Perinatal infections Flashcards
CRITO Toxoplasmosis
Condition: a protozoan parasite which uses cats as hosts. Can infect humans through cat faeces, gardening, under cooked meat and unwashed fruit and vegetables.
Risks:
- ‘X’: low risk of fetal infection 1st trimester increase over time; high risk of fetal damage 1st trimester reducing over time.
- Miscarriage, chorioretinitis, hydrocephalus, intracranial calcifications, hydrops, death, CNS abnormalities.
- Mum: mild flu sx but usually asymptomatic.
Investigations:
- Maternal serology IgM and IgG; if IgM +ve, perform IgA, IgG avidity.
- Refer to MFM for:
- Amniocentesis toxo PCR (>4 weeks from infection or >16 weeks gestation)
- Fetal USS +/- MRI
Treatment:
- If amnio PCR +ve and/or abnormal USS:
- Offer TOP OR
- Tx with pyrimethamine, sulfadiazine and folinic acid. S/E: pancytopenia/bone marrow suppression. Monitor with weekly FBC.
- If amnio/USS -ve: maternal spiramycin
Ongoing management:
- Neonatal Ix:
- Toxo serology
- PCR: placenta, blood, CSF
- Placenta histo
- Cerebral USS +/- MRI
- Maternal IgG
- Neonatal review by: paeds, ophthalm, audiologist, neurologist.
- Tx congenital toxo: pyrimethamine, sulfadiazine, folinic acid.
CRITO CMV
Condition: DNA herpes virus easily spread through bodily secretions or vertically. Increased risk of transmission from children.
Risks:
- Maternal: mild viral illness
- Fetus (overall risk of long term sequelae 10-20%): hepatosplenomegaly, hepatitis, non-immune hydrops, SB, SNHL, CNS abnormalities.
- Risk of vertical transmission increases with gestational age but severity/sequalae decreases with gestational age.
Investigations:
- Maternal CMV IgM and IgG +/- IgG avidity.
- Refer to MFM
- Amniocentesis CMV PCR >6 weeks after infection / >20 weeks GA.
- Fetal USS +/- MRI
Treatment:
- Maternal oral valaciclovir if periconception/1st trimester infeciton.
- Option for TOP knowing difficult to predict severity of sequelae.
- ?Maternal CMV IG if amnio PCR +Ve
Ongoing management:
- Serial fetal USS +/- MRI to monitor progress.
- Neonatal investigations:
- Serology
- PCR secretions
- Fetal USS, MRI
- Review by paeds, ophthalm, audiologist, neurologist
- Neonatal valganciclovir
- Delay next pregnancy by 6 months.
CRITO Parvovirus B19
Condition: DNA virus that infects humans most commonly at school-age through respiratory droplets or vertical transmission. The virus destroys precursor blood cells leading to anaemia and low platelets in the fetus.
Risks:
- Maternal: viral illness, slapped-cheek and lacy rash, sore joints and transient aplasia.
- Fetus: miscarriage, anaemia, thrombocytopaenia, hydrops, stillbirth.
- SB after 20/40 <1% vs 10% before 20/40
- No congenital abnormalities
- 30% spont resolution
- 30% die without IUT
- 30% resolution after IUT
- 6% die despite IUT
Investigations:
- Maternal serology IgG, IgM; repeat in 2-4 weeks if equivocal or symptoms occur in susceptible women.
- Weekly MCA-PSV from 16/40. Stop after 30 weeks if normal.
- Refer to MFM if MCA-PSV >1.5 MoM or hydrops.
Treatment:
- Cordocentesis and IUT
- Deliver if hydropic and close to term.
Ongoing management:
- Paediatric specialist at delivery of hydropic baby.
- No risk to future pregnancies.
CRITO VZV
Condition: DNA herpes virus that is spread through respiratory droplets and contact with vesicle fluid. Causes chickenpox and reactivation causes shingles.
- Neonatal varicella: maternal infection <5 days before or 2 days after delivery.
