Infectious Diseases in Pregnancy
How is the diagnosis of maternal rubella infection made? How do you treat it?
Detection of IgM (does not cross placenta) in infant There is no treatment of rubella
TO avoid toxoplasmosis, what should pregnant women avoid?
Avoid contact with cat litter bnoxes and significant garenindg without glove and mask protection during pregnancy, as the organism is gound in cat feces and soil that may be contaminated with animal feces.
How do you treat chlamydia i pregnancy?
Azithromycin, amoxicillin, or erythromycin because tetracycline and doxycycline are not advised in pregnancy.
Does spiramycin treat fetal infection?
No, because spiramycin does not cross the placenta. Therefore, pyrimethamine and sulfadiazine are recommended for treatment of documented fetal infection.
If a woman with a hsistory of HSV but not active genital lesions or prodromes, what delivery would you pursue?
Not cesarean
How do you determine if a HSV lesion is primary or secondary?
Order IgM and type-specific IgG HSB antibodies
How is chorioamniotis treated?
IV antibiotics using a second or third generation cephalosporin or ampicillin and gentamicin and delivery of the fetus are required
How do you treat CMV in utero infection?
IVIG
With regards to varicella, when does the period of infectivity begin? How does the primary infection present? WHat are sequela?
48 hours before the rask appears and lasts until the vesicles crust over. Causes chicken pox - fever, malasise, and a maculopapular pruritic rash that becomes vesicular. After the primary infection, VZV remains formant in sensory ganglia and can be reactivated to casuse a vesicular erythematous skin rash known as herpes zoster (or shingles).
At the time of an initial outbreak in a pregnant woman, what treatment do you pursue?
Acyclovir or valacyclovir
The incidence of UTIs increases during pregnancy. How are UTIs diagnosed? How is acute cystitis diagnosed?
CLinical signs and symptoms of dysuria, urinary frequency, and urinary urgency in conjuction with a positive urine culture. Dysuria, urinary frequency, urinary urgency, suprapubic discomfort in the absence of systemic symptoms such as high fever and costovertebral tenderness.
What is recommended for women who have two or more UTIs during pregnancy?
COntinuous nightly antibiotic prophlaxis with macrodantin or bactrim
What are HSV sequelae in the neonate?
Can progress to viral sepsis, pneumonia, and herpes encephalitis, which can lead to neruologic devastation and death.
For GBS-colonized women with an allergy to penecillin but low risk for anaphylaxis to (i.e., rash allergy), what is used for prophylaxis? In women with a significant peniciliin allergy (i.e., high risk for anaphylaxis), what is used?
Cefazolin is used for prophylaxis during labor Clindamycin, but it can be used only if the GBS susceptibilities are known
Patients with a history of herpes should have a thorough perineal examination for lesions when presenting in labor because of the risk of transmission of HSV to the fetus during vaginal delivery. If lesions are present, how do you deliver?
Cesarean section
How do you diagnose parvovirus?
Check parvovirus IGM and IgG. If IgM (-), but IgG (+) -> prior immunity If IgM (-), and IgG (-) -> no acute infection but sucseptible to future infections
It a GBS colonized women has a severe penicillin allergy, what do you give her?
Clindamycin or erythromycin if no GBS resistance is noted
How do you treat congenital toxoplasmosis in infants?
Combination therapy with pyrimethamine, sulfadiazine, and leucovorin for 1 year
How does BV present? How do you diagnose it? What common bugs cause it?
Common symptoms include a malodorous discharge or vaginal irritation or asymptomatic Diagnosis can be made with three of four following findings (Amsel's criteria): 1) presence of thin, white or gray, homogenous discharge coating the vaginal walls 2) an amin (or "fishy") odor noted with addition of 10% KOH ("whiff" test) 3) pH of greater than 4.5 4) presence of more than 20% of the epithelial cells as "clue cells" Gardneralla vaginosis, Bacteroides, and Mycoplasma hominis
What congenital malformations are associated with VZV?
Congenital varicella syndrome which is characterized by skin scarring, limb hypoplasia, chorioretinitis, and microcephaly.
