Chapter 8 - Infections

TORCH Infections - Assessment - Risk factors

- Toxoplasmosis is caused by consumption of raw or undercooked meat or handling cat feces. The symptoms are similar to influenza or lymphadenopathy. - Other infections can include hepatitis A and B, syphilis, mumps, parvovirus B19, and varicella-zoster. These are some of the most common and can be associated with congenital anomalies. - Rubella (German measles) is contracted through children who have rashes or neonates who are born to mothers who had rubella during pregnancy. - Cytomegalovirus (member of herpes virus family) is transmitted by droplet infection from person to person, a virus found in semen, cervical and vaginal secretions, breast milk, placental tissue, urine, feces, and blood. Latent virus may be reactivated and cause disease to the fetus in utero or during passage through the birth canal. - The herpes simplex virus (HSV) is spread by direct contact with oral or genital lesions. Transmission to the fetus is greatest during vaginal birth if the woman has active lesions.

Syphilis

Syphilis is an STI caused by the bacterium Treponema pallidum. It can have long-term consequences if it is not adequately treated. ☐ Syphilis has three stages ■ Primary: characterized by presence of a chancre ■ Secondary: characterized by skin rashes, such as a rash on the hands and soles of feet ■ Tertiary: characterized by damage to internal organs ☐ Black, Hispanic, and other racial/ethnic minority groups are disproportionately affected by syphilis in the US. ☐ It can be transmitted through oral, vaginal, or anal sex as well as transmitted to an unborn child. Though the rate of congenital syphilis has recently decreased, more cases of congenital syphilis are reported than cases of perinatal HIV infection. ☐ All pregnant women should be screened at the first prenatal visit and rescreened in the third trimester if at high-risk (live in areas with high number of syphilis cases; not previously tested; or had positive test in the first trimester).

TORCH Infections

TORCH is an acronym for a group of infections that can negatively affect a woman who is pregnant. These infections can cross the placenta and have teratogenic effects on the fetus. TORCH does not include all the major infections that present risks to the mother and fetus. Toxoplasmosis, other infections (e.g., hepatitis), rubella virus, cytomegalovirus, and herpes simplex virus are known collectively as TORCH.

GBS - Laboratory Tests

Vaginal and rectal cultures are performed at 36 to 37 weeks of gestation.

HIV/AIDS

a retrovirus that attacks and causes destruction of T lymphocytes. It causes immunosuppression in a client. HIV is transmitted from the mother to a neonate perinatally through the placenta and postnatally through the breast milk. - Routine laboratory testing of HIV/AIDS in the early prenatal period includes testing for HIV. Early identification and treatment significantly decreases the incidence of perinatal transmission. - Testing is recommended in the third trimester for clients who are at an increased risk, and rapid HIV testing should be done if a client is in labor and her HIV status is unknown. - Procedures, such as amniocentesis and an episiotomy, should be avoided due to the risk of maternal blood exposure. - Use of internal fetal monitors, vacuum extraction, and forceps during labor should be avoided because of the risk of fetal bleeding. - Administration of injections and blood testing should not take place until the first bath is given to the newborn.

Chlamydia

Chlamydia is a bacterial infection caused by Chlamydia trachomatis. It is the most commonly reported STI in American women. - The infection is often difficult to diagnose because it is typically asymptomatic. If left untreated in women, it can lead to pelvic inflammatory disease (PID), which can cause infertility. - According to current guidelines from the Centers for Disease Control and Prevention, all sexually active women younger than 25 years, as well as older women who have risk factors (e.g. new or multiple partners). All pregnant women should be screened at the first prenatal visit and rescreened in the third trimester if younger than 25 and/or a high risk.

HIV/AIDS - Patient-centered care - Medications - Client Education

DISCHARGE INSTRUCTIONS ■ Instruct the client not to breastfeed. ■ Discuss HIV and safe sexual relations with the client. ■ Refer client and infant to providers specializing in the care of clients who have HIV. ■ All states have a reportable diseases list. HIV/AIDS is a commonly reported condition. It is the responsibility of the provider to report cases of these diseases to their local health department.

