Viral Infection in Pregnancy Flashcards
List 6 broad consequences of viral infections during pregnancy
Maternal complications
Miscarriage/ stillbirth
Teratogenicity
IUGR/ prematurity
Congenital disease
Persistent infection
List 3 viral infections that increase risk of maternal complications
Influenza
Varicella Zoster
Hep E
List 3 viral infections that increase risk of miscarriage/ stillbirth
Rubella
Measles
Hep E
Give 2 viral infections that increase risk of teratogenicity
Varicella Zoster
Zika
Give 2 viral infections that cause IUGR/ prematurity
Rubella
CMV
Give 2 viral infections that increase the risk of congenital disease
CMV
HSV
Give 2 viral infections that cause persistent infection in the child
HIV
Hep B/C
Which 12 viral infections are associated with rashes?
VZV (Chickenpox/ shingles)
EBV
HSV
Cytomegalovirus
Parvovirus B19
Enterovirus
Measles
Rubella
Influenza
Hep A-E
HIV
HTLV
List 3 travel associated viral infections that a pregnant woman may present with
Dengue
Zika
Yellow fever
List the first 5 human herpes viruses
HHV1+2: Herpes Simplex Virus
HHV3: Varicella Zoster virus
HHV4: Epstein Barr Virus (EBV)
HHV5: Cytomegalovirus (CMV)
List 3 features of herpes viruses
DNA viruses
Once exposed, cause lifelong infection (often latent)
Have capacity to reactivate under stress/ immunosuppression
Describe the transmission, incubation and latency of HSV 1+2
T: close contact
I: Oropharyngeal 2-12d. Genital 4-7d
L: established in dorsal route ganglion
Give 4 presentations of HSV 1+2
Asymptomatic
Painful vesicular rash
Lymphadenopathy
Fever
What investigations should be sent for HSV 1 + 2?
Swab lesion - PCR
Serology in immunosuppressed
What 3 forms of HSV may occur in pregnancy?
Primary: 1st exposure
Non-primary: Previous HSV1, contract HSV2 during pregnancy
Recurrent: Same HSV as previous infection
How can a foetus contract HSV from its mother?
Ascending infection in PROM (active infection in genital area)
V rare
How can neonates contract HSV?
Direct contact with infected maternal secretions during delivery
Active infection + kissing baby
Non-familial: other relatives/ hospital staff
When is the risk of maternal to foetus HSV transmission highest? What is advised to reduce risk?
Primary genital infection in 3rd trimester
If active HSV in final 6w: C-section
List 4 complications of primary genital HSV infection
Miscarriage
Congenital abnormalities (Ventriculomegaly, CNS abnormalities)
Preterm birth
IUGR
How should a first presentation of genital herpes in pregnancy be managed?
Refer to GUM clinic
Aciclovir 5d
HSV antibody testing
Consider C-section if <6w to delivery
How should recurrent genital herpes in pregnancy be managed?
Often self resolving
Consider suppressive therapy from 36w
Maternal antibody offers some protection (though may not prevent transmission)
Avoid prolonged ROM/ invasive foetal monitoring
Describe the skin, eye and mouth presentation of HSV in a neonate
45% of cases
Initially benign, high risk progression to CNS
Must be treated
Usually occurs in first 14d
May last up to 6w
Describe the CNS involvement (+/- SEM) in neonatal HSV
30% of cases
Usually occurs at 2-3w (up to 6)
Seizures
Lethargy
Irritability
Poor feeding
Fevers
Needs CSF
Describe disseminated HSV in neonates
Presents like Sepsis
Often in 1st week of life
Multi-organ involvement: Liver, Lungs, Heart, CNS, GIT, Renal tract, BM
What is this? How should it be treated until results exclude/ confirm diagnosis?
Skin, eye, mouth HSV
Treat with Aciclovir
Looks like Staphylococcal eye infection- SWAB!
