H:\Infections In Pregnancy 2008 Cert Day 1[1]

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H:\Infections In Pregnancy 2008 Cert Day 1[1]

  1. 1. Infections in Pregnancy Chris Rust, RNC- OB, MSN Sandy Warner RNC-OB, MSN
  2. 2. Acquired Immune Deficiency Syndrome <ul><li>Organisms </li></ul><ul><li>- HTLV III– Human T- Cell Lymphotrophic </li></ul><ul><li>Virus </li></ul><ul><li>- HIV – Human Immune Deficiency Virus </li></ul><ul><li>Classes </li></ul><ul><li>I - Primary HIV </li></ul><ul><li>II - Asymptomatic /Latent HIV – months to yrs </li></ul><ul><li>III - Clinical Illness – life expectancy – 5 yrs. </li></ul><ul><li>IV - AIDS </li></ul>
  3. 3. AIDS <ul><li>Selectively targets and </li></ul><ul><li>destroys T-cells, </li></ul><ul><li>macrophages and </li></ul><ul><li>monocytes thereby </li></ul><ul><li>decreasing and </li></ul><ul><li>eventually eliminating </li></ul><ul><li>cellular immunity. </li></ul>
  4. 4. Mode of Transmission <ul><li>Direct contact with body fluid </li></ul><ul><li>Direct transmission to infant through vagina </li></ul><ul><li>Transplacentally </li></ul><ul><li>Breast milk </li></ul><ul><li>Rates </li></ul><ul><li>- 20 % HIV transmission in utero </li></ul><ul><li>- 80 % during L & D </li></ul>
  5. 5. Risk Factors <ul><li>Multiple sex partners </li></ul><ul><li>Infected with another STI </li></ul><ul><li>Illicit IV drug use </li></ul><ul><li>Emigrant from an HIV-endemic area such as Haiti or Africa </li></ul><ul><li>Prostitution </li></ul><ul><li>Received a blood transfusion between 1977 and 1985 </li></ul><ul><li>Gilbert,E.S. (2007). Manual of high risk pregnancy & delivery . St. Louis: Mosby-Elsevier, p. 568. </li></ul>
  6. 6. Detection <ul><li>Two types of testing </li></ul><ul><li>- Rapid HIV tests </li></ul><ul><li>▪ OraQuick Advance HIV-1 Antibody Test </li></ul><ul><li>▪ Uni-Gold Recombigen HIV Test </li></ul><ul><li>▪ Reveal Rapid HIV-1 Antibody Test </li></ul><ul><li>- Confirmatory tests </li></ul><ul><li>▪ Western blot – most specific test </li></ul><ul><li>▪ IFA – (immunoflourescence Assay) </li></ul>
  7. 7. Maternal Effects <ul><li>Initial symptoms -mono-like initial symptoms – fever, pharyngitis, lymphadenopathy, arthralgia, n&v, fatigue, weight loss </li></ul><ul><li>Erythematous maculopapular rash </li></ul><ul><li>Diffuse urticaria </li></ul><ul><li>Alopacia </li></ul><ul><li>Multiple infections </li></ul><ul><li>Disseminated Kaposi sarcoma </li></ul><ul><li>PTL, IUGR, PROM, postpartum endometritis </li></ul><ul><li>Susceptible to opportunistic infections </li></ul>
  8. 8. Newborn Effects <ul><li>All newborns will have + antibodies for HIV </li></ul><ul><li>20-30% will remain positive by 15-18 months and will develop AIDS (300 per year in the US) </li></ul><ul><li>Increased risk of stillbirth, neonatal mortality </li></ul><ul><li>With treatment transmission risk < 2 % </li></ul>
  9. 9. Treatment <ul><li>Antepartum – ( > 28 wks) - ZDV 200 mg. po. TID or 300 mg. BID. </li></ul><ul><li>Intrapartum – IV ZDV and a single dose of NVA (nevirapine) or 3TC (lamivudine) at onset of labor. </li></ul><ul><li>- If the patient has a viral load of < 1000 copies/ </li></ul><ul><li>ml c-section may not be required </li></ul><ul><li>Postpartum – ZDV po and protease inhibitors </li></ul><ul><li>Neonatal – ZDV syrup 2 mg/kg po Q 6 hrs from 12 hours of birth through 6 weeks of life (Term infants) </li></ul><ul><li>Gilbert,E.S. (2007). Manual of high risk pregnancy & delivery . St. Louis: Mosby-Elsevier, p.569. </li></ul>
