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RGU Exam 2 > Obstetric and Neonatal Infections > Flashcards

Obstetric and Neonatal Infections Flashcards

1
Q

Changes in immune system during pregnancy

A
  • General immunosuppression does not occur w/ pregnancy
  • Shift from TH1 to TH2 immunity

*TH2 stimulates B cells; inc. antibody production; dec. cytotoxic T cell response

  • Innate immunity maintained

*phagocytic activity; neutrophils, moncytes, dendritic cells

  • Inflammatory cytokines dec.; phagocytic cell recruitment and activity inc.
  • Effect of hormones

*low estradiol promotes CD4+ TH1 response and CMI

*high estradiol promotes CD4+ TH2 response and humoral immunity

*progesterone suppresses maternal immune response and alters TH1/TH2 ratio

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2
Q

Common infections during pregnancy

A
  • UTI

*cystitis; pyelonephritis more common

  • Salmonella infections

*incidence higher in pregnancy; no adverse effect on fetus

  • Listeriosis

*incidence higher in pregnancy; mild or asymptomatic in mother; severe consequences in infant

  • Candidiasis

*hormones favor growth of yeast

  • Malaria (plasmodium falciparum)

*increased susceptibility and severity (especially w/ 1st pregnancy)

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3
Q

Infections that are more severe during pregnancy

A
  • Influenza

*higher mortality during pandemics

  • Coccidioidomycosis

*some studies suggest inc. severity and dissemination during pregnancy; (not all studies confirm)

  • Varicella (chicken pox)

*inc. resk of preterm labor, pneumonia and encephalitis (not all studies confirm)

  • Herpes simplex virus

*inc. risk of dissemination and hepatitis w/ primary infection; more frequent genital herpes recurrences

  • Malaria

*P. falciparum- tropism for the placenta

  • Hepatitis E virus

*more severe illness during pregnancy

  • Increased severity tends to be in 3rd trimester
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4
Q

Pyelonephritis during pregnancy

A
  • 2-4% of pregnancies most often during 2nd trimester
  • Symptoms of cystitis plus flank pain, fever, rigors
  • Can cause septic shock and ARDS in pregnancy
  • May require hospitalization, IV antibiotics, monitoring for premature labor
  • Recurrent infections occur in 10-25% of pts
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5
Q

Pathogens assoc. UTIs

A
  • E. coli (~60% of cases)
  • Group B streptococci
  • Proteus mirabilis
  • Enterococci
  • Klebsiella pneumoniae
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6
Q

Chorioamnionitis

A
  • Infection of the placenta, amniotic fluid and fetal membranes
  • 1-2% of term deliveries; 5-10% of preterm deliveries

*high assoc. w/ preterm birth and preterm premature rupture of membranes

*the long the time after rupture of membrane, the higher the likelihood of colonization of the amniotic fluid

  • 96% of cases are ascending polymicrobial infection caused by normal vaginal flora

*most common pathogens: ureaplasma urealyticum, mycoplasma hominis, prevotella bivia, garnerella vaginalis, group b strept, E. coli

  • 4% of cases- spread from mother via blood

*listeria monocytogenes, haemophilus influenzae, streptococcus pneumoniae, salmonella typhi and group A streptococci

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7
Q

Chorioamnionitis Risk Factors

A
  • BV, STI or GBS colonization
  • Prolonged rupture of the membranes
  • Prolonged labor
  • Freq. vaginal exams during labor
  • Internal fetal monitoring
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8
Q

Chorioamnionitis Signs

A
  • Maternal fever

*>100.4

  • Maternal or fetal tachycardia
  • Uterine tenderness
  • Leukocytosis
  • Foul smelling amniotic fluid (uncommon)
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9
Q

Chorioamnionitis Diagnosis

A
  • Definitive diagnosis = culture of amniotic fluid
  • If bacteria remain limited to the amniotic fluid, maternal illness is unlikely
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10
Q

Chorioamnionitis Treatment

A
  • Induction of labor
  • Broad-spectrum antibiotics during labor

*cover gram+, gram -, aerobes and anaerobes

  • Antibiotics not needed after delivery unless mother remains febrile
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11
Q

Chorioamnionitis possible consequences

A
  • Puerperal (intrapartum) fever
  • Severe morbidity/mortality in mother assoc. w/:

*septic shock

*clostridium perfringens infection (myonecrosis or gas gangrene)

*postpartum endomyometritis w/ septic thrombophlebitis

*necrotizing fasciitis- necrosis of fascia and subcutaneous tissue (group A strep or polymicrobial)

