Maternal Infections

HIV Expected Findings

*Fatigue and influenza-like findings*. Influenza-like Symptoms: Symptoms include fever, chills, muscle aches, cough, congestion, runny nose, headaches, and fatigue. People may experience: *Pain areas*: in the muscles *Cough*: can be dry or with phlegm *Whole body*: chills, dehydration, fatigue, fever, flushing, loss of appetite, body ache, or sweating *Nasal*: congestion, runny nose, or sneezing *Also common*: chest pressure, head congestion, headache, nausea, shortness of breath, sore throat, or swollen lymph nodes EXPECTED FINDINGS: -fever -diarrhea and weight loss -lymphadenopathy and rash -anemia

Syphilis Expected Findings

*Primary Stage:* pt notices a *chancre or sore* in the genital area *Secondary Stage:* pt notice *skin rashes* on the *palmar* surfaces of the hands and *soles* of the feet [rough, red or reddish brown spots] *Tertiary Stage:* Damage to internal organs occur for which pt can notice the manifestations including: *difficulty coordinating muscle movements* and *blindness*

Syphilis Lab Testing

*Serology tests:* Sequence of nontreponemal then treponemal tests is considered the standard for testing. 1. *Nontreponemal* (VDRL and rapid plasma reagin): tests are often used for SCREENING 2. *Treponemal* (enzyme immunoassay) test is then done to detect antibodies specific for syphilis to CONFIRM the diagnosis

HIV Nursing Cares

-Administer antiviral prophylaxis, triple-medication antiviral, or highly active antiretroviral therapy as ordered -Encourage immunization against hepatitis B, pneumococcal infections, Haemophilus influenzae type B, and viral influenza -Review plan for *scheduled c-section* 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 Medications

1. *Retrovir* [antiretroviral agent; nucleoside reverse transcriptase inhibitor] -Administer at *14 weeks* gestation, throughout the pregnancy, and *BEFORE the onset of labor* or c-section -Administer to the INFANT at delivery and for *6 weeks* following birth EDUCATION: -Do NOT breastfeed! -HIV/AIDs is a reportable disease in all states.

TORCH Risk Factors

1. *Toxoplasmosis:* caused by consumption of raw or undercooked MEAT or handling CAT FECES. -Manifestations: similar to influenza or lymphadenopathy 2. *Other infections:* 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. 3. *Rubella (German measles):* is contracted through children who have rashes or neonates who are both to women who had rubella DURING pregnancy. 4. *Cytomegalovirus* (member of the 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 can be REACTIVATED and cause disease to the fetus *in utero OR during passage through the birth canal* 5. *Herpes simplex virus (HSV):* is spread by *direct contact* with *oral or genital lesions.* Transmitted to the fetus is greatest during vaginal birth if woman has ACTIVE LESIONS.

TORCH Expected Findings

1. Toxoplasmosis: similar to influenza or lymphadenopathy [malaise, muscle aches, flu-like symptoms: fever and tender lymph nodes] 2. Other: variety 3. Rubella: joint and muscle pain; rash, mild lymphedema, fever, and *fetal consequences: miscarriage, congenital anomalies, and death* 4. Cytomegalovirus: asymptomatic or mononucleosis-like manifestations Mono Symptoms: Symptoms include fatigue, fever, rash, and swollen glands. The elderly may not have typical symptoms. People may experience: Pain circumstances: can occur while swallowing Whole body: fatigue, fever, chills, malaise, or body ache Also common: sore throat, swollen lymph nodes, swollen tonsils, headache, or nausea 5. Herpes simplex infections: symptoms consisting of painful blisters and tender lymph nodes. *Fetal consequences: miscarriage, preterm labor, and intrauterine growth restriction.* -A c-section is recommended for all women in labor with ACTIVE lesions or early symptoms of impending outbreak, such as vulvar pain and itching.