Describe the transmission, infection rate and incubation period of VZV
Transmission: Respiratory
70% infection rate in those susceptible
Incubation: 7-13d
Infectious 24h before rash develops
Describe the presentation of VZV
Prodromal fever, malaise, myalgia
Centripetal maculopapular rash
Vesicular rash appears in crops
Pruritic
Describe the susceptibility of pregnant women to varicella zoster
10-20% childbearing age suscebtible
10-20% of those contracting VZV develop varicella pneumonia
Varicella encephalitis is rare but mortality 5-10%
What are the 3 stages at which a congenital infection can be transmitted?
In utero: Crossing placenta
Perinatal: during childbirth
Postnatally: after birth
What are the risks of congenital varicella syndrome depending on timing?
0-12w: 0.4%
12-20w: 2%
List 6 complications of congenital varicella syndrome
Neurological abnormalities
Occular abnormalities
Skin scarring
Limb abnormalities
GI abnormalities
LBW
In which cases post exposure is a women considered to have sufficient evidence of immunity against VZV?
Hx of previous chickenpox or shingles
2 doses of varicella vaccine
What treatment is required if a pregnant woman is exposed to VZV with no previous infection or immunisation?
Urgent antibody testing on recent blood sample
If VZV IgG <100, offer PEP
What treatment is required if a pregnant woman is exposed to VZV with no previous infection or immunisation?
Urgent antibody testing on recent blood sample
If VZV IgG <100, offer PEP
What PEP is required for women presenting within 7d exposure of VZV?
Oral aciclovir 800mg
or
Oral Valaciclovir 1000mg TDS
from day 7-14 after exposire
What PEP is required for women presenting after 7d from exposure of VZV?
Oral aciclovir 800mg QDS
or
Oral valaciclovir 1000mg TDS
up until 14d post exposure
What drug should be used in active infection with VZV in pregnancy?
Aciclovir
Describe the epidemiology, transmission and incubation of cytomegalovirus
Common early childhood infection: 2-6% infants by 6m, 40% by16y
T: Saliva, Resp. secretions, Urine
I: 4-8w
Give 2 presentations of CMV
Mostly asymptomatic
Maculopapular rash, infectious-mononucleosis like illness
What investigations are used for CMV?
PCR urine/ saliva, amniotic fluid
Serology
When is the biggest risk of CMV transmission during pregnancy?
3rd trimester
List 7 complications of maternal CMV for the infant
Encephalitis
Microcephaly
Ventriculomegaly
Chorioretinitis
Jaundice
Thrombocytopenia
Hepatosplenomegaly
How do most congenitally infected newborns with CMV present?
Initially asymptomatic
15-25% go on to develop neurodevelopmental abnormalities- sensorineural hearing loss within 3y
What happens if maternal CMV infection is suspected?
Test booking bloods for CMV IgG
If had no IgG, but has IgM now= primary infection
What testing is performed on the baby if maternal CMV is suspected?
USS +/- amniocentesis
At birth: Guthrie card
Urine + saliva PCR within 21d
The child of a 35w pregnant woman develops a vesicular rash. What should you do first?
Ask if she has had chickenpox before
What is this rash?
Most likely Measles or Rubella
Flat, Maculopapular
(not vesicular/ blistering like chickenpox)
Describe the spread of the rash in rubeola
Appears at HAIRLINE/ behind ears
Spreads cephaocaudally over 3d
Give 5 signs/ symptoms of rubeola
Conjunctivitis
Cough
Coryza
Fever
Koplik spots on buccal mucosa
What are the alternative names for rubeola and rubella?
Rubeola: Common Measles
Rubella: German measles
Describe the spread and nature of the rash in rubella
Begins on the FACE
Spreads cephalocaudally within hours
Fine, macular rash
Mildly pruritic
Give 6 signs/ symptoms of rubella
Headache
Low grade fever
Sore throat
Coryza
FORCHHEIMER spots on soft palate
Lymphadenopathy- tender
Describe the spread of the rash in roseola infantum
After fever subsides, rash develops
Starts on NECK + TRUNK
Spreads to the face + extremities
Give 3 features of roseola infantum
Affects 3-36m
Caused by HHV6
Abrupt high fever
Describe the nature, transmission and incubation period of rubella
RNA virus
T: Respiratory
I: 12-21d
What investigations are used when suspecting rubella?
Buccal swab for PCR
Serology
In which population is congenital rubella syndrome more prevalent?