Risks:
- Maternal: pneumonitis, maternal death (worse in 3rd trimester), hepatitis, encephalitis, haemorrhagic rash
- Fetal: congenital VZV (skin scars, chorioretinitis, partial limb reduction, mental retardation, hydronephrosis, poor sphincter control), IUGR, PTB, hydrops, fetal death, neonatal disseminated disease and death.
- FVS risk: 1% between 12-28 weeks; nil after 28 weeks.
Investigations:
- Maternal VZV serology IgG, IgM
Treatment:
- Exposure <96 hrs: ZIG
- Exposure >96 hrs: oral aciclovir prophylaxis if risk factors (third trimester, lung disease, immunocompromised, smoker)
- Chickenpox rash onset ≤24 hours: oral aciclovir.
- No aciclovir if >24 hours.
- Chickenpox rash with complications or high risk: IV aciclovir, admission, EmCS if fetal distress or maternal respiratory failure.
Ongoing management:
- Referral to MFM 5 weeks after infection.
- Tertiary anatomy USS +/- fetal MRI
- Amniocentesis varicella PCR if USS abnormal; good NPV only.
- Serial USS until delivery.
- Avoid delivery for at least 7 days after rash onset.
- Regional anaesthesia okay.
- Can breastfeed.
- Neonatal review.
- Neonatal ZIG if maternal chicken pox ≤ 7days before delivery to 28 days after delivery.
CRITO Rubella
Condition: German measles virus. Usually immunised.
Risks:
- Maternal risks: viral illness, rash, arthralgia, petechiae of soft palate.
- Fetal risks: hearing loss, eye, CNS, cardiac, bones, hepatosplenomegaly; IUGR; pneumonia, fetal loss.
- Transmission: highest in 1st trimester and 3rd trimester ‘U’ shaped.
- Damage: highest 1st trimester; none after 20 weeks.
Investigations:
- Maternal serology IgG and IgM; repeat 2 weeks later if positive or pt susceptible.
- Refer to MFM 6 weeks after infection.
- CVS or amniocentesis: rubella PCR, culture, fetal IgM.
Treatment:
- Offer TOP if first trimester infection.
- No treatment available.
Ongoing management:
- Neonatal investigations: rubella IgM, PCR and cultures of urine and throat.
- Can breastfeed
- Review by ophthalm, cardiac and audiologist if infected/sx.
CRITO HSV
Condition: HSV 1 and HSV 2, causes cold sores and genital herpes.
Risks:
- Maternal:
- Primary first episode: fever, severe herpetic rash of genitalia, pain and inability to urinate.
- Recurrent episodes with milder rash.
- Fetal:
- In-utero: rare <1% but serious. Miscarriage, IUGR, hydraencephaly, chorioretinitis, skin scarring, severe disseminated disease, pneumonitis.
- Neonatal: skin/mouth/eye lesions, seizures, disseminated, NND, CNS disease (spastic quadriplegia, sensory loss).
Investigations:
- HSV swab + HSV 1 and 2 IgG.
Treatment:
- Primary episode: valaciclovir 500 mg po BD for 7 days.
- Prevent recurrence: valaciclovir 500 mg po BD from 36 weeks
Ongoing management:
- Primary episode <6 weeks before delivery: deliver by CS, risk transmission 25-50%.
- Lesions at delivery and primary episode >6 weeks before delivery or recurrent herpes at delivery: offer CS but risk transmission 3% so could also have vaginal delivery with IV aciclovir.
- In all instances avoid FSE, FBS and instrumental delivery.
- Follow-up neonate:
- Perform investigations if symptomatic or high-risk and start IV aciclovir.
- Neonatal review.
CRITO Listeria
Condition: Listeria monocytogenes is a gram-positive rod bacteria usually transmitted to pregnant women through the consumption of contaminated foods e.g. chilled, pre-cooked meats/salads, uncooked pre-preared fruit and vegetables, unpasteurised cheese/dairy and soft cheeses. Can be transmitted transplacentally.
