Perinatal infections- GBS, parvo, varicella, listeria, HIV Flashcards
Describe how a swab is taken and sent for culture of Group B Streptococcus (GBS) to provide the highest rate of detection of colonisation. (3 marks)
• Perform at 35-37/40 gestation
• Can be a self swab or by clinician. Speculum should not be used.
• Take swab out of packaging, do not touch cotton bud end
• Insert cotton bud end 2cm into vagina
• Insert same swab 1cm into anus
• Place in sterile medium tube of selective enrichment broth (if not then false negative of 50%), label, send with form requesting GBS culture with pt name, NHI, details and gestation.
• Should be processed as soon as possible.
- Specify that swab has been taken for GBS screening and if penicillin allergy lab should test for sensitivities
Describe and evaluate two different strategies for the prevention of early onset neonatal GBS disease. (8 marks)
A: Name the 2 approaches
Universal screening vs risk based screening
Evaluate universal screening
Universal Screening
- All women are screened with LVS/anogenital swab for GBS at 35-37 weeks gestation. (or 3-5/52 prior to delivery if high risk and being delivered earlier)
- If GBS positive on swab:
o IAP (intrapartum antibiotic prophylaxis) is given
o Recommend immediate IOL if SROM at term
- If GBS negative on swab:
o No IAP required
- Exceptions:
o No IAP required for elective C/S with intact membranes even if GBS positive (but swab should still be done in case of SROM prior to elective date)
o Women with previous affected baby with GBS sepsis or GBS bacturia in current pregnancy should not be swabbed as should receive IAP regardless as result
Benefits:
- Studies have shown decreased rates of early onset GBS sepsis in neonates, RR 0.46 (although decrease in mortality not shown) Australian study shown decrease by 84%, NNT 224
- Will pick up more women colonised with GBS
- Likely cost effective
Disadvantages:
- More expensive
- More labour intensive
- Medicalisation of pregnancy and labour
- Need for greater resources to facilitate immediate IOL for SROM at term
- Some women will be given antibiotics unecessarily
- Antibiotic allergies can occur
- Some women will be missed e.g. late bookers/unbooked women
- Doesnt prevent all cases of maternal/neonatal GBS infection
Evaluate risk based screening
- Risk Based Screenng
- No routine swabs for GBS
- Women should be given IAP if:
o Previous GBS infected neonate
o Previous GBS bacturia (any colony count) in this pregnancy
o GBS on swabs done for another reason in the pregnancy (unless has had LV at 35-37 weeks which is negative)
o Ruptured membranes >18hrs
o Maternal fever >38 degrees or clinical chorioamnionitis
o Preterm labour <37 weeks gestationAdvantages:
- Cheaper
- Fewer unnecessary antibiotics given
- Fewer cases of anaphylaxis/allergic reaction
- Can apply to any woman who presents in labour
- Although less effective, still low EOGBS rate
Disadvantages:
- May miss some GBS postive women
- Less effective at protecting against EOGBS
Discuss the antibiotics used for intrapartum chemoprophylaxis of early onset neonatal GBS disease. (4 marks)
IV antibiotics should be given in labour if GBS positive or risk factors for EOGBS infection.
Aim for at least 4 hours prior to delivery, so give when in active labour until delivery.
Suggested regime from ASID: (however other local guidelines may differ)
- 1st line – benzylpenicillin 3g IV loading dose then 1.8g IV q4 hourly (penicillin preferred over amoxicillin as narrower spectrum of cover)
- Penicillin hypersensitivity without history of anaphylaxis:
o Cefazolin 2g IV loading dose then 1g q8hrly
- Penicillin or cephalosporin allergy at risk of anaphylaxis:
o Clindamycin 600mg IV q8hrly (ask for sensitivities at time of sending swab if penicillin allergic as 20% clindamycin resistance of GBS), OR
o Vancomycin 1g IV q12hrly
o (Erythromycin no longer an acceptable alternative - resistance rates of 30%).
