Perinatal infection Flashcards
An IVDU is 16/40 pregnant and has positive Hep C serology. How do you proceed?
Counsel, manage
Counsel:
Viral infection, blood borne from needle sharing or sexual contact
Easy to treat but not in pregnancy (Category X)
Vertical transmission 5% if RNA +ve - neonatal risk of cirrhosis, liver ca if untreated
Only risk to pregnancy is earlier onset cholestasis
Manage:
MDT - gastro, ID, psych/A&D, obs, paeds
Screen for substance use
Condoms, contact tracing
Viral RNA, LFTs,coags
Extended STI screen - syphilis, HIV
Liver USS
Not for treatment in pregnancy - teratogenic
Delivery - aim vaginal delivery, avoid FBS, FSE, difficult instrumental
Breastfeed okay if nipples not cracked or bleeding, not with meds
Neonatal - bathe before IM vit K, IgG not recommended, no vaccine
Ensure PN referral to gastro for treatment ( >90% cure rate) + contraception
Healthcare workers universal precautions
You are referred a patient who is 20weeks pregnant and has been exposed to chickenpox <96h ago. How do you proceed?
- Assess immunity - prior infection, IgM and IgG if uncertain
- Ascertain significance of exposure
- VZIG if<96h (up to 10days)
- Prophylaxis with valaciclovir if high risk
- Return advice re rash, vesicles, respiratory symptoms
If develops infection:
* Counsel re maternal risks - varicella pneumonia, encephalitis, hepatitis
* Counsel re fetal risks - if <28weeks 1% risk fetal VZS (scarring, eye defects, limb abnormalities, neurological). If >28weeks very low risk. If at term delay delivery 5-7days if possible for passive antibody transferrence
- See in isolation away from other pregnant women and neonates
- Respiratory assessment
- Aciclovior PO, IV if unwell
- USS 5weeks after infection then serial
- Consider MRI
- Consider amniocentesis and PCR
A patient is not immune to Rubella and develops a rash and viral illness consistent with this. How do you proceed?
Counsel, manage, birth
Counsel:
* Maternal risks - lymphadenoapthy, viral infection
* Fetal risks - 80% infection in first trimester, risk of IUGR, cardiac disease, neurological abnormality, cataracts, hearing loss. Third trimester high risk of infection, low risk of concern
Manage:
* Symptomatic control, isolation 7days
* MFM
* Amniocentesis >5weeks post infection (prefer not CVS as contamination risk)
* Detailed anatomy USS
* Offer TOP
At birth:
* Ensure care providers are vaccinated
* Serology, PCR (urine and throat)
* Screen - hearing, sight, cardiac
* Aware infectious for 12m
* Breastfeeding okay
A French patient who runs a cattery has suspected toxoplasmosis at 15 weeks. How do you proceed?
Assess, counsel, manage, birth
Assess:
- Exposure
- Symptoms
- Immunity via IgM, IgG and avidity, IgA
Counsel:
- 1st trim lower risk fetal infection, higher severity. 2nd trim intermediate risk. 3rd trim higher risk fetal infection, low risk complication
- Miscarriage, PTB, IUGR, chorioretinitis, hearing and sight impairment, learning difficulties
Manage:
- MDM - MFM, high risk obs, infectious diseases, neonatal
- Detailed USS, consider fetal MRI
- Amniocentesis for toxoplasmosis gondii PCR >18weeks and >5weeks post infection
- spiramycin to prevent vertical transmission, no placental transferance
- pyrimethamine, sulfadiazine and folinic acid after 1st trimester if infection suspected, and always after 18weeks
- offer TOP
Birth:
- neonatal Ig screen, cultures blood and CSF
- send placenta for PCR
- clinical review
- treat if infection
A patient’s booking bloods show HepBsAg positive. How do you proceed?
Assess:
* Symptoms
* Screen for other blood borne virus
* HepB DNA
* HepE status
* LFTs, coags, USS liver
* Other family members status - screen, treat, vaccinate
Counsel:
* Treatable in pregnancy
* Low risk placental transmission, highest risk at birth
* Risk of maternal cirrhosis, hepatocellular ca, fetal chronic carrier and cirrhosis
Manage:
* MDT - high risk obs, infectious diseases, gastroenterology, paeds
* Treat with Tenofovir if viral load >200,000 after 24 - 28weeks
* HepB DNA, LFT and coags surveillance
* Avoid invasive procedures if possible
Birth:
* Universal infection prevention
* Aim VB
* Avoid FSE, FBS, difficult instrumentals
* Wash before IM vitamin K
* Neonatal - IgGs and vaccination
* Breastfeeding safe (even if on tenofovir!)
