Viral Infections in Pregnancy

Question 1

List the herpes viruses with their numbers

Answer 1

HSV 1 - oral and genital
HSV 2 - genital
Herpes virus 3 - VZV (Z has three lines)
4 - EBV (Barr has four letters)
5 - CMV - (C and 5 look similar)
6 and 7 - roSeola (6 and 7 start with s)
8 - Kaposi’s virus

Question 2

What kind of virus is herpes?

Answer 2

DNA virus

Question 3

What is the incubation period for oropharyngeal herpes viruses?

Answer 3

2-12 days

Question 4

What is the incubation period for genital herpes?

Answer 4

4-7 days

Question 5

What are the symptoms of HSV1/2? How do you diagnose it?

Answer 5

Painful vesicular rash
Can also be asymptomatic
Lymphadenopathy
Fever

Take a swab for PCR

Question 6

What are the ways in which HSV1/2 can be transmitted to babies?

Answer 6

Foetal transmission - due to ascending infection from PROM, sometimes the mother may be asymptomatic.

Neonatal vertical transmission - during delivery.

Question 7

What are the consequences of foetal transmission?

Answer 7

IUGR
Preterm delivery
Miscarriage
Congenital abnormalities

Question 8

What congenital abnormalities can arise from herpes transmission?

Answer 8

Ventriculomegaly
CNS problems

Question 9

What can be done if herpes infection is suspected in a pregnant mother? When is the risk of transmission the greatest?

Answer 9

Risk worst during 3rd trimester

If suspected at 6 weeks before delivery:
- screen for other STDs at GUM clinic
- start acyclovir + + paracetamol and topical lidocaine 2% gel
- CHECK HSV1 ANTIBODY as it can provide some protection but doesn’t fully prevent transmission
- plan for a c-section
- avoid prolonged ROM or instrumental usage

Question 10

What can be done if a mother has recurrent herpes infections? What is the management?

Answer 10

Consider suppressive therapy after 36 weeks; aciclovir 400mg TDS

Supportive treatment - saline bathing and paracetamol

Usually can have vaginal delivery as risk of transmission is low

Question 11

What is the risk of mortality in untreated neonatal HSV?

Answer 11

Over 80 percent of children DIE, and there is severe neurological involvement.

Question 12

How does HSV present in young children? Mild-moderate symptom progression

Answer 12

Initially benign - Skin, eye and mouth involvement; high risk of progresses to CNS

CNS involvement

Disseminated sepsis

Question 13

What CNS symptoms do neonates present with?

Answer 13

CNS involvement
- seizures, lethargy, irritability, poor feeding, fevers

Question 14

When do neonates present with CNS HSV?

Answer 14

Up to first 6 weeks of life

Question 15

When do neonates present with SEM?

Answer 15

Within first 14 days, up to 6 weeks

Question 16

When do neonates present with disseminated sepsis HSV?

Answer 16

Within 1st week of life

Question 17

How does VZV present in adults?

Answer 17

If they had chickenpox, it presents as a unilateral dermatomal rash (can also progress to encephalitis, mengitis, myelitis - spine pain)

If not, it can cause varicella pneumonia (very bad)

Question 18

How is VZV transmitted? How transmissible is it?

Answer 18

Respiratory droplets; 70% of people who have never had chickenpox before can get it if in a room with someone with chickenpox

Question 19

When are you infectious with varicella?

Answer 19

24 hours before the rash
5-7 days after the rash OR after the rash has crusted over

Question 20

In women who have not had chickenpox before and get pregnant, what is the risk for mum and baby?

Answer 20

Maternal varicella:

They can get varicella pneumonia
Varicella encephalitis (rare but 10 percent mortality)

Congenital varicella syndrome (higher risk in second trimester)

Question 21

What are the symptoms of congenital varicella syndrome?

Answer 21

Neuro abnormalities
Skin scarring
Limb abnormalities
GI abnormalities
Occular abnormalities

Question 22

A woman comes in saying she’s pregnant and came into contact with someone with chickenpox. What do you ask her? If she says no, what do you do?

Answer 22

Has she had chickenpox previously?
Has she had TWO doses of varicella vaccine?
If not, do an urgent antibody testing

Question 23

What do you test for on a varicella antibody screen? What level are you aiming for?

Answer 23

VZV igG above 100mlU/ml

Question 24

If the VZV IgG is less than 100mlU/ml, what do you do?

Answer 24

If presenting within 7 days of exposure, offer until day 14 after exposure

Look at green top guidance
Give aciclovir 800mg TDS OR valaciclovir 1000mg TDS 3

If presenting after 7 days since exposure:

800mg oral aciclovir QDS OR
1000mg oral valaciclovir TDS
until day 14 post exposure

Question 25

If presenting within 7 days since exposure of VZV, what do you offer the woman?

Answer 25

Look at green top guidance
Give aciclovir 800mg TDS OR
Valaciclovir 1000mg TDS

until 2 weeks after exposure

Question 26

If presenting after one week since exposure to VZV, what do you give?

Answer 26

If presenting after 7 days since exposure:

800mg oral Aciclovir QDS OR
1000mg oral valaciclovir TDS (this is correct, TDS)
until day 14 post exposure

Question 27

CMV - which herpes virus number is this?

Answer 27

Herpes virus 5

Question 28

Who gets affected by CMV?

Answer 28

Everyone gets CMV - very common early childhood infection, however only really problematic if immunocompromised or pregnant

Question 29

CMV route of transmission

Answer 29

Saliva, respiratory secretions, urine (changing nappies)

Question 30

CMV symptoms

Answer 30

Infectious mono-nucleosis type symptoms
Mostly asymptomatic

Question 31

Diagnosis of CMV

Answer 31

PCR of saliva, urine, tissue, amniotic fluid
Serology

Question 32

When is CMV transmission risk worst?

Answer 32

3rd trimester

Question 33

If you suspected varicella meningitis, what bedside tests could you do? Explain these two tests.

Answer 33

Kernig’s test - Straightening the leg after hip and knee flexion causes back pain (irritation in the meninges)

Brudzinski’s test - passive head flexion causes involuntary hip flexion