  10. 10. Other Factors <ul><li>Total isolation </li></ul><ul><li>No scalp electrodes </li></ul><ul><li>Double glove </li></ul><ul><li>Vaginal delivery </li></ul><ul><li>No breastfeeding </li></ul><ul><li>If scheduled C/S drug administration 3 hours prior to surgery is optimal </li></ul>
  11. 11. Other Factors for Infant <ul><li>Mechanical suction of newborn </li></ul><ul><li>Minimize infant exposure to maternal fluids </li></ul><ul><li>Give infant a bath as soon as possible </li></ul><ul><li>No injections or eye ointment until bath is given </li></ul><ul><li>HIV DNA PCR blood test along with CBC as part of their admission lab work </li></ul><ul><li>(Infants become anemic when taking ZDV) </li></ul>
  12. 12. Hepatitis <ul><li>Hepatitis A - 40% </li></ul><ul><li>Hepatitis B - 45% </li></ul><ul><li>Hepatitis C - 5-10% </li></ul><ul><li>Hepatitis D - 5-10% </li></ul><ul><li>Hepatitis E - 5-10% </li></ul><ul><li>136,000 new cases/yr. </li></ul>
  13. 13. Hepatitis <ul><li>Inflammation of the liver caused by a viral infection </li></ul><ul><li>Acute or chronic </li></ul><ul><li>Degeneration and necrosis of the liver </li></ul><ul><li>Inflammation and swelling blocks bile duct secretion </li></ul><ul><li>Incubation period 1-6 months </li></ul><ul><li>Affects 1 in 500-1,000 pregnancies </li></ul><ul><li>Bile backs up leading to jaundice </li></ul><ul><li> ALT, Alk Phos,  Bilirubin </li></ul>
  14. 14. Hepatitis B -Transmission <ul><li>Sexual contact </li></ul><ul><li>Shared needles </li></ul><ul><li>Transplacental </li></ul><ul><li>Direct contact with secretions (blood, stool, semen, saliva, amniotic fluid, breast milk) </li></ul><ul><li>Shared personal items (toothbrush, razor, washcloth) </li></ul><ul><li>HBV can survive up to one week in dried blood or body secretions </li></ul>
  15. 15. Detection <ul><li>Hepatitis B virus is a double-stranded DNA virus consisting of: </li></ul><ul><li>- HBcAG – [core antigen] acute infection </li></ul><ul><li>only found in liver </li></ul><ul><li>- HBsAG –[surface antigen]- acute/chronic </li></ul><ul><li>first to appear </li></ul><ul><li>- HBeAG – [e antigen] HBV is active in serum and patient is highly infective </li></ul>
  16. 16. Acute HBV infection: <ul><li>HBsAg is elevated </li></ul><ul><li>HBeAg is elevated </li></ul><ul><li>Immunoglobulin M (IgM) anti-HBc is elevated </li></ul><ul><li>Gilbert,E.S. (2007). Manual of high risk pregnancy & delivery . St. Louis: Mosby-Elsevier, p.561. </li></ul>
  17. 17. Chronic HBV Infection (Carrier state) <ul><li>HBsAg remains elevated </li></ul><ul><li>IgG anti-HBc remains elevated </li></ul><ul><li>IgM anti-HBc is absent </li></ul><ul><li>If HBsAg is positive but HBeAg is negative this indicates a carrier state without active liver disease. </li></ul><ul><li>If HBsAg & HBeAg are both positive it indicates a carrier state with active liver disease. </li></ul><ul><li>Gilbert,,E.S. (2007). Manual of high risk pregnancy & delivery . St. Louis: Mosby-Elsevier , p.561. </li></ul>
  18. 18. Maternal Effects <ul><li>Pregnant patient with acute HBV : </li></ul><ul><li>- Chronic low grade fever </li></ul><ul><li>- Nausea and vomiting </li></ul><ul><li>- Anorexia </li></ul><ul><li>- Fatigue </li></ul><ul><li>- Skin rashes </li></ul><ul><li>- Arthralgia </li></ul><ul><li>Gilbert,E.S. (2007). Manual of high risk pregnancy & delivery . St. Louis: Mosby-Elsevier,p.561. </li></ul>
