus, hepatitis B, HIV, and late syphilis, which led to a new mnemonic TORCHeS (ignore this because not all of these lead to TORCH syndrome)

Question 6

__________________ is caused by the protozoon Toxoplasma gondii, which is transmitted through cat feces, contact with oocysts in soil, or undercooked meat that contains cysts.

Answer 6

Toxoplasmosis

Question 7

What brain changes do you see in toxoplasmosis?

Answer 7

Brain toxoplasmosis in the fetus includes intracranial calcifications, ventriculomegaly on TVUS, and ring-enhancing lesions on MRI

Question 8

Avoid cat litter and undercooked meats to avoid exposure.

Answer 8

Toxoplasmosis

Question 9

Maternal infection is treated with spiramycin to reduce transplacental spread to the fetus. Fetal infections (confirmed with PCR on the amniotic fluid) are treated with pyrimethamine and sulfadiazine.

Answer 9

Toxoplasmosis

Question 10

Blueberry looking mf’er

Answer 10

TORCH

Question 11

What happens if mom has syphilis and it isn’t treated?

Answer 11

If mom is infected with syphilis (or there is secondary syphilis) in the first trimester, the fetus will likely not survive, presenting as a dead and macerated fetus. If the fetus doesn’t die, and the gestation is at less than 20 weeks, the fetus will present with TORCH syndrome.
Unique to congenital syphilis,there will also be bony deformities, such as saddle nose, saber shins, Hutchinson’s teeth, deafness, and mucopurulent nasal discharge, termed snuffles.

Question 12

What are the elements of congenital syphilis?

Answer 12

Unique to congenital syphilis,there will also be bony deformities, such as saddle nose, saber shins, Hutchinson’s teeth, deafness, and mucopurulent nasal discharge, termed snuffles.

Question 13

How do we treat syphilis in pregnancy?

Answer 13

penicillin even if mom is allergic

Question 14

The distinguishing characteristics of this infection are deafness, cataracts, and cardiac septal defects,in addition to the typical TORCH syndrome.

Answer 14

Rubella.

Once mom and fetus are infected, there is no treatment. As with most congenital infections that cause birth defects, there aren’t usually fetal symptoms after 20 weeks’ gestation, but stillbirth, spontaneous abortion, or TORCH syndrome are possible before 20 weeks.

Question 15

How is rubella transmitted?

Answer 15

Respiratory droplets

Question 16

How is CMV transmitted?

Answer 16

CMV is transmitted in all body fluids and is ubiquitous in the environment.

Question 17

The unique feature in addition to TORCH syndrome is periventricular calcifications (cerebral ventricles, not cardiac).

Answer 17

CMV

TORCH syndrome or spontaneous abortion if before 20 weeks, no impact if after 20 weeks. The unique feature in addition to TORCH syndrome is periventricular calcifications (cerebral ventricles, not cardiac).

Question 18

Why is herpes a concern in pregnancy?

Answer 18

If the cervix, vagina, or vulva demonstrates any active lesions, the physical contact made by the passing fetus will essentially guarantee widespread infection—wherever the fetus touches a lesion, that region of skin (or eyes, mouth, throat) will be infected with HSV. This is definitely not a transplacental infection that results in TORCH syndrome. Instead, this is a preventable cause of HSV neonatal meningitis, neonatal pneumonia, and neonatal viremia (notice it is neonatal, not fetal).

Question 19

If a woman has ever had herpes, how to we approach managment?

Answer 19

If a woman has ever had a genital HSV infection, she is placed on acyclovir starting at week 36 to prophylax against a potential outbreak. If there are active lesions at delivery, a cesarean delivery is required to avoid fetal exposure.If vaginally delivered, start intravenous acyclovir for the neonate.

Question 20

If HSV is a concern for neonatal meningitis and such, why is HSV in the TORCH mnemonic?

Answer 20

So, why is HSV in the TORCH mnemonic? Because primary HSV causes TORCH syndrome.With all herpesviruses, there is primary viremia—virus in the blood—but only on the first infection (a woman never exposed is then exposed while pregnant). This allows HSV to cross the placenta and wreak havoc on the fetus—TORCH syndrome or miscarriage if infected before 20 weeks’ gestational age.

reactivation involves virus in the neurons and skin, but NOT in the blood. Thus only primary viremia with HSV can cause TORCH syndrome

Question 21

How can you ID HSV lesions?