* Contraception
* VTE prophylaxis
* Follow up, complete treatment 6weeks
You see a patient with anatomy scan showing echogenic bowel and you suspect CMV infection. How do you proceed?
Assess:
* Symptoms - timing of illness
* Exposure risks - young children, daycare
* Previous infection
* IgG and IgM - primary vs reinfection
Counsel:
* Risk of vertical transmission increases with gestational age but severity/sequalae decreases with gestational age.
* 30-40% in 1st trimester
* Risks 10-20% longterm sequalae - hepatosplenomegaly, hepatitis, hydrops, IUGR sensorineural hearing loss, learning disability
* Outcome is difficult to predict - may still have sequelae even if asymptomatic in pregnancy
Manage:
* MFM, infectious diseases, neonatal
* Amniocentesis - PCR >6weeks post infection and >20weeks gestation
* Detailed anatomy USS then serial
* Fetal MRI
* Offer TOP if affected, knowing difficult to predict severity of sequelae.
* Consider maternal Immunoglobulins
* Maternal oral valaciclovir if periconception/1st trimester infeciton.
Birth:
* Aim VB
* Breastfeeding support
* Contraception
* Neonate - serology, secretions PCR
* Neonatal valganciclovir
* Neonatal follow up - neurodevelopmental, hearing, opthalmology
* Caution that neonate will secrete for up to 12months
* Future prevention - No sharing of food, drinks utensils used by children < 3years, avoid inserting dummies into mouth, hand hygiene
when in touch with young child’s bodily fluids.
HIV
Periconceptual
Antenatal
Delivery
Postnatal
Periconceptual:
* Counsel risks - no effect on diseae progression. Transmission lowest <1% if on HAART (safe), low viral load, CS birth, not breastfeeding. Up to 50% if no intervention and mixedfeeding. Also GDM (meds), PTB, IUGR.
* Baseline viral load, CD4 count
* Screen for other infections, in particular Hep C
* HAART
* Fertility - assess partner status if unknwon (ELISA thenWestern Blot). If partner -ve give them PrEP, time condomless sex pre-ovulation or IUI, IVF.
* Check smear - needs annual
* Vaccines - pneumococcus and meningococcal
Antenatal:
* MDT - high risk obs, ID, neonates anaesthetics, social work
* Continue HAART
* Viral load and CD4 count - monthly until undetectable, then each trimester and 36weeks
* Aneuploidy screen - CFTS +/- NIPT and avoid invasive testing
* Growth USS surveillance
* OGTT
* MMH screening
Delivery:
* ElCS lowest transmission risk (aim intact membranes). Consider VB if undetectable viral load, on HAART.
* If VB - Zidovudine if viral load >50. Keep membranes intact if possible. Augment if SROM. Avoid FBS, FSE, difficult instrumental.
* Ensure universal precautions adhered to + eye protection - PEP if needlestick
* Delayed cord clamping acceptable
* Active 3rd stage
Postnatal:
* Neonatal examination
* Skin clean prior to IM vitamin K, heelp pricks etc
* HAART prophylaxis
* Neonatal HIV PCR surveillance
* Breastfeeding - best to avoid, offer dostinex. If do, msut be exclusive. Mixed feeding carries highest risk.
* Contraception - LARC to reduce menstrual loss, condoms recommended in addition
* VTE prophylaxis
* MMH screening
You see a 34week pregnant lady with fevers and shortness of breath in the middle of influenza season. How do you proceed?
