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FRANZCOG OBSTETRICS > Perinatal infections > Flashcards

Perinatal infections Flashcards

1
Q

Maternal symptoms of toxoplasmosis

A

often asymptomatic. malaise, fever, lymphadenopathy.

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2
Q

Maternal complications of CMV in pregnancy?

A

Maternal infection: febrile illness, myocarditis, pneumonitis, hepatitis, retinitis, gastroenteritis, or meningoencephalitis

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3
Q

Symptoms of rubella infection

A
  1. maculopapular rash
  2. fever
  3. myalgia
  4. lymphadenopathy
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4
Q

antenatal obstetric complications from rubella infection?

A

miscarriage

preterm birth

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5
Q

What is the incidence in Australia (general population) of listeria?

A

1:100,000

15% of annual cases are pregnant women

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6
Q

Describe secondary syphilis timing?

A

Systemic dissemination 2-8 weeks after resolution of chancre

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7
Q

Symptoms of secondary syphilis?

A

50% asymptomatic
Systemic illness
Condyloma lata

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8
Q

During what time period does early latent phase of syphilis develop?

A

Within 2 years of acquisition

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9
Q

During what stages is syphilis infectious?

A

primary, secondary and early latent phases only

Not infectious to sexual contacts during latent and tertiary stages. No longer infectious 48 hours after antibiotic

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10
Q

Complication of syphilis treatment in pregnancy?

A

Jarisch Herxheimer reaction (40%)

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11
Q

Incidence of congenital CMV?

A

0.2-2% neonates show signs of infection

primary = 30% fetal infection
secondary = 1% fetal infection
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12
Q

Describe pathogen causing CMV?

A

herpes type DNA virus

multiple strains

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13
Q

Serological signs recent CMV

A 
elevated aminotransferases
lymphocytosis
IgM +
IgG +/-
low IgG avidity
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14
Q

Toxoplasmosis epidemiology

  • NZ pregnancy cases/yr
  • fetus/yr
A

NZ pregnancy cases per year = 164

foetuses affected per year = 66

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15
Q

Neonatal sequelae of congenital CMV infection?

A
  • IUGR 50%
  • petechiae 76%
  • purpura 13%
  • jaundice 67%
  • hepatosplenomegaly 60^
  • microcephaly 53%
  • chorioretinitis/optic atrophy 20%
  • seizures 7%

mortality <3mo = 10%

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16
Q

Sequelae of neonatal rubella syndrome (6)?

A
  1. heart defects
  2. cataracts/retinopathy
  3. SNHL
  4. anaemia
  5. hepatosplenomegaly
  6. meningoencephalitis
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17
Q

What do non-treponema tests defect?

A

non specific
RPR and VRDL give indication of infectivity, response to treatment or reinfection.

False negatives in early infection, HIV or immunosuppression.

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18
Q

Maternal investigations for listeria?

A

blood cultures
MSU
vaginal swabs

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19
Q

Pregnancy/fetal complications of listeria infection?

A

miscarriage
preterm birth
high risk IUFD (40-50%)

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20
Q

Neonatal sequelae of listeria infection?

A

early onset disease: <7 days 20-60% mortality

Conjunctivitis, pneumonitis, meconium, granulomatosis infantiseptica (skin granuloma, papular or pustular rash)
placental and cord granuloma

late onset disease (7d-6w). 10-20% mortality.

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21
Q

Vertical transmission rate of parvovirus once mother infected?

A

50%

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22
Q

Aspects of history which influence risk of maternal parvovirus infection?

A

maternal susceptibility = 40%

exposure at home (50% risk of transmission) = 20% infected

exposure at school = 20-30% transmission
10-15% infected

exposure in community = 20% risk transmission
10% infected.

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23
Q

maternal symptoms parvovirus

A 
asymptomatic
slapped cheeck
arthropathy
aplasia
myocarditis
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24
Q

If parvovirus suspected by IgG and IgM negative, when would you repeat serology?

A

2-4 weeks after exposure

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25
Q

Recommended fetal monitoring in pregnancy following parvovirus infection?

A

2w USS with MCA PSV for 12 weeks

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26
Q

When should IVIG be given in pregnancy after varicella exposure?

A

non immune
<96 hours after exposure
exposure <7 days prior to delivery, until 2 days postnatal

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27
Q

Within what time Fram can VZIG be given after exposure to varicella?

A

<96 hours

some effect demonstrated up to 10 days

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28
Q

What is the risk of fetal disease after infection with toxoplasmosis in pregnancy in first trimester?

A

10% fetal infection

85% fetal damage (severe)

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29
Q

SYPHILIS Epidemiology (NZ cases/yr + CS cases/yr)

A

2018 NZ 500 infectious cases. Between 2016 and 2020, 14 congenital syphilis reported cases
(>100/year cases, >4 CS cases/year)

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30
Q

What is the initial screening test for syphilis (1)?