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12
Q

Puerperal fever

A
  • Fever that lasts >24hrs within the 1st 10 days post delivery
  • Most common cause—> postpartum infection of the uterus (at placental site)

*endomyometritis

  • Contaminated amniotic fluid sets mother up for infection

*post c-section wound infection

*could involve infection of lacerations in cervix, vagina or perineum (wound infection)

  • Dissemination via blood or lymphatics:

*sepsis; peritonitis

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13
Q

Postpartum Endomyometritis Risk Factors

A
  • Same as chorioamnionitis

*prolonged labor and premature rupture of membranes

*BV, freq. vaginal exams, fetal monitoring

  • Cesarean, forceps or vacuum delivery
  • Manual removal of the placenta
  • Retained placental fragments of fetal membranes

*provide favorable environment for bacteria growth

  • Usually mixed infections

*anaerobes (bacteroides, prevotella, peptostreptococci)

*E. coli and GBS- major pathogens

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14
Q

Postpartum Endomyometritis Symptoms

A
  • Fever, uterine tenderness, tachycardia, purulent vaginal discharge
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15
Q

Postpartum Endomyometritis Treatment

A
  • Broad-spectrum antibiotics
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16
Q

Postpartum Endomyometritis possible consequences

A
  • Can develop into septic shock, pelvic thrombophlebitis, pelvic abscess

*thrombi form in pelvic veins as a result of pregnancy-induced hypercoagulability

17
Q

Neonatal infections acquired during passage down an infected birth canal

A
  • GBS, E.coli, Group A strep

*manifest w/ sepsis, pneumonia, meningitis

  • Enterococcus

*UTI, sepsis

  • Listeria monocytogenes

*sepsis, meningitis, diarrhea

  • NG and CT

*neonatal conjunctivitis (opthalmia neonatorum)

  • Herpes simplex virus

*neonatal herpes

  • Genital papillomavirus

*laryngeal warts in young children

  • Candida albicans

*oral thrush

18
Q

Neonatal Sepsis

A
  • Systemic illness w/ bacteremia that occurs in the 1st month of life

*often includes pneumonia and meningitis

*incidence = 1-5/1000 live births (more common in very low birth weight babies)

  • Mortality = 13-25%

*higher in premature infants

19
Q

Clinical manifestation of neonatal sepsis

A
  • Can be nonspecific, subtle
  • Temp. irregularity

*hypothermia more common than fever w/ bacterial sepsis

*fever more common w/ viral agents (HSV)

  • Lethargy, irritability
  • Cyanosis, mottling, pallor, petechiae, rashes, jaundice
  • Tachypnea, respiratory distress, apnea
  • Vomiting, diarrhea, abdominal distention
  • Hypoglycemia, hyperglycemia, metabolic acidosis
20
Q

Early onset sepsis

A
  • Occurs in 1st 5-7days of life
  • Multisystem illness; prominent respiratory symptoms

*chorioamnionitis can lead to aspiration of infected amniotic fluid, which may contribute to respiratory involvement

  • Sudden onset that can progress rapidly to septic shock and death
  • Most common organism- group B streptococcus
  • 2nd most common- gram (-) enterics, especially E.coli
  • Others- listeria monocytogenes, enterococci, anaerobes
21
Q

Late onset sepsis

A
  • Occurs >5 days of life
  • Nosocomial infection

*transmission from mother, health care worker in nursery

  • Bacteremia, sepsis and often meningitis

*less severe systemic and respiratory symptoms

  • Major pathogen- coagulase neg. Staphylococcus (S. epidermidis)
  • Others: gram (-) rods (pseudomonas, klebsiella, serratia, proteus), s. aureus, GBS, listeria monocytogenes
22
Q

Group B streptococcus

A
  • Streptococcus agalactiae; Beta-hemolytic
  • Normal flora of GI tract and GU tract

*vaginal carriage rates 15-40% (transient colonization ~2/3, chronic 1/3)

  • Transmission to neonate during birth

*35-70% transmission rate

*invasive disease uncommon in term infants; morbidity and mortality more common in preterm infants

  • Most common cause of neonatal sepsis in the US

*1-2 cases/1000 live births

23
Q

Maternal GBS infections

A
  • UTI
  • Chorioamnionitis
  • Septicemia
  • Endomyometritis
  • Postoperative wound infection after cesarean section
24
Q

GBS transmission infection to newborns risk factors

A
  • Preterm labor
  • Preterm rupture of membranes
  • Low birth weight
  • Prolonged rupture of membranes (>12hrs before delivery)
  • Maternal puerperal fever
  • History of previous infant w/ GBS