Bacterial Vaginosis

A *bacterial* infection most commonly caused by Haemophilus vaginalis or Gardnerella vaginalis. Most common vaginal infection in women 15-44 years. It CANNOT be r/t sexual activity! If left untreated can lead to PID and cause infertility. Tx is especially important for pregnant women. BV is associated with *preterm labor* and babies with *low birth weight* (less than 5.5 lbs) RISK FACTORS: -new or multiple sex partners -unprotected sex -*altered pH balance of vagina*, such as caused by douching

GBS Nursing Cares & Medications

Administer intrapartum antibiotics prophylaxis to the following pts: 1. Pt who has GBS bacteriuria during current pregnancy 2. Pt who has a GBS-positive screening during current pregnancy 3. Pt who has unknown GBS status who is delivering at less than 37 weeks of gestation 4. Pt who has maternal fever of 38c [100.4f] 5. Pt who has rupture of membranes for 18+ hours MEDICATIONS: Penicillin G or Ampicillin are most commonly prescribed. Bactericidal antibiotics are used to destroy the GBS. -Administer penicillin 5 million units initially IV bolus, followed by 2.5 million units intermittent IV bolus q 4 hrs. -The pt may receive ampicillin 2 g IV initially, followed by 1 g every 4 hrs.

Candidiasis

Also known as *vulvovaginal candidiasis* or *yeast infection,* is a *fungal* infection caused by Candida albicans. Second most common vaginal infection. All women who have symptoms should be tested. RISK FACTORS: -pregnancy -DM -oral contraceptives -recent ABX treatment -obesity -diet high in refined sugars

Chlamydia

Chlamydia is a *bacterial infection* and is the most commonly reported STI. The infection can be difficult to diagnose bc it is often *asymptomatic.* If left untreated, it can lead to PID which can cause infertility! The CDC recommends *yearly screenings of ALL sexually active women younger than 25 years old*, as well as older women who have risk factors (new or multiple partners). All pregnant women should be screened at the *first prenatal visit* and *rescreened during 3rd trimester if younger than 25 and/or at high risk* RISK FACTORS: -multiple sex partners -unprotected sex

TORCH Nursing Cares

For *Rubella,* immunization of women who are pregnant is CONTRAINDICATED bc rubella infection can develop. -These women should AVOID crowds of young children. -Women who have *low titers PRIOR* to pregnancy should receive immunizations EDUCATION: -educate on prevention practices, including correct hand hygiene and cooking meat properly. Instruct pt to avoid contact with contaminated cat litter. -bc NO TX for cytomegalovirus exists, tell the pt to prevent exposure by frequent hand hygiene before eating, and after handling infant diapers and toys!!!

Group B Streptococcus

GBS is a *bacterial* infection that can be passed to a fetus during *labor and delivery* RISK FACTORS: hx of positive culture with previous pregnancy -Maternal age <20 years old -African American or HIspanic -Prolonged rupture of membranes -Preterm delivery and Low birth weight -Use of intrauterine fetal monitoring -Intrapartum maternal fever (38c [100.4f] or greater)

ATI QUESTION: Which infections can be treated during labor or immediately following birth?

Gonorrhea, Chlamydia, HIV, GBS TORCH infection can be treated during pregnancy depending on the infection.

HIV/AIDs

HIV is a retrovirus that attacks and causes destruction of T lymphocytes causing immunosuppression. HIV is transmitted from the mother to the neonate perinatally through the *placenta* and postnatally through the *breast milk.* -Testing is recommended in the *third trimester* for pts who are at an increased risk. Rapid HIV testing should be done if pt is in labor and her HIV status is unknown! -Procedures such as amniocentesis and 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 due to the risk of fetal bleeding. -Administration of injections and blood testing should NOT take place until the *first bath* is given to the newborn.

Human Papilloma Virus (HPV)

HPV is the most common STI. Some types can cause genital warts (aka Condyloma acuminata) and cancers. Spreads through *oral, vaginal, and anal sex* (most commonly through vaginal or anal routes). When large, widespread, or occluding the birth canal, genital warts can complicate a vaginal delivery. Therefore, a c-section can be recommended. Routine Screening for women 21-65 years old can provide early detection. *Screening should occur, even during pregnancy!* RISK FACTORS: -multiple sex partners -unprotected sex

Chlamydia Nursing Care

Identify and treat ALL sexual partners! Pt who are pregnant should be *retested 3 weeks after completing prescribed regimen!*