Risks:
- Maternal: 30% asymptomatic; fever, viral-like illness, diarrhoea, miscarriage
- Fetal: PTB, IUD (40-50% in 2nd and 3rd trimesters), neonatal sepsis, meningitis and NND.
Investigations:
- Peripheral blood cultures
- Genital tract swabs
- Specify looking for Listeria
Treatment:
- Amoxicillin 14 days
- Urgent delivery depending on severity of illness and gestation.
Ongoing management:
- Infectious diseases input
- No alteration to fetal monitoring.
CRITO Syphilis
Condition: a bacterial infection caused by Treponema pallidum. It is spread through sexual contact and can cause chancre (genital ulcers) and affect other organs e.g. CNS, cardiovascular, gummatous
Risks:
- Transmission risk to fetus:
- Primary: high
- Secondary: moderate
- Latent and tertiary: low
- Fetal: stillbirth, IUGR, PTB
- Neonatal: NND, CNS chorioretinitis, bone abnormalities, seizures, etc.
- Jarisch-Herzheimer reaction: acute febrile illness following treatment; can precipitate PTL and CTG abnormalities.
Investigations:
- Maternal VDRL or RPR (non-treponemal test) screening: if positive perform EIA and TPPA (treponemal tests).
- Chancre swab: darkfield microscopy
Treatment:
- <28/40: Benzathine penicillin 1.8g IM stat
- >28/40: Benzathine penicillin 1.8g IM stat on day 1 and day 8.
- Late syphilis: 3 doses day 1, 8 and 15.
Ongoing management:
- Refer to MFM and sexual health
- Contact tracing, full STI screening.
- Fetal USS: hepatomegaloy, placentomegaly, polyhydramios, ascites, MCA-PSV >1.5 MoM
- RPR titres monthly and immediately following birth.
- 4-fold decrease or becomes negative = successful tx.
- Inform paediatric/neonatal team at birth.
- Can breastfeed unless active lesion on breast.
- Examination, placenta histology, infant serology if congenital infection suspected.
CRITO COVID-19
Condition: coronavirus caused by SARS-Cov-2. Mainly respiratory illness causing fever, runny nose, cough, SOB, diarrhoea, loss of smell. ⅔ pregnant women asymptomatic.
Risks:
- Risk factors for severe disease: ethnic minority, BMI ≥30, HTN, T2DM, age ≥35, low SES, smoker
- Maternal: 5 x ICU, 22 x death, respiratory distress/pneumonia, stroke, MI, AKI, CNS
- VTE, PET/HELLP
- Fetal: IUGR, PTB, SB
Investigations:
- Nasopharyngeal swab
- Bloods: FBC, CRP, U&Es, LFTs, coags, G&S, blood gas, lactate.
- Urine: MSU, PCR
- CXR, CTPA or HRCT chest
- +/- ECG, troponin, ECHO
- +/- CT/MRI head or MRA cerebral
Treatment:
- Full PPE precautions.
- Supplemental oxygen, maintain sats ≥94%
- IVFs
- Steroids if oxygen requirement: dexamethasone IM if also needed for fetal lungs; otherwise prednisone PO.
- Remdesivir: mod-severe.
- Tocilizumab: anti-IL6
- No live vaccines in first year of life.
- VTE prophylaxis: clexane or SCDS
- +/- treat secondary bacteria infections.
- Consider ICU
Ongoing management:
- EmCS if respiratory deterioration.
- VTE prophylaxis
- Serial growth scans
- Serial CXR
- COVID vaccine: 4 weeks after recovery if no tocilizumab.
- PET surveillance
Labour with COVID-19
- Inform obstetric SMO, CMW, obstetric anaesthetist and OT
- Negative pressure room.
- Full PPE worn by staff.
- TEDS
- IVL, FBC, U&Es, LFTs, G&S
- MEOWS hourly
- Maintain oxygen >96%
- Analgesia: entonox, early epidural
- CEFM
Postpartum with COVID-19
- Mum wears surgical mask, good hand hygiene.