  19. 19. Fetal /Newborn Effects <ul><li>70% chance of fetus being infected if acute onset is in 3 rd trimester </li></ul><ul><li>70-90 % chance of being infected if mother is chronic carrier </li></ul><ul><li>Rarely develops symptoms </li></ul><ul><li>90% chance of becoming chronic carrier </li></ul><ul><li>25% chance of developing cirrhosis and/or liver cancer by age 50. </li></ul><ul><li>Also at risk if other family members are chronic carriers </li></ul>
  20. 20. Treatment <ul><li>Mother – If exposed during pregnancy and HBsAg (–) give HBIG, repeat HBIG in 1 month, followed by Hepatitis vaccine series. </li></ul><ul><li>If the Mother contracts HBV during pregnancy – can only treat symptoms (bedrest, diet high in protein, low in fat) </li></ul><ul><li>Infant – </li></ul><ul><li>If Mom is HBsAg (+) give HBV vaccine and </li></ul><ul><li>HBIG within 12 hrs. of delivery and at 1 & 6 </li></ul><ul><li>months. </li></ul>
  21. 21. High Risk Categories <ul><li>Pregnant women from: </li></ul><ul><li>1) China </li></ul><ul><li>2) Southeast Asia </li></ul><ul><li>3) Central Africa </li></ul><ul><li>4) Middle Eastern </li></ul><ul><li>5) Pacific Island </li></ul><ul><li>6) Alaska </li></ul><ul><li>IV drug users </li></ul><ul><li>Prostitutes </li></ul><ul><li>Other STIs’ and/ or multiple partners </li></ul><ul><li>Recipients of multiple transfusions </li></ul><ul><li>Health care workers with blood and needlestick exposure </li></ul>
  22. 22. Hepatitis A <ul><li>Formerly known as infectious hepatitis </li></ul><ul><li>1:1,000 pregnancies </li></ul><ul><li>Found in southeast Asia, Africa, Central America, Mexico, Middle East </li></ul><ul><li>Spread through fecal-oral route, person to person contact or ingestion of contaminated food or water – Not spread by blood </li></ul><ul><li>Incubation period 28 days </li></ul><ul><li>Transmission common in Day Cares </li></ul><ul><li>Acute Infection – IgM Anti-HAV </li></ul><ul><li>Not a chronic carrier </li></ul><ul><li>Immunization available </li></ul>
  23. 23. Hepatitis C <ul><li>Major cause of acute and chronic hepatitis </li></ul><ul><li>Asymptomatic in most people </li></ul><ul><li>Breastfeeding does not increase transmission rate </li></ul><ul><li>Transmission same as Hepatitis B but not as easy to spread through sexual intercourse </li></ul><ul><li>High rate of chronic disease </li></ul>
  24. 24. Hepatitis C <ul><li>C/S has not proved beneficial in lowering vertical transmission rates </li></ul><ul><li>Diagnosis – detecting the antibody to Hepatitis C through Enzyme Immune Assay (EIA). If positive the confirmative test is RIBA. </li></ul><ul><li>(Anti-HCV). Specimen obtained by liver biopsy </li></ul><ul><li>No cure </li></ul>
  25. 25. Hepatitis D (Delta) <ul><li>Occurs with Hepatitis B </li></ul><ul><li>Incubation 2-8 weeks </li></ul><ul><li>More common in the Mediterranean Sea </li></ul><ul><li>Identify antibody to Hepatitis D Anti-HDV or liver biopsy </li></ul><ul><li>Highly infectious </li></ul><ul><li>Obtained from multiple transfusions, IV drug abuse, hemophilia </li></ul><ul><li>Covered by Hepatitis B vaccine </li></ul><ul><li>Diminished liver function, increased jaundice, altered mental status </li></ul>