Immigrants from countries with high burden of CRS
Lots circulating
Sparse vaccination programes/ avoidance
When is risk of CRS highest? What consequences correlate with the time of infection?
Greatest risk: 1st trimester
<8w: 20% spontaneous abortion
<10w: 90% fetal defects
>18w: hearing defects + retinopathy
>20w: risk much lower
List 8 complications of congenital rubella syndrome for the infant at time of birth
Microcephaly
Meningioencephalitis
Cataracts
Retinopathy
Bone lesions
Cardiac defects in 50%: PDA, PS
Purpura
Hepatosplenomegaly
List 5 late manifestations of CRS
Pancephalitis
Hearing loss: bilateral SNHL
Intellectual disability
DM
Thyroid dysfunction
What is seen here? What condition is this associated with?
Severe cataracts at birth
Congenital Rubella Syndrome
Describe the nature, transmission and incubation period of measles (rubeola)
RNA virus
T: Respiratory, Conjunctiva
I: 7-18d
Describe the prodrome in rubella and rubeola
Rubella: 1-5d pre-rash
Rubeola: 2-4d
What complication for the mother may arise if they contract measles in pregnancy?
Secondary bacterial infection
Otitis media/ pneumonia/ GI/ Encephalitis
List 3 complications for the baby from measles during pregnancy
Foetal loss
Preterm delivery
Subacute sclerosis panencephalitis (SSPE)
What is SSPE?
Occurs 7-10y after natural infection
Fatal, progressive degenerative disease of CNS
What is this rash?
Parvovirus B19
“Slap cheek syndrome”
Describe the nature, transmission, incubation and infectious period of parvovirus B19
DNA virus
T: Respiratory, blood products
I: 6-8d
Infectious 6d post exposure- 1w after Sx onset
Give 4 symptoms/ presentations of parvovirus B19
Mostly asymptomatic
Erythema infectiosum/ slapped cheek/ 5ths disease
Polyarthropathy
Transient aplastic crisis (vulnerable pop. e.g. sickle cell)
What investigations are used for parvovirus B19?
Virus detection PCR
Serology
What are the statistics of complications from parvovirus in pregnancy?
Transmission in 33%
9% of which get infected
Of those infected 3% develop Hydrops fetalis
1% foetal abnormalities
7% foetal loss
How does parvovirus B19 cause hydrops fetalis?
Cytotoxic to foetal red blood precursor cells
Severe anaemia
Accumulation of fluid in soft tissues + serous cavities: ascites, pleural effusion, pericardial effusion, cardiomegaly
What should be done if parvovirus B19 is suspected in pregnancy?
Refer to foetal med for monitoring
If develops Hydrops: Intrauterine transfusion
Test booking + current bloods for IgG + IgM to parvovirus
What is this rash?
Hand foot and mouth disease
(HFM)
Cocksackie enterovirus
Describe the transmission and incubation of enterovirus
T: Respiratory +/- faecal
I: 2-40d
List 4 symptoms/ presentations of enterovirus
Hand, foot + mouth disease
Rash
Encephalitis
Myocarditis
Of all enteroviruses, which poses the main risk during pregnancy?
Cocksackie virus
Perinatal newborn infection can occur in last week of pregnancy
List 5 complications of neonatal cocksackie infection
Myocarditis
Fulminant hepatitis
Encephalitis
Bleeding
Multi-organ failure
List 7 important topics to cover in a pregnant woman presenting with a rash
Gestation: date of LMP, due date by scan
Date of onset, clinical features, type + distribution of rash, associated features
Past hx infection
Past hx of antibody testing
Past immunisation hx
Known contacts with rash
Travel hx
What should be investigated for a pregnant woman presenting with rash?
Antenatal booking bloods: antibody test to determine immunity/ susceptibility
Swab/ scrape rash if vesicular
Blood sample: antibody +/- PCR
List 3 ways in which Zika virus can spread
Mosquito bite
STI
Blood transfusion
List 4 complications of Zika for the baby
Microcephaly
Severe cranial abnormalities
Seizures
Problems with feeding, limb movement, vision + hearing