HIV/AIDS - Assessment - Expected Findings

Fatigue and influenza-like findings PHYSICAL ASSESSMENT FINDINGS ● Fever ● Diarrhea ● Lymphadenopathy and rash ● Anemia

Group B Streptococcus (GBS)

Group B streptococcus ß-hemolytic (GBS) is a bacterial infection that can be passed to a fetus during labor and delivery.

GBS - Assessment - Risk Factors

Hx of positive culture with previous pregnancy RISK FACTORS ◯ Maternal age less than 20 years ◯ African American or Hispanic ethnicity ◯ Positive culture with pregnancy ◯ Prolonged rupture of membranes ◯ Preterm delivery ◯ Low birth weight ◯ Use of intrauterine fetal monitoring ◯ Intrapartum maternal fever (38° C [100.4° F])

TORCH Infections - Assessment - Diagnostic Procedures

■ A TORCH screen is an immunologic survey that is used to identify the existence of these infections in the mother (to identify fetal risks) or in her newborn (detection of antibodies against infections). ■ Prenatal screenings

GBS - Patient-Centered Care - Client Education

Instruct the client to notify that L&D nurse of her GBS status.

Overview

Maternal infections during pregnancy require prompt identification and treatment by a provider. These include HIV, AIDS, TORCH infections, group B streptococcus (GBS), chlamydia, gonorrhea, syphilis, human papillomavirus (HPV), trichomoniasis, bacterial vaginosis (BV), and candidiasis.

TORCH Infections - Patient-Centered Care - Client Education

■ Educate the client on prevention practices, including correct hand hygiene and cooking meat properly. Instruct clients to avoid contact with contaminated cat litter. ■ Because no treatment for cytomegalovirus exists, tell the client to prevent exposure by frequent hand hygiene before eating, and after handling infant diapers and toys. ■ Emphasize to the client the importance of compliance with prescribed treatment. ■ Discuss safe sexual relations with client. ■ Provide client with emotional support.

TORCH Infections - Assessment - Laboratory Tests

■ For herpes simplex, obtain cultures from women who have HSV or are at or near term.

HIV/AIDS - Assessment - Laboratory Tests

■ Obtain informed maternal consent prior to testing. Testing begins with an antibody screening test, such as enzyme immunoassay. Confirmation of positive results is confirmed by Western blot test or immunofluorescence assay. ■ Use rapid HIV antibody test (blood or urine sample) for a client in labor. ■ Screen the client for STIs such as gonorrhea, chlamydia, syphilis, and hepatitis B. ■ Obtain frequent viral load levels and CD4 cell counts throughout the pregnancy.

Gonorrhea - Assessment - Laboratory Tests

■ vaginal cultures: females ■ Urine culture: males

HIV/AIDS - Assessment - Risk Factors

● IV drug use ● Multiple sexual partners ● Maternal history of multiple STIs ● Blood transfusion (rare occurrence) ● Men who have sex with men

Chlamydia - Assessment - Risk Factors

● Multiple sexual partners ● Unprotected sexual practices

Gonorrhea - Assessment - Risk Factors

Multiple sexual partners Unprotected sexual practices

Gonorrhea - Assessment - Expected Findings

● Subjective Data (Male) ◯ Urethral discharge ◯ Painful urination ● Subjective Data (Female) ◯ Vaginal bleeding between periods and dysmenorrhea ◯ Dysmenorrhea PHYSICAL FINDINGS ■ Yellowish-green vaginal discharge ■ Easily induced endocervical bleeding

TORCH Infections - Patient-Centered Care - Medications

◯ Administer antibiotics as prescribed. ◯ Treatment of toxoplasmosis includes sulfonamides or a combination of pyrimethamine and sulfadiazine (potentially harmful to the fetus, but parasitic treatment is essential).