Infants with CMV who are symptomatic can develop?
Cytomegalic inclusion diesease manifeste by a constellation of findings including hepatomegaly, splenomegaly, thrombocytopenia, jaundice, cerebral calcifications, chorioretinitis, and interstitial pneumonitis.
What bugs commonly cause UTIs and asymptomatic bacteriuria? How do you treat it?
E. coli Gram (-) -Klebsiella, Proteus Gram (+) - Staphlococcus, GBS, Enterococcus Amxocilln/ nitrofurantoin/ bactrim/ cephalexin
How does pyelonephritis present?
Fever, chills, flank pain, dysuria, urgency, and frequency. On physical exam, fever and costovertebral angle tenderness.
How does congenital toxoplasmosis infection present?
Fevers, seizures, chorioretinitis, hydro- or microcephaly, hepatosplenomegaly, and jaundice. Disseminated purpuric rash, enlargement of the spleen and liver, ascites, chorioretinitis, uveitis, periventricular calcifications, ventriculomegaly, seizures, and mental retardation.
Approximately one-third to one-half of cases of neonatal herpes are caused by?
HSV 1
Neonates delivered to seropositive mothers should receive what?
Hep B immune globulin within 12 hours after birth. Before their discharge from the hospital, these infants also should begin the hepatitis B vaccination series.
How is gonococcal infection treated?
IM ceftriaxone, oral cefixime, or iM spectinomycin in cases where cephalopsorins cannot be tolerated. Patients should be treated with azithromycin or amoxicillin for presumed chlamydial infection.
Chorioamniotis is the most common precursor of neonatal sepsis, which has a high rate of neonatal mortality. What is chorioamniotis?
Infection of the membranes and amniotic fluid surrounding the fetus
How do you confirm an active Hepatitis B infection?
Know all the combinations
DO patents receive the measles, mumps, and rubella (MMR) vaccine?
No, because of the theoretical risk of serious fetal injury.
Parvovirus is a DNA virus that causes erythema infectiosum (fifth disease). How does it present? What additional sequelea may appear in children?
Low-grade fever, malaise, myalgias, arthralgias, and a red maculopapular "slapped cheek" facial rash. An erythematous , lace like rash also may extend onto the torso and upper extremities. Transient aplastic crisis.
How is chorioamniotis clinically diagnosed? What is the gold standard for diagnosis?
Maternal fever (body temperatue > 100.4 or 38C), uterine tenderness, maternal tachycardia, and/or fetal tachycardia (> 160), and a foul smelling amniotic fluid Culture of amniotic fluid which can be obtained via amniocenteis
VZV pneumonia in pregnancy is a risk factor for?
Maternal mortality
Rubella = German measles How does rubella present in adults? How does rubella present congenitally?
Mild illness with a widely disseminated, nonpruritic erythematous manulopapular rash, arthritis, arthralgias, and a diffuse lymphadenopathy that lasts 3 to 5 days. Postauricular adenopathy and mild conjuctivitis also are common. COngenital rubella syndrome - deafness, cataracts/retinopathy, CNS defects, cardiac malformations (PDA, supravalvular pulmonic stenosis)
Is GBS prophylaxis indicated for cesarean delivery before ROM and labor?
No
Is screeing for BV in asymptomatic women routinely recommended? Is treatment of symptomatic women who are diagnosed in pregnancy recommended?
No Yes
Intrapartum prophylaxis with penicillin for GBS is reserved for what situations?
PTL (< 37 weeks) Prolonged ROM (> 18 hrs) Fever in labor regardless of colonization status Women identified as colonized with GBS through screening at 35 - 37 weeks of gestsation Women with GBS bacteriuria or with previous infant with GBS dz
How do you treat maternal syphilis? How do you prevent maternal syphilis tranmission to the fetus? How do you treat fetal infection?
Penicillin Penicillin Penicillin
How do you manage a pregnant woman withone episode of pyelonephritis or two or more episodes of ASB and/or cystitis?
Place on antimicrobial prophylaxis, usually macrodantin or bactrum nightly, for the remainder of the duration of the pregnancy.