- If signs of maternal sepsis broaden antibiotic cover to:
o Amoxycillin 2g IV q6hrly, PLUS
o Gentamicin 4-6mg/kg IV daily, PLUS
o Metronidazole 500mg IV q12hrly
If delivered by elective pre rupture of membranes C/S – not required.
Leading cause of neonatal sepsis in developed countries?
GBS
Incidence of GBS without abx prophylaxis?
Mortality rate?
0.4-4 per 1,000 live births
Mortality rate of 14%. 20% if preterm.
Parvovirus - pregnancy complications and effects on fetus?
- In pregnancy it can cause miscarriage, still birth, fetal anaemia, hydrops.
- Rate of vertical transmission in an acute parvovirus infection is 50% and greatest risk to fetus is between 8 and 20/40.
- Inhibits fetal EPO synthesis – leading to anaemia, hydrops and death.
- Excess mortality 10% in affected fetuses.
- Of affected fetuses, around 3% will develop hydrops.
- Consequences of infection should be seen by 8/52 after infection.
- If no evidence of USS proven abnormality by 30/40 - can be managed as low risk pregnancy
- No evidence that the virus causes long term disability.
Risk factors and how is parvovirus transmitted?
Rate of transmission: respiratory, via blood products, vertical.
Sx: non specific muscle aches and pain, febrile illness with rash, can also have diarrhoea/vomiting/headache/nausea. Can then develop rash on face and trunk.
Sx typicially last 1/52.
Women working at childcare are at an increased risk of exposure. Overall risk around 2-4%.
How to diagnose Parvovirus?
Diagnosis with IgG and IgM testing. Can use PCR but usually reserved for amniocentesis or if convincing hx with negative IgM.
Management if confirmed parvovirus infection?
1-2 weekly USS surveillance for hydrops and MCA PSV for fetal anaemia for 12 weeks from exposure or until 30/40.
If abnormal MCA PSV or hydrops - transfer to unit for cord blood sampling +/-IUT.
If evidence of hydrops delivery or intrauterine transfusion may be required.
In the event of delivery- at level 3 unit with NICU.
What advice should be given to pregnant women to reduce their risk of getting listeria?
Obtained from eating contaminated food, listeria lives indust/sewage/water/plants/soil/animal dropping.
Recommend avoiding soft cheese, chilled meals, cold meats, pate, unpasteurised milk.
Recommend pregnant women adopt safe food handling practices e.g. washing hands/keeping uncooked meat separate from vegetables etc.
Pregnancy risks of Listeria?
miscarriage,
stillbirth,
preterm labour,
neonatal infection (pneumonia, meningitis).
Suspect listeria in a preterm baby with mec liquor.
i) Explain the characteristics of Listeria monocytogenes that account for this rare infection being 20 times more common in pregnant women than in the general population. (2 marks)
- Listeria is a facultative intracellular gram positive bacilli
- Cell-mediated infection is a primary host defence against listeria
- Reduced cell-mediated immunity in pregnancy leads to higher susceptibility.
- Listeria has a low virulence in general population
Probability of mother to child transmission with HIV? How to prevent transmission?
The probability of mother to child transmission:
2% in low risk cases - where proper prophylaxis used (probably lower <1%)
20% MTCT in high risk cases
Additional 20% risk if breast feeding
Risk of transmission if breastfeeding on HAART = 5%
Interventions to reduce vertical transmission include:
• Antiretroviral therapy to mother
• Elective caesarean section if viral load not fully suppressed (>50 copies)
• If viral load ≥400 consider zidovudine intrapaartum prophylaxis
• Avoid invasive obstetric procedures (eg. amniocentesis, fetal scalp monitoring, fetal scalp blood sampling, episiotomy)
• Neonate needs ARV - low risk cases zidovudine sufficient, high risk cases needs combine HAART - for 4 weeks
• Test PCR at 1 wk, 6 wk, 3 months and test HIV Abs at 18 months
• Formula feeding (avoiding breastfeeding) - highest risk is with mixed breast/formula feeding