  26. 26. Hepatitis E (HEV) <ul><li>Obtained through sewage contaminated food or water </li></ul><ul><li>Increased during times of floods, hurricanes or rainy season </li></ul><ul><li>Similar to Hepatitis A </li></ul><ul><li>Found in India, Southeast Asia, Africa, South America </li></ul><ul><li>Usually affects people of childbearing age (15-40 years old) </li></ul><ul><li>Does not exist as a chronic carrier </li></ul><ul><li>IgG anti-HEV shows immunity </li></ul>
  27. 27. Hepatitis E (HEV) <ul><li>Characterized by mild illness – high mortality rate if infection is acute in third trimester due to liver failure </li></ul><ul><li>Neonates die from HEV infection more than from any other type of viral hepatitis </li></ul><ul><li>Vertical transmission has been reported </li></ul><ul><li>Acute infection diagnosed by a positive serum test for IgM anti-HEV antibody. This test is not available in most labs. </li></ul>
  28. 28. Gonorrhea <ul><li>Agent - Neisseria Gonorrhea (gram negative) </li></ul><ul><li>Mode of Transmission – Oral, rectal, genital.vertical transmission to fetus </li></ul><ul><li>Incubation – 10 days – Does not cross the placenta </li></ul><ul><li>0.5 to 7 % in pregnancy </li></ul><ul><li>Screen for chlamydia and trich </li></ul><ul><li>PID in 40% if untreated </li></ul><ul><li>Symptoms – Chills, fever, vaginal discharge/ bleeding </li></ul>
  29. 29. Gonorrhea <ul><li>Detection </li></ul><ul><li>- Endocervical /Urethral /rectal/ throat culture </li></ul><ul><li>- ELISA Immunoassays </li></ul><ul><li>- If asymptomatic do DNA culture </li></ul><ul><li>Treatment </li></ul><ul><li>- Fetus – Erythromycin eye ointment </li></ul><ul><li>- Mother – Ceftriaxone 125 mg IM </li></ul><ul><li>and Cefixime 400 mg PO </li></ul><ul><li>- Treat all sexual partners </li></ul>
  30. 30. Maternal Effects <ul><li>70-80% asymptomatic </li></ul><ul><li>Endocervicitis causes weakening of the fetal membranes and leads to PROM /PTL </li></ul><ul><li>Associated with septic abortions </li></ul><ul><li>GU infections with dysuria, pyuria </li></ul><ul><li>Often seen with chlamydia </li></ul><ul><li>Postpartum endometritis, decreased fertility </li></ul><ul><li>Yellow purulent discharge </li></ul><ul><li>Tenderness of Skein/ Bartholin glands </li></ul><ul><li>May cause sever disseminated infection – arthritis, perciarditis, meningitis, dematitis </li></ul>
  31. 31. Maternal Effects <ul><li>Postpartum endometritis, decreased fertility </li></ul><ul><li>Yellow purulent discharge </li></ul><ul><li>Tenderness of Skein/ Bartholin glands </li></ul><ul><li>May cause sever disseminated infection – arthritis, pericarditis, meningitis, dematitis </li></ul>
  32. 32. Fetal Effects <ul><li>PROM </li></ul><ul><li>Chorioamnionitis </li></ul><ul><li>Purulent conjunctivitis </li></ul><ul><li>Sepsis/meningitis </li></ul><ul><li>May breastfeed after antibiotic treatment – frequent handwashing extremely important </li></ul>
  33. 33. Syphilis <ul><li>Agent – Spirochete - Treponema Pallidium </li></ul><ul><li>Incubation – 10 - 90 days (average 21 days) </li></ul><ul><li>Mode of transmission – Sexual, oral, anal, vaginal, direct contact with lesion, placental transmission, through vagina during birth </li></ul>
  34. 34. Congenital Syphilis