Gonococcal infections are asosciated with pelvic inflammaotry disease in early pregnancy, as well as preterm delivery, PPROM, and puerpal infections throughout pregnancy duration. How does the amniotic infection syndrome present?
Placental, fetal membrane, and umbilical cord inflammation that occurs after PROM and is associated with infected oral and gastric aspirate, leukocytosis, neonatal infection, and maternal fever.
How is pyelonephritis treated?
Pyelonephritis is not only a risk factor for preterm labor but also has particularly serious associated maternal complications including septic shock and ARDS. Treat with IV hydration, IV antibiotics - cephalospoins (cefazolin, cefotetan, or ceftriaxone) or ampicillin and gentamicin.
GBS is responsible for UTIs, chorioamnionitis, and endomyometritis during pregnancy, and neonatal sepsis. When is it screened for and how? How is it treated?
Rectovaginal culture between 35 and 37 weeks IV penicillin G at the time of labor or rupture of membraes (ROM).
How should the diagnosis of HSV be confirmed?
Serologically or with viral culture.
Peniciilin remains the only treatment with sufficient evidence demonstrating efficacy for treating syphyllis. If a pregnant patient diagnosed with sypilis is penicillin allergic, what do you do?
She must undergo desensitization and then be treated with penicillin
How does congenital CMV present? How is it diagnosed?
Sonographic findinds - microcephaly, ventriculomegaly, intercerebral calcification, fetal hydrops, growth restriction, and oligohydramnios Identification of the virusi n a mniotic fluid by eithe rculture or PCR.
WHen acute toxoplasmosis occurs during pregnancy, treatment is indicated because maternal therapy reduces the risk of congenital infection and decreases the late sequelae of infection. What do you treat maternal disease with?
Spiramycin
If studies indicate an acute parvovirus infection (IgM (+) and IgG (+) or (-)) beyond 20 weeks of gestation, what should you do?
The fetus should undergo serial ultrasounds up to 8 to 10 weeks after maternal infection is suspected to have occurred. A more precise way to detect evolving fetal anemia is to use Doppler velocimetry to examine the peak systolic velocity of the middle cerebral artery. Icnreases -> fetal anemia. If so, a cordocentesis should be performed to determine the fetal hematocrit. If anemia is confirmed, an intrauterine blood transfusion should be performed.
Bacterial vaginosis increases the risk for preterm premature rupture of membranes (PPROM), preterm delivery, and puerpal infections, including chorioamnionitis and endometritis. How do you manage it?
Treat (metronidazole (Flagyl) or clindamycin)and follow up with a test of cure 1 month after treatment completion
Infants of mothers who develop varicella disease within 5 days before delivery or 2 days after should also receive what? If a susceptible patient is exposed to someone with caricella, she should be treated with what?
VZIG and/or acyclovir/valacyclovir VZIG and oral acyclovir/valacyclovir
In patients with a severe penicillin allergy where GBS is resistant to clindamycin or of unknown susceptibility, what is used for prophylaxis?
Vancomycin
How are HSV infection in the neonate diagnosed? How do you treat it?
Viral culture of the herpetc lesions, oropharynx, or eyes IV acyclovir
Parvovirus First trimester infections have been associated with miscarriage, but midtrimester and later infetions are associated with fetal hydrops. How does this happen?
WHen materrnal parvovirus infection occurs during pregnancy, the virus can cross the pacenta and infect RBC orogenitors in the fetal bone marrow. The virus attaches to an antigen on RBC stem cells and supresses erythropoeisis, thereby resulting in severe anemia and high-output congestive heart failure.
When is transmission most common in toxoplasmosis?
When disease is acquired in the third trimester. INfections acquired in the first trimester are transmitted less commonly; however, the infection has far more serious consequences in the fetus.
Is the varicella vaccine contraindicated in pregnancy?
Yes, because it is a live virus vaccine that is highly immunogenic.
Are women with an unknown GBS status and experiencing labor before 37 weeks treated? If so, with what?
Yes, with penicillin G until delivery
Atre women with an unknown GBS status and have ROM greater than 18 hours treated? If so, with what?
Yes, with penicillin G until delivery