Answer 21

The virus in one neuron reactivates every so often, presenting with cutaneous symptoms—vesicles on an erythematous baseconfined to one dermatome.

Question 22

True or False: reativation of HSV can cause TORCH

Answer 22

false, only primary infection can cause TORCH

Question 23

periventricular calcifications

Answer 23

CMV

Question 24

intracranial calcifications, ventriculomegaly

Answer 24

toxo

Question 25

True or False: VZV can lead to TORCH syndrome.

Answer 25

FALSE! VZV does not lead to TORCH syndrome.

Question 26

What is fetal risk with VZV?

Answer 26

The fetal risk is congenital varicella syndrome—long-bone deformities, limb hypoplasia, and cicatricial skin reactions (see right). As with the TORCH infections, fetuses exposed after 20 weeks’ gestation seem to be mostly unaffected. In the first trimester, infection often leads to spontaneous abortion. Between weeks 13 and 20, congenital varicella syndrome is possible, although only 2% of symptomatic mothers transmit the virus to the fetus. There is no treatment other than VZIG, and there is a vaccine

Question 27

teratogenic mosquito-borne illness

Answer 27

ZIKA

Question 28

Where do you avoid travelling if you want to avoid ZIKA?

Answer 28

South America (especially Brazil), India, and the Caribbean islands

Question 29

What are our concerns for Hep B and a fetus?

Answer 29

We are NOT concerned for congenital defects but we are concerned for vertical transmission and being a chronic carrier leading to cirrhosis and HCC later in life.

Question 30

How do we know if someone has a current HEP B infection?

Answer 30

The presence of IgM but not IgG is a marker of current infection.

The presence of core and surface antigens is a sign of chronic (or recent) infection, whereas the presence of infectious antigen is a marker of infectivity.

Question 31

How do we know if someone has a recent or chronic infection?

Answer 31

The presence of core and surface antigens is a sign of chronic (or recent) infection, whereas the presence of infectious antigen is a marker of infectivity.

Question 32

What do we test for in women with a Hep B surface antigen thats positive in prenatal visits?

Answer 32

hep B cAg (core antigen), hep B eAg (infectious antigen), and anti-hep B antibodies.

Question 33

How can a fetus get HIV from a positive mom?

Answer 33

Therefore, we want you to learn that there is no transplacental infection and that infection comes from the mixing of maternal and fetal blood.

Question 34

What are the indications for carT therapy and mode of delivery for an HIV positive mother?

Answer 34

Patients diagnosed with HIV should be started on a pregnancy-safe regimen of combination antiretroviral therapy (cART). Near the time of delivery, if the viral load is > 1,000 copies/mL, both an early cesarean delivery and intrapartum intravenous zidovudine are indicated. If the viral load is < 1,000 copies/mL, a vaginal deliveryis safe. Intrapartum IV zidovudine is not needed if the mother’s viral load is undetectable (< 50 copies/mL). Between 50 and 999 copies/mL, IV zidovudine is not required but is still acceptable to give.

Question 35

causes fifth disease in children and may cause peripheral arthropathy and a reticular rash in immunocompetent adults

Answer 35

parvo B19

Question 36

Congential infection with Parvo B19 can result in…

Answer 36

When congenital infection results from acute maternal infection during pregnancy, outcomes vary significantly, ranging from spontaneous resolution with no long-term sequelae to aplastic anemia with severe hydrops fetalis and stillbirth.

Question 37

What titers can tell us if there is an active parvo B19 infection?

Answer 37

Negative IgM and positive IgG titers indicate immunity, whereas a positive IgM titer is concerning for recent infection.

Question 38

How do we treat cystitis and asymptomatic bacturia in pregnant women?

Answer 38

Amoxicillin is first-line for cystitis (urinary tract infection) and asymptomatic bacteriuria in pregnancy, and nitrofurantoin is considered a close second (used in penicillin-allergic women). For pyelonephritis,the first line is intravenousceftriaxone.

Question 39

When do we give prophylaxis for GBS?

Answer 39

prophylactic penicillin G is given during delivery, whether cesarean or vaginal.

Question 40

When do we screen for GBS?

Answer 40

36 weeks