  35. 35. Syphilis <ul><li>Detection </li></ul><ul><li>- RPR (Rapid Plasma Reagin) </li></ul><ul><li>VDRL ( Venereal Disease Research Laboratory) > 1:32 = reactive </li></ul><ul><li>FTA-ABS – Flourescent treponeum </li></ul><ul><li>antibody absorption – Confirmatory test </li></ul><ul><li>Must have 2 positive tests for confirmation </li></ul><ul><li>Will have positive test within 4 wks of exposure </li></ul>
  36. 36. Maternal Effects <ul><li>Primary chancre – painless ulcer on lips, genitalia, oral cavity </li></ul><ul><li>Secondary- flu-like symptoms, red macules on soles and palms, generalized lymphadenopathy, patchy hair loss, neuromuscular and cardiovascular symptoms </li></ul><ul><li>Latent – can lay dormant for many years </li></ul><ul><li>Tertiary-involves heart, blood vessels, nervous system, muscle movement, dementia </li></ul>
  37. 37. Fetal Effects <ul><li>Varies depending on gestation </li></ul><ul><li>IUGR, anomalies, IUFD, PTL,stillborn </li></ul><ul><li>Absent nasal bridge, pneumonia, hepatitis, jaundice, skin lesions, hydrops, seizures </li></ul><ul><li>Placenta large and pale with club-like, thick villi </li></ul><ul><li>25% die in utero, 30 % die post delivery, 40% develop tertiary syphllis </li></ul>
  38. 38. Treatment <ul><li>Prevention </li></ul><ul><li>Primary, secondary and early latent – PCN G 2.4 mil units IM x 1 dose </li></ul><ul><li>Latent & tertiary - PCN G 2.4 mil units IM q weekly x 3 weeks </li></ul><ul><li>< 1 yr old - PCN G 2.4 million units IM x 1 dose </li></ul>
  39. 39. Group Beta Strep <ul><li>Agent </li></ul><ul><li>- Beta Hemolytic Streptococcus (Gram + </li></ul><ul><li>cocci) – contains 5 subtypes </li></ul><ul><li>Mode of transmission – 10 - 30 % maternal carriage (Colonizes in rectum, vagina, cervix & urethra </li></ul><ul><li>- Ascending infection - 50% </li></ul><ul><li>- Vaginal tract infection– 25% </li></ul><ul><li>- Other – 25% </li></ul><ul><li>Detection </li></ul><ul><li>- Urine culture </li></ul><ul><li>- Anogenital culture </li></ul>
  40. 40. GBS <ul><li>Most common cause of neonatal sepsis </li></ul><ul><li>- Early – within 24 hours – 80% </li></ul><ul><li>- Late – within a week </li></ul><ul><li>Greatest risk to preterm infants </li></ul><ul><li>Screen all patients at 35-37 weeks, earlier if past hx PTL </li></ul><ul><li>Risk of GBS transmission: </li></ul><ul><li>- Not treated -1:200 </li></ul><ul><li>- Treated – 1:4000 </li></ul><ul><li>All women who have been GBS + in the past should receive treatment </li></ul>
  41. 41. Maternal Effects <ul><li>Asymptomatic </li></ul><ul><li>UTIs’ </li></ul><ul><li>Labor or postpartum infection with fever, tachycardia and abdominal distention </li></ul><ul><li>Duration of carrier unpredictable </li></ul><ul><li>Current research on vaccine to tx GBS </li></ul>
  42. 42. Fetal Effects <ul><li>Treatment at term eliminates 85 % of early onset GBS </li></ul><ul><li>PPROM </li></ul><ul><li>Infant with sepsis at delivery and GBS in CSF and /or blood </li></ul><ul><li>Symptoms – lethargy, jaundice, poor feeding , temperature instability, abdominal distention, pallor, tachycardia </li></ul><ul><li>5-20% mortality rate – get sick quick </li></ul>
  43. 43. Late Onset GBS <ul><li>Usually meningitis </li></ul><ul><li>15-30% will have permanent neurological damage, deafness, blindness, learning disabilities </li></ul><ul><li>Very rate – Only 25 % of these babies have moms that are GBS + </li></ul>
