Obstetric Infections Flashcards
Impact of CMV on neonate?
-hearing loss
-vision loss
-small head size(
-cerebral palsy
-developmental delay or intellectual disability
-death(very rare)
Prevalence of CMV?
50% population infected by adolescence ,
85% population infected by age 40.
Remains alive but dormant.
Peaks at age 2 or in adolescence.
Reactivated in pregnancy.
What is the mode of Transmission of CMV?
Human saliva, nasal mucosa, urine, vaginal secretions, semen, breastmilk of infected person.
Very small chance it crosses placenta barrier, higher if primary infection in pregnancy.
When do we test for CMV antenatally?
- Not routine
- Test antenatally if high exposure to children or if early onset IUGR or fever of unknown origin.
- Test newborn if mother positive or baby fails newborn hearing tests.
What’s the Impact of Rubella on neonate?
• Deafness (60/75%)
• CNS dysfunction- intellectual disability, developmental delay, microcephaly(10-25%)
• Opthalmological abnormalities- cataracts, retinopathy, glaucoma(10-25%)
• Cardiac defects
• Growth restriction
• Haematological abnormality
• GI tract abnormalities
• Pneumonitis
• Osteitis
What is the rate of Transmission of Rubella?
Rate of transmission of Congenital Rubella Syndrome is determined by timing of maternal infection.
@1-12 weeks = 80% infection rate, 85% congenital defects rate
@13-16 weeks = 54% infection, 35% congenital defects(CD)
@17-22 weeks = 36% infection, rare CD
@23-30 weeks = 30%infection, rare CD
@31-36 weeks = 60% infection, rare CD
@>36 weeks = 100% infection, rare CD
Management of Rubella in pregnancy?
•20ml IM injection of Non-Human Immunoglobulin within 72hrs of rubella exposure may modify disease symptoms in Mother and marginally reduce infection rate in fetus, but risk is not eliminated.
•Post- Exposure- check IgG and IgM Titre 7-10 days post exposure or onset of rash (whichever is known first). If both positive or negative, repeat in 2-3 weeks to confirm. At that stage, if IgM positive, or IgG rising, infection confirmed. Counsel re; risk of transmission, consider options of continuing pregnancy.
Screening for Rubella?
•Pre-pregnancy- check rubella IgG titre, if <15, re-immunise then wait 28 days before attempting conception.
•Antenatal- if negative titre or <10 immunise post-partum, if <15, consider re-immunisation post-partum.
•Exposure- check IgG and IgM Titre 7-10 days post exposure or onset of rash (whichever is known first). If both positive or negative, repeat in 2-3 weeks to confirm. At that stage, if IgM positive, infection confirmed. Counsel re; risk of transmission, consider options of continuing pregnancy.
•Neonate- If at risk- examine for CRS symptoms, check IgG and IgM titre in parallel with mother, check urine PCR, culture urine, throat swabs, tears.
Management of Rubella infected neonate?
• infective for 12 months from birth.
• isolate while in hospital (droplet and contact precautions)
• breastfeeding is not contraindicated
• ensure hearing, opthamology and cardiac assessments at birth.
• ensure 3-6 monthly follow on assessments for first few years of life to detect late manifestations.
What is the rate of transmission of CMV from Mother to Baby?
CMV = most common congenital infection, affects 0.2-2% of live births
If maternal infection in first trimester= 30-40% risk of congenital infection.
If maternal infection in 2nd or 3rd trimester= <20%
Of infected fetuses, 30% will develop congenital infective symptoms, and of those 1% will end up with neurological sequelae.
What is the impact of HIV on the neonate with MTCT?
**Note- Neonate may be asymptomatic in first few months of life.
- Susceptible to opportunistic infections- eg Pneumocystis jirovechi pneumonia, Candida oesophagitis, etc
- Low birth weight and failure to thrive/ growth delay.
- Recurrent bacteremia.
- Frequent diarrhoea
- Cardiomyopathy
- Hepatitis
- Hepatitis/ Hepatomegaly
- Generalised lymphadenopathy
- Splenomegaly
- Cancers
- CNS manifestations- growth delay, delayed cognition, low IQ, global developmental delay.
- Life long HIV complications including progression to AIDS and ART drug resistance.
What is the Rate of MTCT of HIV?
Mother not on ART:
• Antenatal= 25% risk of vertical Mother to Child Transmission.
•Intrapartum=
• Breastfed = 12-14% risk of MTCT.
Mother on ART or alternative:
• Antenatal= 2% risk of vertical Mother to Child Transmission.
• Intrapartum=
• Breastfed = <1% risk of MTCT.
What is the mode of MTCT of HIV?
- Antenatally- trancystosis across placenta, increased rate with infections/inflammation in pregnancy.
- Intrapartum- Fetal exposure to maternal cervicovaginal secretions and blood, increased risk with prolonged ROM >4hrs, or prematurity of neonate.
- Postnatal- breast feeding, HIV RNA in breastmilk and colostrum, invades neonate through intestines and tonsils.
How is HIV detected in the neonate?
• Requires qualitative or quantitative HIV RNA assay or DNA PCR assays (nucleic acid tests)- sensitive up to 30-50% at birth and 100% at 4-6 months, with 100% specificity at birth.
***Routine methods of antigen/antibody testing is inaccurate due to presence of maternal antibodies upto 18 months.
• Confirm negative if 2x negative tests at 1 month and before 6 months, with normal to high CD4 count and no clinical symptoms.
• If breastfed by HIV mother, retest infant every 3 months, then post-breastfeeding recheck at 4-6 weeks, 3 months and finally 6 months.
What is the management of HIV infected neonate?
• MDT approach- ID, Perinatologist, Paediatrician, Neonatologist, Obstetrician, HIV Pharmacist, Nursing staff.
• Immediate(within 6 hrs of birth) commencement of neonatal dose antiretroviral therapy ART.
** Decreases morbidity and mortality by 80-90%. Including opportunistic infections and rate of progression to AIDS.