GBS - Patient-Centered Care - Nursing Care

◯ Administer intrapartum antibiotic prophylaxis (IAP). ■ Client who has GBS bacteriuria during current pregnancy ■ Client who has a GBS-positive screening during current pregnancy ■ Client who has unknown GBS status who is delivering at less than 37 weeks of gestation ■ Client who has maternal fever of 38° C (100.4° F) ■ Client who has rupture of membranes for 18 hr or longer

Gonorrhea

Neisseria gonorrhoeae is the causative agent of gonorrhea. Gonorrhea is a bacterial infection that is primarily spread by genital-to-genital contact. However, it also can be spread by anal-to-genital contact or oral-to-genital contact. It can also be transmitted to a newborn during delivery. ☐ Women are frequently asymptomatic. If gonorrhea is left untreated in women, it can lead to PID, which can cause infertility. ☐ The CDC recommends yearly screening for all sexually active women younger than 25 years as well as older women who have high risk factors (e.g., new or multiple sex partners). All pregnant women at risk should be screened at the first prenatal visit and rescreened in the third trimester if at continued high risk.

GBS - Expected Findings

PHYSICAL ASSESSMENT: Positive GBS can have maternal and fetal effects. ■ premature rupture of membranes ■ preterm labor and delivery ■ chorioamnionitis (intra-amniotic infection) ■ infections of the urinary tract ■ maternal sepsis.

Chlamydia - Patient-Centered Care - Medications - Azithromycin (Zithromax) and amoxicillin (Amoxil)

◯ Azithromycin (Zithromax) and amoxicillin (Amoxil) are prescribed during pregnancy. ■ Broad-spectrum antibiotic ■ Bactericidal action NURSING CONSIDERATIONS: Administer erythromycin (Romycin) to all infants following delivery. This is the medication of choice for ophthalmia neonatorum. This antibiotic is both bacteriostatic and bactericidal, thus it provides prophylaxis against Neisseria gonorrhoeae and Chlamydia trachomatis.

Gonorrhea - Patient-Centered Care - Medications

◯ Ceftriaxone (Rocephin) IM and azithromycin (Zithromax) PO for gonorrhea ■ Broad-spectrum antibiotic ■ Bactericidal action

Chlamydia - Assessment - Expected Findings - Female

◯ Dysuria ◯ Urinary frequency ◯ Spotting or postcoital bleeding PHYSICAL ASSESSMENT FINDINGS: ☐ Mucopurulent endocervical discharge ☐ Easily induced endocervical bleeding

Chlamydia - Patient-Centered Care - Nursing Care

◯ Instruct the client to take the entire prescription as prescribed. ◯ Identify and treat all sexual partners. ◯ Clients who are pregnant should be retested 3 weeks after completing the prescribed regimen.

TORCH Infections - Patient-Centered Care - Nursing Care

◯ Monitor fetal well-being. ◯ For rubella, immunization of women who are pregnant in contraindicated because rubella infections can develop. These women should avoid crowds of young children. Women who have low titers prior to pregnancy should receive immunizations.

Syphilis - Patient-Centered Care - Medications

Penicillin G IM in a single dose.

GBS - Patient-Centered Care - Medications

◯ Penicillin G or ampicillin (Principen) is most commonly prescribed for GBS. ■ Administer penicillin 5 million units initially IV bolus, followed by 2.5 million units intermittent IV bolus every 4 hr. The client may be prescribed ampicillin 2 grams IV initially, followed by 1 g every 4 hr. ■ Bactericidal antibiotic is used to destroy the GBS.

Syphilis - Assessment - Laboratory Tests

Serology tests: Nontreponemal (VDRL and rapid plasma reagin) and treponemal (enzyme immunoassay, immunoassays) ☐ Nontreponemal tests are often used for screening, then treponemal tests to detect antibodies specific for syphilis to confirm the diagnosis. ☐ The sequence of nontreponemal then treponemal tests is considered the standard for testing.

Gonorrhea - Patient-Centered Care - Nursing Care

◯ Provide client education regarding disease transmission. ◯ Identify and treat all sexual partners. ◯ Administer erythromycin to all infants following delivery. This is the medication of choice for ophthalmia neonatorum. This antibiotic is both bacteriostatic and bactericidal, thus it provides prophylaxis against Neisseria gonorrhoeae and Chlamydia trachomatis.