  44. 44. Treatment <ul><li>Maternal treatment </li></ul><ul><li>- In labor- PCN 5 million units initial dose and </li></ul><ul><li>then 2.5 mil. units q 4 hrs, or Ampicillin </li></ul><ul><li>2 gm IVPB then 1 gm q 4 hrs – prefer at least two doses prior to delivery and the last dose to be at least 4 hours prior to delivery </li></ul><ul><li>- PPROM – Ampicillin 1 gm IVPB q 6 hrs </li></ul><ul><li>for 24 hrs then po when a prenatal patient </li></ul><ul><li>(Clindaycin if pt. allergic to PCN) </li></ul><ul><li>Ampicillin and Gentamycin for the infant after delivery </li></ul>
  45. 45. Who should be treated? <ul><li>Positive GBS in urine culture during pregnancy </li></ul><ul><li>Previous infant with GBS </li></ul><ul><li>Birth before 3 7 weeks(10-15 fold increase) </li></ul><ul><li>Rupture of membranes > 18 hrs. </li></ul><ul><li>Temperature > 100.4 </li></ul>
  46. 46. Chlamydia <ul><li>Agent – Chlamydia Trachomatis (Gram negative) </li></ul><ul><li>Mode of transmission – Genital </li></ul><ul><li>Most common bacterial STI – especially high in teens </li></ul><ul><li>5-30% carriage by pregnant women </li></ul><ul><li>Commonly seen with GC and Trich </li></ul><ul><li>Pregnant mother colonizes infant </li></ul>
  47. 47. Chlamydia <ul><li>May be asymptomatic (75%) </li></ul><ul><li>Detection – </li></ul><ul><li>- Endocervical / urethral / tissue culture </li></ul><ul><li>- ELISA (Enzyme-linked immunosorbent assay)- </li></ul><ul><li>rapid detection test </li></ul><ul><li>- Direct smear using flourescent antibody </li></ul><ul><li>Treatment </li></ul><ul><li>- Mother – Erythromycin 500 mg po qid x 7 days </li></ul><ul><li>in pregnancy or Amoxicilliin 500 mg po tid x 7 </li></ul><ul><li>days </li></ul><ul><li>- Infant – Erythromycin opthalmic ointment at </li></ul><ul><li>birth </li></ul>
  48. 48. Maternal Effects <ul><li>If not treated – PID, infertility, tubal pregnancy, chronic pelvic pain </li></ul><ul><li>Dysuria, yellow purulent discharge, cervicitis, bleeding, postpartum endometritis up to 2 weeks after delivery </li></ul><ul><li>Associated with other STIs’ </li></ul><ul><li>Treat sexual partner </li></ul>
  49. 49. Fetal Effects <ul><li>PTL/PROM </li></ul><ul><li>IUGR </li></ul><ul><li>Chorioamnionitis </li></ul><ul><li>10% infants develop pneumonia </li></ul><ul><li>50% develop conjunctivitis,10% develop pneumonia– usually 5-12 days after deliver </li></ul><ul><li>2/3 of infants born vaginally to mothers with Chlamydial infection become infected during delivery </li></ul><ul><li>May breastfeed after treatment </li></ul>
  50. 50. Bacterial Vaginosis <ul><li>Agent - Non-specific vaginitis - Hemopilus, Gardnerella vaginalis or Candidiasis </li></ul><ul><li>Anerobic gram negative rods or fungal organism </li></ul><ul><li>Mode of transmission – Sexual transmission or tissue trauma </li></ul>
  51. 51. Bacterial Vaginosis <ul><li>Due to sexual intercourse, hormonal changes, antibiotics, spermicidal products, pregnancy, douching– very contagious vaginosis </li></ul><ul><li>Cause – Overgrowth of one or more types of normal bacteria present in 15-25% of pregnancies </li></ul>
  52. 52. BV <ul><li>Detection – positive diagnosis if 3 of 4 characteristics below are present: </li></ul><ul><li>- Clue cells (wet prep) </li></ul><ul><li>- pH > 4.5 </li></ul><ul><li>- Fishy odor when discharge </li></ul><ul><li>mixed with KOH </li></ul><ul><li>- Thin, grayish-white discharge </li></ul><ul><li>or white curdy, cottage cheese discharge </li></ul>