Assess, counsel, manage
Assess:
* Symptoms
* Risk factors for illness progression - high BMI, asthma, 3rd trimester
* Immunity ?vaccine
* ABCs
* Bloods - FBC, CRP, renal, LFTs, coags, ABG, blood cultures
* Nasophyaryngeal PCR - H1N1, RSV, COVID-19
* Sputum culture if able
* Imaging - CXR, CTPA if concern for PE
* Consider Ddx and screenc accordingly e.g. PE, sepsis
Counsel:
* Pregnancy more likely to be hospitalised, ICU admission, ventilation, mortality
* Risk of sPTB, fetal hypoxia, neonatal infection if born in infectious period
Manage:
* Admit - consider HDU/ICU
* Assess in isolation
* Oxygen, respiratory support if respiratory fatigue
* IVFs
* IDUC, fluid balance
* Cooling cares
* Analgesia
* Tamiflu if within 48hours, consider ABx of superimposed bacterial infection
* VTE prophylaxis
* CTG BD - NB may have transient abnormalities in response to maternal condition, usually resolves once maternal condition does
* Consider corticosteroids
* Delivery if needed for maternal ventilation improvement or fetla compromise
* Follow up antenatal care - growth USS, clinic review
You see a patient at booking who has a painless vulval ulcer. You suspect syphilis which is confirmed on swab via dark ground microscopy. How do you proceed?
Assess, counsel, manage
Assess:
* Extent of impact of ulcer
* Stage - primary (ulcer/chancre) secondary (fever, rash, lymphadenopathy), latent, tertiary (CVS, neurological, gummas).
* Extended STI screen
* RPR
Counsel:
* It is a systemic infection that has different phases. Primary syphilis can given you a non painful ulcer called a chancre, secondary syphilis you can be unwell with fevers and lymphadenopathy and teritary syphilis can affect your brain and heart.
* Fetal infection risk highest after 20weeks, early stage disease
* Miscarriage, PTB, IUGR, hepatosplenomegaly, hydrops, placentomegaly, moth eaten bones, stillbirth
* 1-2% risk congenital syphilis even if treated
Manage:
* MDT - high risk obs, MFM, ID
* Notfiable diseaes
* Contact tracing and testing (where safe and possible)
* Treatment with Penicillin G 2.4millioniU IM
* Repeat dose in 1 week if >28weeks
* Give 3x doses, week apart if late latent
* Desensitise if allergic
* Admit due to risk of Jarisch Herscheimer reaction - fevers, tachycardia, PTB, reduced FMs
* RPR monitoring - day of treatment then monthly. 4x fold reduction = response
* Detailed fetal anatomy scan
* Vaginal birth okay
* Send placenta for histolgoy
* Paeds review at birth, neonatal IgM RPR compare to mother
You see a patient at 34weeks with a painful vulval ulcer. You suspect primary HSV. How do you proceed?
Assess:
* Viral PCR
* Serology ?primary vs recurrent
* Ability to PU - post void baldder scan as risk urinary retention
Counsel:
* HSV is a sexually transmitted infection. It does not necesarily suggest unfaithfulness as the virus may lay dormant in nerve roots. It is a lifelong disease with flares on occasion e.g. immune suppressed, times of stress.
* Risks of severe maternal infection - misacrriage, hepatitis, encephalitis
* Risks of fetal/neonatal infection - superficial lesions, CNS involvement, encephalitis and mortality
* Transmission risk is largest intrpartum, depends on disease state and lesion presence
* Primary <6weeks = highest risk 50%
* Secondary, lesions present = 1-3%
* Secondary, lesions absent = <1% (still present as risk of asymptomatic shedding)
Manage:
* Treatment with valaciclovoir 1g BD then prophylaxis 500gm BD from 36weeks
* Analgesia - lignocaine gel, sitz baths
* Ensure can PU - pee in bath, may need IDUC
* Mode of delivery depends on above
* Primary <6weeks = CS recommended as no seroconversion yet
* Secondary, lesions present = offer CS
* Secondary, lesions absent = okay for VB. Need careful speculum on admission
* Best to avoid FBS, FSE, difficult instrumentals
* Still likely benefit of CS if membranes not intact
* If lesions and having VB - IV valaciclovior
* Paeds review at birth, neonatal swabs and valaciclovir if concerns
* Breastfeeding okay if no lesions on nipple
* Hand hygiene, educate parents on HSV
Choroid plexus cysts
Causes:
* Usually not associated with anything else if small and isolated
* Strong association with trisomy 18
Assess:
* Detailed anatomy scan
Counsel:
* If not other concerning features no long term complications
Manage:
* Amnio only if other abnormalities
