Class 4 (Perinatal Infections)

Highly Active Antiretroviral Therapy

(ART) is the combination of several antiretroviral medicines used to slow the rate at which HIV makes copies of itself (multiplies) in the body. A combination of three or more antiretroviral medicines is more effective than using just one medicine (monotherapy) to treat HIV.

Bacterial Vaginosis

- Most common in ages 15-44 -Cause: Bacterial imbalance-> of good and bad vaginal bacteria Unknown as well -Transmission Not sexually transmitted Unbalanced flora in the vagina -Symptoms: Asymptomatic-> 50% Fishy odor and thin, watery, yellow/gray discharge -Effects: Preterm labor/birth, premature rupture of membranes, chorioamnionitis -Treatment: Metronidiazole-> can lead to pre-term labor-> can be given at anytime during pregnancy Prevention measures

Listeria & Coxsackie

-Bacteria: Listeria monocytogenes Often associated with drinking outdated dairy products; eating soft cheeses; cantaloupe outbreak in 2011; pre-packaged caramel apples Transmission: Transplacentally Fetal-neonatal effects Miscarriage; fetal death Neonatal death related to pyogenic meningitis (bacterial meningitis) Prevention- (especially for compromised individuals) avoid eating high risk foods -Coxsackie virus infection- Hand, foot and mouth (less common) Transmission: upper resp. secretions; body fluids Very uncommon in ages 5 and less Fetal-neonatal effects Death Chorioamnionitis, placental infection Myocarditis, encephalitis (inflammation of the brain) - No treatment -Prevention-> good wand washing, avoid close contact with infected individuals

Chlamydia

-Bacterium: Chlamydia trachomatis -Most common STI in U.S. -Symptoms: Often asymptomatic-> known as the silent disease Untreated may cause PID (Pelvic inflammatory disease) leading to infertility and increased ectopic pregnancy (a pregnancy in which the fetus develops outside the uterus, typically in a Fallopian tube.) risk -Transmitted to fetus via infected contact of the birth canal -Treatment IN pregnancy: Azithromycin Treat partners with Doxycycline (NOT in pregnancy) -Neonatal effects: Most common cause of ophthalmic neonatorum -> Prevent conjunctivitis with e-mycin ophthalmic ointment Chlamydial pneumonia - can cause preteen labor and fetal death -all woman should be tested for this STD during plan of pregnancy or early in pregnancy - Azithromycin-> both partners are treated and woman should avoid any sexual intercourse till treatment is complete-> tested cure-> if failed than woman are re-tested in the third trimester

Gonorrhea

-Bacterium: Neisseria gonorrhoeae -Second most common STI in the U.S. -First indication-> positive routine prenatal cervical culture -Symptoms: Aymptomatic especially in women (80%) Purulent vaginal discharge -Treatment: Usually ceftriaxone Treat ALL sexual partners also Re-culture to verify cure -Transmission to fetus through contact in birth canal-> vaginal delivery -Newborn effects: Ophthalmia neonatorum, sepsis, joint infection Erythromycin ophthalmic ointment after delivery -Nursing Role-> education concerning safe sexual practices; help prevent exposure and transmission

Rubella Manifestations

-Clinical signs in neonate Congenital cataracts Sensorineural deafness Congenital heart defects (PDA) -Other abnormalities Mental retardation Cerebral Palsy -Isolate infants with rubella Can shed the virus for 12 months

HPV Delivery

-Delivery: C-section delivery NOT warranted Recommended to deliver vaginally warts are non-tender, pink, soft, -May impede vaginal delivery if warts are very large and obstruct vaginal canal

Human B19 Parvovirus Risks and treatments

-Fetal-Neonatal Risks Fetal death- 10%-> Usually occurs 4-12 weeks after infection Non-immune hydrops and marked fetal anemia-> Approximately 1/3 will resolve spontaneously-> May need intrauterine fetal transfusion Development is normal if fetus survives infection Fetal surveillance with ultrasound evaluation of peak systolic velocity of the middle cerebral artery-> can help to determine fetal anemia -Treatment: avoidance of exposure

Toxoplasmosis Risks and treatment

-Fetal-neonatal risks Fetal infection Severe neonatal disorders Blindness, deafness, retardation, seizures Highest risk in 3rd trimester Severe fetal disease or death Hydrocephaly( build up of fluid in brain cavities), microcephaly( baby head is smaller) Highest risk of death in 1st trimester -Treatment: Recent infection: Spiramycin Decreases transmission to fetus but does not cross placenta to treat fetus Suspected fetal infection: Sulfadiazine, pyrimethamine and folinic acid Given after the first trimester