*history of GBS colonization

25
Q

Early onset GBS infection

A
  • 1-2% of colonized infants develop early onset GBS infection; 11-50% fatality

*preterm infants at higher risk of sepsis and death than full term infants

  • Symptoms within 1st 48hrs after birth
  • Respiratory distress and pneumonia
  • Septicemia—>shock
  • Meningits in 30%

*assoc. w/ GBS serotype III

  • ~equal representation of serotypes Ia-c, II and III
26
Q

Late onset GBS infection

A
  • 0.5-1.8/1000 live births
  • Mortality ~10%
  • Usually due to nosocomial infection in the nursery
  • Occurs after 1st week of life
  • Meningitis- 80-90% of cases

*most cases of late onset GBS infection are due to serotype III

*neurological sequelae in 15-30% of meningitis survivors

  • Sepsis and pneumonia also possible
27
Q

GBS screening/prophylaxis

A
  • Screen at 35-37wks gestation for vaginal and rectal colonization

*culture or PCR

  • Intrapartum antibiotics given to GBS carriers

*GBS isolated from urine (sign of heavy colonization)

*women w/ previous infant w/ GBS sepsis

*signs of chorioamnionitis

*rupture of membranes for >18hrs w/ unknown GBS infection

  • Prophylaxis prevents ~80% of GBS infections
  • Incidence of late onset disease is not decreased
28
Q

Neonatal Herpes

A
  • Primary genital herpes in mother—>inc. risk of sponataneous abortion, intrauterine growth retardation and preterm birth
  • Reactivation of infection- complications rare
29
Q

Neonatal Herpes Transmission

A
  • Transmission

*intrauterine- 5%

*peripartum- 85%

*postnatal- 10%

  • Risk of neonatal infection in mom w/ genital herpes actively shedding virus at the time of birth:

*primary infection = 30-45%

*recurrent infection = ~5-8%

  • Onset of symptoms typically b/w 4th and 10th day of life
30
Q

Neonatal Herpes Clinical Manifestations

A
  • Skin, eye and/or mouth infection
  • Disseminated disease involving numerous organs

*pneumonitis, hepatitis, cardiovascular involvement, meningoencephalitis

  • CNS disease (encephalitis)
31
Q

Neonatal Herpes Treatment

A
  • Active genital HSV infection at time of birth = cesarean section
  • Treatment = IV acyclovir

*disseminated disease can result in infant mortality or sequellae, even w/ treatment (microcephaly, mental retardation, seizures)

32
Q

Varicella Zoster virus infection prior to delivery

A
  • Maternal infection 5-21 days before delivery

*mild, self-limited infection in newborn

*maternal antibodies provide protection

  • Maternal infection 5 days before to 2 days after delivery

*transplacental transmission places newborn at risk for severe morbidity

*no transplacental transfer of maternal antibodies (requires at least 5 days after onset of rash in mother)

*25-30% mortality for newborn

*infant treated w/ varicella zoster immune globulin (VZIG)

33
Q

Varicella Zoster virus consequences for newborn

A
  • Possible outcomes in newborn following maternal primary infection near time of birth

*typical varicella (chicken pox)

*disseminated infection

*shingles-months or years after birth

  • Zoster during pregnancy- not assocl. w/ sequellae in fetus

*protected by maternal antibody

34
Q

Listeria monocytogenes infection during pregnancy

A
  • Maternal infection- usually mild influenza-like illness
  • Transmission to baby

*across placenta

*postnatal

  • Neonatal infection

*meningitis

35
Q

Hepatitis B virus during pregnancy

A
  • Course of acute HBV in mother no changed during pregnancy
  • Transmission can be prenatal, during delivery or postpartum

*transmission during delivery is most common

  • HBV immune globulin (HBIG) should be given to neonate of infected mother with 12hrs of birth; followed by HBV vaccine
36
Q

Transmission of HBV statistics

A
  • Risk of transmission = ~90% in mother w/ active infection (HBsAg and HBeAg pos.)
  • Risk of transmission = ~10-30% in inactive carrier (HBsAg and anti-HBe pos.)
  • Maternal infection in 1st trimester - 10% of neonates are seropositive
  • Maternal infection in 3rd trimester - 80-90% of neonates are infected
  • HBeAg in neonate - 85-90% likelihood of chronic infection in newborn
37
Q

Hepatitis C virus during pregnancy

A
  • Mother to baby transmission ~4-6% in HCV RNA+ mother

*co-infection with HIV increases risk of HCV transmission to baby

  • Transplacental trasnmission puts neonate at increased risk of acute HCV and probably chronic infection
  • No teratogenic syndromes assoc. w/ HCV

RGU Exam 2 (21 decks)

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