Questions from S 12 Flashcards
What is the management of 18/40 antenatal woman exposed to VZV
Contact - is this a confirmed case? Has a GP diagnosed this rash?
Contact details - nature of contact
F2F
Household
Same room 15 mins
PMHx - previous history of chickenpox/ shingles.
Check this with patient/ parent/ GP
Any immunosuppression
Management -
Test booking blood
If >100 iu/ml immune
If <100 iu/ml - needs PEP
PEP options
Aciclovir 800mg 4x
Valaciclovir 1000mg TDS
Days 7-14 from contact
VZIG only if issues with renal function or absorption
Give worsening advice - if develops rash/ fever, to seek medical assistance
Consider VZV vaccine after pregnancy if plans to have further children
What is the management of 39/40 antenatal woman exposed to VZV
What is management of patient and neonate
Similar to other question on VZV.
Unique factors:
- A. If mother immune, and baby at term, then baby is considered immune.
Avoid contact with the index VZV case - A. If mother non-immune - give aciclovir day 7-14 post exposure
B. If mother non-immune, but develops rash 7 days before, to 7 days after delivery, then Mother - swab for diagnosis/ give aciclovir
Neonate - give VZIG and IV aciclovir as high risk severe infection
Can give VZIG without testing neonate, as we know they will not have antibodies as mother has developed chickenpox
Not official exam question
Mother wants to take new child home following delivery.
But some children at home have chickenpox.
Mother had had chickenpox before.
What would you advise to mother?
If other children in the family have chickenpox, and the mother has had chickenpox prior to this pregnancy or is shown to have varicella-zoster virus antibody, then there is no reason to
prevent a new baby going home.
If the mother is susceptible, contact with siblings with chickenpox should ideally be delayed until the new baby has reached 7 days of age. This is to prevent disease in the first month of life which carries a greater risk of severe disease (34).
If a new baby returns to a home where siblings are still in the infectious phase of chickenpox, the risks must be clearly explained to the parents and every effort should be made to avoid significant contact with the siblings. VZIG is not a suitable alternative to avoiding such contact. The family should be advised to bring the infant back promptly if any chickenpox spots develop so that they can be treated with intravenous aciclovir at the earliest opportunity.
Not official exam question
Neonates exposed to VZV
Who are candidates to receive VZIG PEP?
Group 1
Group 2
Group 3
Group 1
Neonates whose mothers develop chickenpox (but not shingles) in the period 7 days before to 7 days after delivery: VZIG can be given without VZV IgG antibody testing of the neonate or mother; in addition, prophylactic intravenous aciclovir (10 mg/kg every 8 hours for 10 days) should also be considered in addition to the VZIG for infants whose mothers develop
chickenpox 4 days before to 2 days after delivery as they are at the highest risk of fatal outcome despite VZIG prophylaxis. As this will be an intrauterine exposure treatment should be started as soon as possible and there is no need to wait for 7 days.
Group 2
VZV antibody-negative infants under one year who have remained in hospital since birth who are born before 28 weeks gestation or weighed less than 1,000g at birth
or VZV antibody-negative infants who have a severe congenital or other underlying condition that requires prolonged intensive or special care during the first year of life.
Group 3
VZV susceptible neonates exposed to chickenpox or shingles (other than in the mother) in the first 7 days of life In infants over the age of 4 weeks (regardless of gestation at birth) oral aciclovir is the recommended PEP, unless contraindicated (renal toxicity or malabsorption). If contraindicated, VZIG should be given
Not official exam question
4 day neonate exposed to family member who has chickenpox
Mother has uncertain history of VZV
What action would you take?
Group 3 exposure - neonate exposed in 4 weeks of life (not from own mother)
For infants in Group 3, VZV antibody testing is not required for mothers or their infants, if the mother has a positive history of chickenpox or shingles. As antibody levels following vaccination are lower, for infants in Group 3, whose mothers have received varicella vaccine, antibody testing of the mothers (preferred) or infant is recommended.
In addition, for infants in Group 3 whose mothers have a negative or uncertain history of chickenpox or shingles, testing is also recommended. A higher cut off (150mIU/ml) is used to determine need for VZIG for neonates (when testing either mother or infant’s bloods) compared to pregnant women. This is because the aim is to try to prevent infection as opposed to attenuating disease complications.
PEP is recommended for VZV antibody-negative neonates or infants, as defined as:
* infants whose mothers are VZV antibody-negative by a qualitative assay or <150
mIU/ml by a quantitative assay
* infants who are themselves tested and found to be VZV antibody-negative by a
qualitative assay or <150 mIU/ml by a quantitative assay
Important difference is immunity is considered
with level of 150, and not 100 as usual
Management of 18/40 antenatal woman exposed to slapped cheek syndrome child
Contact - is this confirmed? Who has seen rash?
Nature of contact -
Household
F2F
Same room 15 mins
Infectious period - from 10 days before to day of rash. Contact must be within this time
Antenatal Parvo IgM/ IgG
If immune, no further action
If non-immune -
- worsening advice about symptoms - fever, rash, arthralgia
- repeat bloods 4 weeks see if antibody response
If infected -
- USS foetus looks for any signs of infection - e.g Hydrops foetalis
- consider amniocentesis with Parvo B19 DNA PCR
- if Parvo DNA positive - foetus infected. Consider intrauterine transfusion if mother has severe anaemia, or if severe hydrops
Management of a 25/40 antenatal woman whose USS revealed intrauterine growth restricted foetus.