CMV Risks and Treatments

-Fetal-neonatal risks: Fetal death Small for gestational age Microcephaly/Hydrocephaly Cerebral palsy Mental retardation No damage at all -Treatment: None known at this time -Diagnosis: Blood testing Sero-conversion Amniocentesis-> amniotic fluid test

Herpes Simplex Virus

-HSV 1 or HSV 2 -Causes lesions in the genital tract -Transmission: Direct contact with lesion during birth Ascending infection during birth After amnionic membranes rupture 50% infants develop HSV infection if mother has primary genital HSV infection and delivers vaginally; risk drops to 1-5% if recurrent infection Transplacental infection: Rare -Neonatal infection 50-60% mortality with exposure to primary lesion -If occurs in the first trimester-> risks of spontaneous miscarriage gets increased Neurological complications, sepsis and death

HIV Risks and Treatment

-Labor considerations IV Zidovudine C/S + intact membranes can decrease vertical transmission by 50% (depends on CD4 count) avoid FSE, scalp pH, forceps & vacuum extraction -Neonatal care: Wipe off secretions immediately Bathe ASAP once stable Use strict infection control techniques Breastfeeding contraindicated in U.S. population-> avoiding maternal secretions-> in third world countries where there is little to none access to cleaner water, babies are recommended to be breastfeed Neonatal treatment- Highly active antiretroviral therapy -Other considerations Observe for other infections in immunosuppressed women If no treatment in pregnancy testing done postpartum to determine therapy need

Juvenile laryngeal papillomatosis

-Laryngeal papillomatosis, also known as recurrent respiratory papillomatosis or glottal papillomatosis or associated with condyloma acuminata, is a rare medical condition (2 per 100,000 adults and 4.5 per 100,000 children), caused by a human papillomavirus (HPV) infection of the throat. -Oral Human Papilloma Virus (HPV) Infection. Human papilloma virus (HPV), commonly known as the virus that causes genital warts and cervical cancer in women, is increasingly being recognized as a cause of infections that colonize the back of the mouth (throat), including the tongue base and tonsils.

Varicella

-Member of the herpes family -If unknown immunity check titer -Exposure: Give Varicella-Zoster Immune Globulin (VZIG) within 96 hours-> may help of active form of infection to develop -Effects of infection: Maternal: High risk of death due to pneumonia (50%) Fetal: Infection in first 20 weeks can lead to congenital varicella syndrome (1-2 % risk) Limb hypoplasia, contractures, eye and CNS involvement Neonatal: Highest if maternal infection within 5 days of delivery and less than 2 days after delivery -Maternal antibodies do not cross placental barrier-> neonate are vaccinated later in life

TB

-Mycobacterium tuberculosis -Testing: Recommended TB skin testing in high risk population Chest x-ray if IPPD is positive -Active TB Treated with Isoniazide, rifampin, ethambutol No direct contact with newborn until non-infectious-> no breastfeed -Inactive TB May breastfeed Delay treatment until pp

ophthalmic neonatorum

-Neonatal conjunctivitis, also known as ophthalmia neonatorum, is a form of conjunctivitis and a type of neonatal infection contracted by newborns during delivery. The baby's eyes are contaminated during passage through the birth canal from a mother infected with either Neisseria gonorrhoeae or Chlamydia trachoma's.)-> caused eye discharge -> Prevent conjunctivitis with e-mycin ophthalmic ointment

Syphilis Stages of Infection

-Primary -Secondary -Latent - late - Highest transmission placenta in primary and secondary

Trichomoniasis

-Protozoan parasite: Trichomonas vaginalis -Transmission: Sexually -Effects: May be asymptomatic Foul Smelling Malodorous yellow-green discharge Vulvar irritation; strawberry patches on cervix - It causes Preterm labor, birth, or premature rupture of membranes -Treatement: Metronidazole (Flagyl): Treatment can also lead to preterm labor-> one time dose-> treatment of choice

Toxoplasmosis

-Protozoan: Toxoplasma gondii -Transmission Eating raw or undercooked meat/game meats Contact with the feces of infected cats Transplacental -Statistics: In the US, ~ 38% pregnant women have antibodies & 40% to 50% of the general population have antibodies When a pregnant woman becomes infected, there is a 40% chance the fetus will get congenital toxoplasmosis -Symptoms: Usually mild flu like symptoms Asymptomatic

HIV

-Serum testing should be offered to all women www.cdc.gov/hiv/topics/surveillance/basic.html Two methods of rapid testing blood or saliva: OraQuick Rapid HIV antibody test Results in 20 min. > 99% accuracy rate -Monitor CD4 count -AZT (ZVD) recommended in pregnancy 70% reduction transmission to fetus Without AZT(ZVD) 13-30% of neonates will be infected & 100% will die -Prevention: Encourage safer sex: mother can be REINFECTED and cause new viral load