Trichomoniasis

Is an STI caused by the *protozoan parasite* Trichomonas vaginalis. Spread *penis-to-vagina* or *vagina-to-vagina* If left untreated it can lead to PID which can cause infertility. Pregnant women who have trich are more likely to have *preterm delivery* and babies with *low birth weight* (less than 5.5 lbs.) RISK FACTORS: -multiple partners -unprotected sex

Candidiasis Lab Tests & Diagnostics

Lab Tests: 1. pH paper 2. Wet mount 3. Whiff Test Diagnostics: 1. pH LESS than 4.5 [normal pH] 2. Wet mount POTASSIUM HYDROXIDE prep [all other saline] indicates presence of *yeast buds, hyphae, and psuedohyphae* 3. NEGATIVE whiff test

Trich Lab Tests & Diagnostics

Lab test: A sample of discharge is used for application to 1) *pH paper* 2) *wet mount* and 3) *whiff test* performed Diagnostics: 1. pH greater than *4.5* 2. Wet mount saline prep indicates presence of trichomonads 3. Whiff test can be *positive or negative*

Gonorrhea Expected Findings

MALES: -dysuria -urethral discharge FEMALES: -dysuria -vaginal bleeding between periods and *dysmenorrhea* -Yellowish-green vaginal discharge; easily induced endocervical bleeding

Trich Expected Findings

MALES: -penile itching or irritation -dysuria -urethral discharge [can be swabbed for microscopy] FEMALE: -yellow-green, FROTHY vaginal discharge w FOUL ODOR [discharge in vaginal vault can be sampled for microscopy] -dyspareunia and itching -dysuria -*Strawberry spots* on the cervix [tiny petechiae]; cervix BLEEDS EASILY

Chlamydia Expected Findings

MALES: -urethral discharge [mucoid or watery discharge] -dysuria FEMALES: -dysuria -urinary frequency -spotting or postcoital bleeding [bleeding after sex] -mucopurulent endocervical discharge; easily induced endocervical bleeding

Chlamydia Lab Tests

Males: urine culture Females: endocervical culture

Maternal Infections

Maternal infections during pregnancy require prompt identification and treatment by a provider. These include: 1. Human Immunodeficiency virus (HIV) 2. Acquired Immune Deficiency Syndrome (AIDS) 3. TORCH infections: Toxoplasmosis, Other infections (e.g. hepatitis), Rubella, Cytomegalovirus, Herpes Simplex Virus 4. Group B Streptococcus (GBS) 5. Chlamydia 6. Gonorrhea 7. Syphilis 8. Human papillomavirus (HPV) 9. Trichomoniasis 10. Bacterial vaginosis (BV) 11. Candidiasis

BV Medications & Education

Medication: *Metronidazole* -anti-infective EDUCATION: Same as Trich plus... -avoid tight-fitting clothing -wear cotton lined underwear -avoid douching

Candidiasis Medications & Education

Medications: 1. *Fluconazole* -can be prescribed as a single low dose -topical therapies recommended for all pregnant women! -antifungal agent 2. *OTC: Clotrimazole* OTC tx are available. However, it is important for the MD to diagnose candidiasis initially! EDUCATION: -avoid tight clothing -wear cotton panties -limit wearing damp clothing -avoid douching -increase dietary intake of yogurt with active cultures!!!

HPV Medications & Education

Medications: For genital warts, options include: -Imiquimod: pt-applied cream -Trichloroacetic acid: provider-administered therapy EDUCATION: -Vaccines are recommended to protect against low-risk type of HPV that cause genital warts and high-risk types of HPV that cause cancer. The vaccine is indicated for pt 9-26 years, through ideally given at age 11-12 years.

Chlamydia Medications & Education

Medications: *Azithromycin or Amoxicillin* -prescribed DURING pregnancy -broad-spectrum ABX -bactericidal action Nursing Considerations: -Administer erythromycin to ALL INFANTS following delivery! This is the med of choice for *ophthalmia neonatorum.* This med is both bacteriostatic and bactericidal, and thus provides prophylaxis against Neisseria gonorrhoeae and Chlamydia trachomatis. EDUCATION: -Educate on the possibility of *decreasing effectiveness of oral contraceptives* -Chlamydia is on the reportable disease list in all states!