CMV IgM pos current sample
CMV IgM neg on booking blood
What is the management?
CMV IgM suggests a recent infection.
Testing -
- CMV IgG/ avidity on booking/ current bloods.
- Clarify timing of this infection, and whether this is primary infection or reactivation
- Consider performing viral load/ EBV serology
USS - any other feautres of CMV - microcephaly, intracranial calcifications, echogenic bowel
If CMV infection in pregnancy confirmed:
- consider amnio + CMV DNA PCR
If CMV infection confirmed in neonate
- at birth:
neonate urine/ saliva CMV DNA PCR
hearing test
eye test
FBC/ UE/ LFT
Consider other causes of IUGR
CMV
Parvo B19
Rubella
Syphilis
Toxoplasma
Not exam question
What is risk of transmission to the foetus if mother is infected:
CMV primary infection
CMV reactivation
CMV primary infection -
approx 35% 1st/2nd trimester
Approx 70% 3rd trimester
CMV reactivation -
approx 3%
Management of 18/40 antenatal woman who presents with a labial rash consistent with primary HSV2 infection
Confirm diagnosis - swab rash
Primary or recurrence?
- check patient history
- check swab result history
- HSV type specific antibody
PMHx
renal dysfunction
Screen for other STIs -
HIV, Chlamydia, Gonorrhoea, Syphilis
Primary management -
- aciclovir 400mg 5x for 7 days
- start suppressive therapy from week 36 to delivery - aciclovir 400mg TDS
- if no lesions at birth, can have vaginal delivery
Secondary management
- aciclovir 400mg 5x for 7 days
- start suppressive therapy from week 36 to delivery - aciclovir 400mg TDS
- if no lesions at birth, can have vaginal delivery
Management of 35/40 antenatal woman who presents with a labial rash consistent with primary HSV2 infection
what is different about management?
Same as previous
Primary management -
- aciclovir 400mg 3x for 7 days
- then immediately start suppressive therapy until delivery - aciclovir 400mg BD
- caesarean section recommended, even if no lesions. This is recommended in third trimester, and definitely if within 6 weeks of delivery
Secondary management
- aciclovir 400mg 3x for 7 days
- start suppressive therapy from week 36 to delivery - aciclovir 400mg TBD
- if no lesions at birth, can have vaginal delivery
What is management of 18/40 pregnant woman exposed to Measles?
Contact - is this a confirmed case?
Exposure history -
F2F
Household
Same room 15 mins
Infective period - 4 days before to 4 days after
Immunity
- history of 2x MMR vaccines, or history of infection
- if unclear, check booking blood Measles IgG
If immune - no action
If non-immune:
- HNIG within 6 days, ideally ASAP
- recommend MMR vaccine after pregnance
Management of 39/40 antenatal woman who presents with a labial rash consistent with primary HSV2 infection, in labour
what is different about management?
Primary management -
- aciclovir - give IV immediately intra-partum, then consider oral dosing
- caesarean section recommended. This is recommended in third trimester, and definitely if within 6 weeks of delivery
- neonate - swab skin/ eyes/ LP - give IV aciclovir
Secondary management
- aciclovir 400mg 5x for 7 days
- recommend vaginal delivery
- neonate - swab skin/ eyes/ LP if unwell
39 year old Nigerian woman, immigrant to UK. Present to GP
2 week history intermittent RUQ pain, fatigue, headache, arthralgia
Jaundice 2 days prior to admission
Afebrile
Yellow discolouration of eyes
Firm liver edge,
ALT 1865
Bil 135
Gastroenterology specialist registrar contacts you for advice investigations
What investigations would you advise?
Viral/ non-viral
HBsAg + neutralisation
Anti-HCV/ HCV RNA
HIV ½ Ag/Ab
Hepatitis A IgM/IgG
Hepatitis E IgM/ IgG
CMV IgM/IgG
EBV VCA IgM/ VCA IgG/ EBNA IgG
Liver USS/ fibroscan
39 year old Nigerian woman, immigrant to UK. Present to GP
2 week history intermittent RUQ pain, fatigue, headache, arthralgia
Jaundice 2 days prior to admission
Afebrile
Yellow discolouration of eyes
Firm liver edge,
ALT 1865
Bil 135
Gastroenterology specialist registrar contacts you for advice investigations
Diagnosis confirmed as Chronic HBeAg negative
HBV DNA 2000
Liver USS is normal - no fibrosis
Does this explain the clinical picture?
No - has chronic hepatitis B, with low viral load
Could be hepatitis B flare - but would expect HBV DNA to be higher
Likely HDV co-infection
HDV is dominant virus, to suppresses HBV viral load
39 year old Nigerian woman, immigrant to UK. Present to GP
2 week history intermittent RUQ pain, fatigue, headache, arthralgia
Jaundice 2 days prior to admission
Afebrile
Yellow discolouration of eyes
Firm liver edge,
ALT 1865
Bil 135
Gastroenterology specialist registrar contacts you for advice investigations
Diagnosis confirmed as Chronic HBeAg negative
HBV DNA 2000
What are the two types of HDV infection?
HBV/HDV co-infection - acquired simultaneously
HBV infection, with subsequent HDV infection - superinfection
Higher risk of faster progression to fibrosis and cirrhosis