A 
Enzyme immunoassay (EIA) in guidelines. 
VRDL NZ
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31
Q

Syphilis treatment in pregnancy

A

Benzathine benzylpenicillin tetrahydrate. 1 dose 1st and 2nd trimester. Two doses third trimester. Daily if neurosyphilis.

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32
Q

Antenatal complications of syphilis in pregnancy

A

Mid-trimester miscarriage

Stillbirth

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33
Q

Congenital anomalies caused by syphilis evident on fetal USS

A 
Small bowel dilatation
PolYhydramnios
      Placentamegaly
      Hydrocephalus/hydrops
      IUGR
      Lower limb abnormalities
      IUFD
      S
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34
Q

Neonatal abnormalities caused by syphilis?

A 
KISS DR: 
keratitis, 
illness (jaundice, anaemia, low plt)
saber shins
saddle nose
Deafness
Rhagades (perioral lesions)
Other: cerebral palsy, hepatosplenomegaly.
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35
Q

Diagnosis of CMV

A

Serum IgM and IgG positive with low (<65%) IgG avidity (<3mo since infection)

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36
Q

TOXOPLASMOSIS Transmission

A

Transmission: raw or undercooked meat, not washing hands or veges, contact with cat faeces

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37
Q

Treatment of toxoplasmosis <18 weeks

A

spiramycin

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38
Q

Treatment of toxoplasmosis >18 weeks

A

pyrimethamine, sulfadiazine and folonic acid (latter two teratogenic in 1st trimester)

39
Q

Sensitivity and specificity of amniotic fluid PCR for toxoplasmosis?

A

high sensitivity between 17-21 weeks (90-100%)

40
Q

Ultrasound findings with congenital toxoplasmosis?

A

hydrocephalus,
brain or hepatic calcifications,
ascites,
splenomegaly

(CASH)

41
Q

Rubella virology

A

Rna togavirus

42
Q

Mode of transmission rubella (2)?

A

droplet and vertical

43
Q

Highest risk gestation of contracting congenital rubella syndrome?

A

<12w = 85% CRS, 80% maternal infection

44
Q

From what gestation is there minimal risk of congenital defects secondary to fetal infection with rubella?

A

17 weeks

45
Q

Neonatal specialist assessments recommended with congenital rubella syndrome?

A

Ophthalmology
Hearing screening
Cardiac screening

46
Q

List trepononemal and non-treponemal investigations?

A

non-treponemal: RPR, VDRL

treponema = TPPA, TPHA, EIA

47
Q

What do treponemal tests detect?

A

Antibodies to T. pallidum
Will demonstrate if someone has ever had syphilis, whether or not they were treated. Does not indicate when infection occurred. Small false positive rate.

48
Q

If someone is at increased risk of syphilis infection in pregnancy, when would you screen them?

A

Booking, 28w, 36w, birth, 6w PP.

49
Q

What are the microbial features of listeria?

A

Gram positive rod, facultative anaerobe.

flagellated

50
Q

Antenatal complications of listeria infection (4)?

A

miscarriage
IUFD 19%
NND 60%

51
Q

For what congenital infections would you not perform amniocentesis for diagnostic purposes?

A

parvovirus
listeria
COVID-19
Syphilis

52
Q

Prevalence of parvovirus in pregnancy?

A

1:400 pregnancies

53
Q

Risk of parvovirus fetal infection and loss after exposure at home?

A

40% susceptible
50% fetal infection
10% miscarriage
< 10% fetal hydrops

54
Q

Risk of parvovirus fetal infection and loss after exposure in community?

A 
40% susceptible
(20% transmission mum)
= 8% maternal infection
= 4% fetal infection
= 0.4% fetal loss
55
Q

What infections may cause fetal anaemia?

A

parvovirus, syphilis, rubella

56
Q

When would one expect onset of hydrops after parvovirus infection?

A

2-17 weeks

57
Q

Maternal investigations parvovirus?

A

Paired parvovirus IgG and IgM.
Can compare to booking screening.
If both negative repeat in 2w for seroconversion

58
Q

What tests can be performed for rubella with invasive fetal testing?

A

PCR
culture
fetal IgM
can be performed after CVS and amniocentesis

59
Q

Describe fetal varicella syndrome (5 systems).

A

Rash/scar (80%)
Limb hypoplasia (70%)
Cataracts (60%)

Microcephaly, ventriculomegaly. Neurodevelopmental delay (50%)

mortality (30%)
Hydrops
IUGR
Hyperechoic bowel and hepatic calcifications. Hepatosplenomegaly.

60
Q

What are some maternal complications of varicella?

A

Severe maternal disease: pneumonia, hepatitis, encephalitis, death.

61
Q

What is a significant exposure to chickenpox?

A

5 minutes face to face, 1 hour same room.

62
Q

What are the obstetric complications of varicella?

A

no increased risk of miscarriage

PTB

63
Q

What risk factors would prompt you to consider PEP with PO valaciclovir after varicella exposure after 20 weeks?