Syphilis

-Spirochete- Treponema pallidum - Causes pink, round, firm, painless where the bacteria settled -Transmission: Sexually transmitted infection Transplacentally -Serologic testing recommended on all pregnant-> most state laws require it -Treatment: Usually Penicillin G Screen and treat ALL partners -Fetal-Neonatal effects (if mom is untreated): Second trimester loss Still birth at term Congenital infection-> causes cataracts, deafness, and seizures Live unaffected infant

TORCH infections

-TORCH"- acronym for the following infections: Toxoplasmosis Other: Varicella, Human B19 Parvovirus, Syphilis, Listeria, & Coxsackie Virus Rubella CMV HSV -Exposure to infections may impact fetus any time in pregnancy

Transmission

-Transplacental-> infections crossing through the placenta -Ascending infection-> ascend from the birth canal -Direct contact through the vaginal delivery

Varicella Treatment

-Treatment with antiviral medication for maternal infection - 3 Vir! -Acyclovir, Valcyclovir, or Famcyclovir to reduce symptoms, duration and intensity -Safe for use in pregnancy

Herpes Simplex Virus Treatment

-Treatment: Prophylactic anti-viral medications beginning at 35-36 weeks offered -Zovirax (acyclovir) 500 mg BID-> can begin earlier f there are multiple out breaks during pregnancy-> this is to prevent further outbreaks until birth Begin anti-viral medications if 2-3 outbreaks during pregnancy -Delivery: C-section if active lesions-> recommended Vaginal delivery no active lesions for 7 days-> is acceptable

Human Papillaoma Virus

-Viral- more than 60 genotypes-> only about 30 infects the genital tract -Transmission: Sexually Transplacental transmission remains controversial-> or unclear -Neonatal risk: Juvenile laryngeal papillomatosis-> highest in initial outbreak or contact More a risk with initial outbreak HPV & direct contact -Can be treated in pregnancy with Tricholoracetic acid, laser, or surgery Often resolve without treatment warts can return after treatment is completed -HPV vaccine-> doesn't prevent all HPV infections-> best administered prior to intercourse-> all (males females) should start administration in their teens-> not recommended during pregnancy-> may be given during breastfeeding

Cytomegalovirus (CMV)

-Virus -Belongs to herpes family most common in young children and their parents -Transmission: Across placenta to fetus Cervical route during birth Transmission in day care centers is very high Close contact with infected individual Viral shedding can occur continually over many years -Usually harmless in adults and children, common to be asymptomatic -Most common viral cause of intrauterine infection

Hepatitis B

-Virus -Transmission: Blood exposure Not transmitted transplacentally-> fetus is only infected via infected blood or during delivery -Diagnosis: Hepatitis B surface antigen part of initial OB labs Hep e antigen positive=diagnosis of active infection -Prevention of transmission to newborn Bathe ASAP Hepatitis B immune globulin-> to prevent in active infection Hepatitis B vaccine-> soon as possible after birth-> to help create antibodies Other family members-> should be tested as well

Rubella

-Virus -Transmission: contact with infected secretions Across placenta to fetus The period of greatest risk is the 1st 10 weeks; 90% of fetuses will be affected In weeks 11 and 12 the risk drops to 50% -Treatment: Prevention Vaccination of all children Vaccination of women of reproductive age (prior to pregnancy or postpartum)-> should be avoided during pregnancy due to it being a live vaccination

Human B19 Parvovirus

-Virus that targets rapidly dividing cells -Also called Fifth's disease in children Very common in day care and schools Greater than ½ of pregnant women already immune -Symptoms in adults: Usually mild Most common->May develop "slapped cheek" rash, low grade fever, nasal discharge, head aches, nausea, joint pain -Transmission to fetus-> Transplacentally-> approximately 33%

Hydrous

-is a serious fetal condition defined as abnormal accumulation of fluid in two or more fetal compartments, including ascites, pleural effusion, pericardial effusion, and skin edema

Sero-conversion

-is the period of time during which HIV antibodies develop and become detectable. Seroconversion generally takes place within a few weeks of initial infection.

chorioamnionitis

also known as intra-amniotic infection (IAI) is an inflammation of the fetal membranes (amnion and chorion) due to a bacterial infection. It typically results from bacteria ascending into the uterus from the vagina and is most often associated with prolonged labor.

intrauterine fetal transfusion

provides blood to an Rh-positive fetus when fetal red blood cells are being destroyed by Rh antibodies. A blood transfusion is given to replace fetal red blood cells that are being destroyed by the Rh-sensitized mother's immune system.