- Can breastfeed.
- VTE prophylaxis
- Contraception
COVID vaccine in pregnancy spiel
- Millions of pregnant women have already received vaccination.
- No evidence of miscarriage, teratogenicity, infertility.
- Safe during breastfeeding. Antibodies you develop can be passed to baby and help protect them.
- Why you should get it: pregnant women are 5 x more likely to require ICU admission and 22 x more likely to die.
- What’s in the vaccine: it is not a live vaccine. It contains mRNA to virus surface proteins that will teach your body how to recognise COVID-19.
- Normal expected S/Es: sore arm, headache, tiredness, fever
CRITO HIV
Condition: human immunodeficiency virus, spread through sexual intercourse, blood and vertical transmission (in-utero, maternal blood and bodily fluids at delivery, breast milk). Untreated infection leads to low CD-4 lymphocyte cells and the development of AIDS.
Risks:
- MTCT risk <1% if VL <50 copies/mL/undetectable.
- MTCT risk 20% if not BFing and not tx. 40% if BFing.
- Maternal: miscarriage, PET, GDM (HAART S/E)
- Fetal: PTB, IUGR, low BW.
Investigations:
- HIV ELISA screening followed by Western Blot test.
- HIV RNA viral load, CD4 lymphocyte count, HIV resistance testing
- FBC, LFTs, U&Es
- Full STI screening: syphilis, HepB/C, chlamydia, GBS
Treatment:
- Referral to HIV specialist, MFM and sexual health.
- HAART
- Contact tracing
Ongoing management:
- Bloods every month and at 36 weeks: viral load, CD4 count, LFTs, lactate.
- Avoid invasive procedures until undetectable viral load.
- Serial growth scans.
- Low viral load/HAART:
- No intrapartum zidovudine.
- Vaginal delivery
- Viral load >50:
- Intrapartum zidovudine
- CS delivery
- Breast feeding is contraindicated.
- Neonatal anti-retroviral prophylaxis
- Regular neonatal HIV testing
CRITO Hepatitis B
Condition: Hepatitis B is a viral infection spread by blood, sexual contact and at the time of delivery. Hepatitis B can cause liver cirrhosis and hepatocellular carcinoma.
Risks
- Fetal/neonatal: chronic hep B carrier with above risks.
Investigations:
- Hep B serology: HBsAg
- Additional Hep B testing: HBeAg, Anti-HBe, HBV DNA level
- LFTs +/- coags, liver USS
Treatment:
- Refer to hepatitis service.
- HBV DNA level 26-28 weeks.
- Tenofovir at 30-32 weeks if high viral load (>200,000), continue for 6 weeks postpartum.
Ongoing management:
- Avoid invasive procedures e.g. CVS, FBS, FSE, ventouse.
- Vaginal delivery
- HBIg passive immunisation at birth.
- Hep B vaccination 6 weeks, 3 months, 5 months.
- Can breastfeed.
- Neonate serology 9 months: HBsAg and AntiHBs
CRITO Hepatitis C
Condition: Hepatitis C is a virus where chronic infection leads to liver cirrhosis and hepatocellular carcinoma. It is transmitted through blood, sex and MTCT (in-utero and delivery).
Risks:
- Maternal: obstetric cholestasis.
- Fetal/neonatal: chronic Hep C infection.
Investigations:
- *Anti-HCV antibody positive = chronic infection.
- Hep C RNA = risk of MTCT 5%
- LFTs
Treatment:
- Contraindicated in pregnancy. TOP an option if patient chooses.
Ongoing management:
- Referral to hepatitis service.
- Avoid invasive procedures.
- Vaginal delivery.
- Can breastfeed but avoid if nipples cracked and bleeding.
- Neonatal Hep C antibody test 12-18 months.
- Ribavirin curative treatment postnatally:
- Not compatible with breastfeeding.
- Contraception
- No conception 6 months after.