A

immunocompromised
lung disease
smoker
<24hrs of symptoms

64
Q

Highest risk gestation of FVS?

A

Highest risk between 12-28 weeks (1.4%)

65
Q

What is the prevalence of varicella infection in pregnancy?

A

3:1000

66
Q

Maternal symptoms of varicella virus?

A

Rash: papules, vesicles + crusts.
Pneumonia 5%
Encephalitis rare

67
Q

Fetal investigations for CMV infection

A

Amniocentesis with CMV NAAT. Perform >6w after infection and after 22/40 if possible for best sensitivity.

68
Q

What are the classic fetal complications of toxoplasmosis in pregnancy?

A

hydrocephalus
chorioretinitis
intracranial arteriosclerosis
+/- hydrops, deafness, blindness, neurodevelopment delay, seizures.

69
Q

Highest risk gestation for infection causing congenital toxoplasmosis?

A

> 27 weeks gestation

70
Q

What is the risk of fetal disease after infection with toxoplasmosis in the third trimester?

A

30-75% fetal infection

10% fetal damage (mild)

71
Q

For what congenital infection should termination not be offered?

A

Parvovirus

Malaria

72
Q

What are the maternal/antenatal implications of toxoplasmosis infection?

A

miscarriage
IUFD.
Usually maternal disease is mild, with fever malaise and lymphadenopathy.

73
Q

What is the risk of perinatal transmission at vaginal delivery with previous HSV-1 or 2 with no lesions?

A

<1%

74
Q

What is the risk of perinatal transmission with recurrent genital HSV-1 at time of vaginal delivery?

A

15%

75
Q

What is the risk of perinatal transmission with vaginal delivery after primary HSV at 36 weeks?

A

25-50% transmission risk

76
Q

What is the risk of perinatal transmission of HSV to the neonate?

A

HSV encephalitis

77
Q

Discuss increase risks associated with HSV and scalp electrodes

A

OR 6.8 if virus present.

78
Q

Discuss evidence around maternal antiviral suppression of HSV for vaginal delivery.

A

Reduces risk of clinical recurrence and asymptomatic shedding.
Clinical trials underpowered to evaluate efficacy of preventing transmission to newborn.

79
Q

What are signs of neonatal HSV infection?

A

vesicular skin lesions, seizures, unexplained sepsis, low platelets, elevated LFTs, DIC, respiratory distress, corneal ulcer/keratitis

80
Q

After an HIV +ve screening result, what further testing should be done?

A

Vaginal swabs
VRDL, HCV, HBV
HIV RNA viral load, HIV resistance testing, CD4+lymphocytes, FBC, LFT, UEC

81
Q

If HIV+, when would vaginal delivery be suitable?

A

on HAART from at least 24 weeks, viral load <50copies/mL at 36 weeks.

82
Q

If HIV+ with viral load 50-399 copies/mL @36 weeks, what mode of delivery would be recommended?

A

+/- intrapartum zidovudine
planned CS 38-39w
formula fed

83
Q

What is the risk of HIV transmission without modern therapy +/- breastfeeding?

A

20% no modern therapy

40% no modern therapy + breastfeeding.

84
Q

HIV-What are the criteria to be fulfilled for low risk of MTCT <2%.

A

maternal viral load undetectale
appropriate mode of delivery
formula fed baby
baby received PEP

85
Q

What is the MTCT risk of a women on HAART breastfeeding?

A

1-5%

86
Q

Risk vertical transmission of syphilis if

  1. primary
  2. secondary
  3. early latent
A
  1. 70%
  2. 70%
  3. 40%
87
Q

Implications of symptomatic congenital infection CMV (occurring in 10% of infected fetus’)?

A

50% will have long term sequelae.
early mortality <3mo = 5-10%
neurodevelopmental and sensory deficits (eyes, hearing)

88
Q

Risk of ‘symptomatic’ CMV infection after fetal transmission?

A

10%
50% of those will have long term sequelae.

Only 10% of asymptomatic foetuses/neonates have long term sequelae.

89
Q

Investigations after delivery for toxoplasmosis infection?

A

placenta- histo and PCR

neonate: whole blood PCR, cerebral USS, CSF for PCR

90
Q

Trend for vertical transmission of toxo in pregnancy?

A

Increasing incidence of infection with GA (10–>30—>50%)

Decreasing proportion of fetal damage (85–>20–>10%)

91
Q

Trends in rubella infection with advancing GA

A

rUbella- u shape fetal infection
<12-36+ (80–>50–>30–>60–>100%) with GA

fetal disease most likely <12w 85%
Then decreases with time (35%@13-16, rare after)

92
Q

Incubation and infectious period of varicella?

A

incubation 10-21 days
infectious 2 days prior to rash
rash lasts 6 days
infectious until two days after lesions crusted

93
Q

Testing for neonate after delivery at risk of congenital parvovirus?

A

FBC and plt check on day 1

FRANZCOG OBSTETRICS (25 decks)

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