Trich Medication & Education

Medications: *Metronidazole or Tinidazole* -orally in a single dose; anti-infective EDUCATION: -avoid alcohol while taking these meds due to the *disulfiram-like reaction* that occurs (severe nausea and vomiting) -decreasing the effectiveness of oral contraceptives -ID and treat all sex partners

Syphilis Medication & Education

Medications: *Penicillin G IM* in a *single dose* EDUCATION: -instruct to *abstain* from sex until sores have completely healed! -advise pt that partners need to be tested and treated -listed on reportable disease list in all states

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 can also be spread by *anal-to-genital or oral-to-genital contact.* It can also be transmitted to a newborn during delivery!!! The infection can be difficult to diagnose bc it is often *asymptomatic.* If left untreated, it can lead to PID which can cause infertility! The CDC recommends *yearly screenings of ALL sexually active women younger than 25 years old*, as well as older women who have risk factors (new or multiple partners). All pregnant women should be screened at the *first prenatal visit* and *rescreened during 3rd trimester if younger than 25 and/or at high risk* RISK FACTORS: -multiple sex partners -unprotected sex

Gonorrhea Nursing Care, Medications & Education

Nursing Cares: same as chlamydia Medications: *Ceftriaxone IM and Azithromycin PO* Education: Same as chlamydia -repeat the culture to assess for medication effectiveness

HIV Lab Tests

Obtain informed maternal CONSENT prior to testing! 1. Testing begins with an *antibody screening test* (such as enzyme immunoassay). 2. Confirmation of positive results is confirmed by *Western blot test* or *immunofluorescence assay.* 3. Use rapid HIV antibody test (bloor or urine sample) for a pt in labor 4. Screen clients for STIs such as *gonorrhea, chlamydia, syphilis, and hepatitis B* 5. Obtain frequent *viral load levels and CD4 cell counts* throughout pregnancy

HPV Lab Tests & Diagnostic Procedures

Pap test: -Woman 21-29 years old should have pap test q 3 years -woman 30-65 years old should have both pap test and HPV test q 5 years -woman 65+ years who have had regular screening with normal results should NOT be screened for cervical cancer, unless they have cervical precancer, in which they should be screened for 20 years after the precancer diagnosis. Diagnostic Procedures: Based on pap test results, *colposcopy and biopsy* can be performed to diagnose cervical precancer and cancer.

GBS Expected Findings

Positive GBS can have maternal AND fetal effects -Premature rupture of membranes -preterm labor and delivery -chorioamnionitis -UTI -Maternal sepsis

HPV Expected Findings

Pt reports *bumps* in genital area that might not itch or hurt. -small warts or group of warts in the genital area that can have a *cauliflower-like* appearance -abnormal changes to cervix that can be detected by a Pap test

BV Lab Test & Diagnostics

Same as Trich Diagnostics: 1. pH greater than 4.5 2. Wet mount indicated presence of clue cells 3. Positive whiff test

Syphilis

Syphilis is an STI caused by the *bacterium* Treponema pallidum. It can have *long-term complications* if not adequately treated. Syphilis has *three stages:* 1. *Primary:* characterized by the presence of *chancre* 2. *Secondary:* characterized by *skin rashes,* such as a rash on the *palms of hands and soles of feet.* 3. *Tertiary:* characterized by *damage to internal organs* Can be transmitted through *oral, vaginal, or anal sex;* can also be transmitted to an *unborn child.* All pregnant women should be screened at the *first prenatal visit* and *rescreened in the 3rd trimester if at high risk* (live in area with high # of syphilis; not previously tested; or had positive test in first trimester) RISK FACTORS: -multiple partners -unprotected sex

BV Expected Findings

Thin, white or gray discharge with a *fish-like odor,* especially after sex.

TORCH Infections

Toxoplasmosis, Other infections (e.g. hepatitis), Rubella virus, Cytomegalovirus, and Herpes simplex virus are known collectively as TORCH - which is 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.

GBS Lab Tests

Vaginal and rectal cultures are performed at *35-37 weeks gestation*

Candidiasis Expected Findings

Vulvar and vaginal pruritus -thick, creamy, white, *cottage-cheese* like vaginal discharge -vulvar and vaginal erythema and inflammation -white patches on vagial walls -gray-white patches on the *tongue and gums (NEONATE)*