HIV/AIDS - Patient-centered care - Nursing care

◯ Provide counseling prior to and after testing. ◯ Refer the client for a mental health consultation, legal assistance, and financial resources. ◯ Use standard precautions. ◯ Administer antiviral prophylaxis, triple-drug antiviral, or highly active antiretroviral therapy (HAART) as prescribed. ◯ Obtain prescribed laboratory testing. ◯ Encourage vaccination against hepatitis B, pneumococcal infection, Haemophilus influenzae type B and viral influenza. ◯ Encourage use of condoms to minimize exposure if partner is the source of infection. ◯ Review plan for scheduled cesarean birth at 38 weeks for maternal viral load of more than 1,000 copies/mL. ◯ Infant should be bathed after birth before remaining with the mother.

HIV/AIDS - Patient-centered care - Medications - Retrovir

◯ Retrovir (Zidovudine) ■ Antiretroviral agent ■ Nucleoside reverse transcriptase inhibitor NURSING CONSIDERATIONS ■ Administer retrovir at 14 weeks of gestation, throughout the pregnancy, and before the onset of labor or cesarean birth. ■ Administer retrovir to the infant at delivery and for 6 weeks following birth.

TORCH Infections - Assessment - Expected Findings

◯ Toxoplasmosis findings similar to influenza or lymphadenopathy (malaise, muscle aches, flu-like symptoms) ◯ Rubella: sx of joint and muscle pain ◯ Cytomegalovirus: asymptomatic or mononucleosis-like manifestations ◯ Herpes simplex infection: Sx consisting of painful blisters and tender lymph nodes PHYSICAL ASSESSMENT FINDINGS ■ Manifestations of toxoplasmosis include fever and tender lymph nodes. ■ Manifestations of rubella include rash, mild lymphedema, fever, and fetal consequences, which include miscarriage, congenital anomalies, and death. ■ Herpes simplex virus (HSV) initially presents with lesions and tender lymph nodes. Fetal consequences include miscarriage, preterm labor, and intrauterine growth restriction. A c-section is recommended for all women in labor who have active genital herpes lesions or early Sx of impending outbreak, such as vulvar pain and itching.

Chlamydia - Assessment - Expected Findings - Male

◯ Urethral discharge ◯ Dysuria PHYSICAL ASSESSMENT FINDINGS: mucoid or watery urethral discharge.

Syphilis - Patient-Centered Care - Client Education

☐ Instruct the client to abstain from sexual contact until sores have completely healed. ☐ Advise the client that partners need to be tested and treated. ☐ Educate the client regarding safe sex practices (e.g. mutual monogamy and correct, consistent condom use). ☐ All states have a reportable diseases list. Syphilis is a commonly reported condition. It is the responsibility of the provider to report cases of these diseases to their local health department.

Chlamydia - Patient-Centered Care - Client Education

☐ Instruct the client to take all prescriptions as prescribed. ☐ Educate the client about the possibility of decreasing effectiveness of oral contraceptives. ☐ Educate the client regarding safe sex practices (e.g. mutual monogamy and correct, consistent condom use). ☐ All states have a reportable diseases list. Chlamydia is a commonly reported condition. It is the responsibility of the provider to report cases of these diseases to their local health department.

Gonorrhea - Patient-Centered Care - Client Education

☐ Instruct the client to take all prescriptions as prescribed. ☐ Educate the client about the possibility of decreasing effectiveness of oral contraceptives. ☐ Educate the client regarding safe sex practices (e.g. mutual monogamy and correct, consistent condom use). ☐ All states have a reportable diseases list. Gonorrhea is a commonly reported condition. It is the responsibility of the provider to report cases of these diseases to their local health department.

Chlamydia - Assessment - Laboratory Tests

☐ Males: urine culture ☐ Females: endocervical culture

Syphilis - Assessment - Risk Factors

☐ Multiple partners ☐ Unprotected sexual practices

Syphilis - Assessment - Expected FIndings

☐ Primary stage: The client can notice a chancre or sore in the genital area. ☐ Secondary stage: The client can notice skin rashes, such as a fash on the palmar surface of the hands and the soles of the feet. ☐ Tertiary stage: Damage to the internal organs can occur for which clients can notice the manifestations including difficulty coordinating muscle movements and blindness. PHYSICAL ASSESSMENT FINDINGS ☐ Primary stage: Provider can observe a chancre in the genital area. ☐ Secondary stage: Provider can observe skin rashes, such as tough, red or reddish brown spots on the palms of the hand and soles of the feet.