  53. 53. Maternal /Fetal Effects <ul><li>Risk increased by douching, using intrauterine devices (IUDs), and smoking </li></ul><ul><li>Associated with ectopic pregnancies, spontaneous abortions, PID, PROM, PTL, postpartum endometritis </li></ul><ul><li>May cause neonatal septicemia </li></ul>
  54. 54. Treatment <ul><li>First trimester - Clindamycin vaginal cream 5 gm hs x 7 days or Flagyl gel 0.75% </li></ul><ul><li>(5 gm) vaginal cream twice daily x 5 days </li></ul><ul><li>Second trimester – Flagyl 250 mg po tid x 7 days or Clindamycin 300 mg po tid x 7 days </li></ul><ul><li>If breastfeeding – Flagyl 2 gm po x 1 and discard milk for 24 hrs. </li></ul><ul><li>Hydrogen peroxide douche </li></ul><ul><li>Condoms to prevent re-infection </li></ul>
  55. 55. Human Papilloma Virus (HPV) <ul><li>Agent – Condylomata Human Papilloma virus – > 200 types of HPV </li></ul><ul><li>Appears as genital warts </li></ul><ul><li>Incubation period – </li></ul><ul><li>3-9 months prior to </li></ul><ul><li>appearance of warts </li></ul><ul><li>Most prevalent STI </li></ul>
  56. 56. Human Papilloma Virus (HPV) <ul><li>Mode of transmission – </li></ul><ul><li>1) Sexual contact </li></ul><ul><li>2) Pass on to the fetus during labor and </li></ul><ul><li>delivery </li></ul><ul><li>3) If burned off they vaporize in the air and </li></ul><ul><li>begin to grow on human surfaces that they </li></ul><ul><li>land on. </li></ul><ul><li>Several strains of HPV cause cancer – (16, 18, 45, 56) </li></ul><ul><li>Strains 6 & 11 are found in newborn laryngeal papillomatosis </li></ul>
  57. 57. Detection <ul><li>1) Visually – Dry, wart-like clusters that </li></ul><ul><li>resemble cauliflower. May be small or large. </li></ul><ul><li>Most often found on vagina, labia, cervix and </li></ul><ul><li>perineal area </li></ul><ul><li>2) Microscopic pathology (cytology culture – </li></ul><ul><li>Hybrid II capture tubes containing anti- </li></ul><ul><li>RNA/DNA hybrid antibody – Light spectrum </li></ul><ul><li>is measured to determine one of 70 strains) </li></ul><ul><li>Important to have annual pap smears </li></ul>
  58. 58. Maternal/Fetal Effects <ul><li>Maternal – Warts, pruritis, bleeding, dysparunea, cervical dysplasia ( May enlarge in pregnancy) </li></ul><ul><li>Fetal/Newborn – Vaginal delivery unless lesions obstruct passage(.04% risk of exposure). C/S may decrease exposure risk </li></ul><ul><li>- Observe for laryngeal pappilomatosis – stridor, hoarseness, cough, abnormal cry, respiratory distress as late as 2-3 months </li></ul>
  59. 59. Treatment <ul><li>During pregnancy -Trichloracetic acid applications weekly </li></ul><ul><li>Post delivery -Laser, cryotherapy, Interferon injections (anti-neoplastic drug used in women over 18 who have not responded to other treatments) </li></ul><ul><li>Newborn treatment depends on size of warts </li></ul><ul><li>Treat partners </li></ul><ul><li>Use condoms </li></ul><ul><li>May breastfeed </li></ul>
  60. 60. Trichimoniasis <ul><li>Agent- Trichomoniasis Vaginalis </li></ul><ul><li>Mode of transmission – Multiple sexual contacts. It is not transmitted across the placenta </li></ul><ul><li>Lives for a varying amount of time I fresh water, semen, urine toilet tissue, toilet seats, damp wash cloths, </li></ul><ul><li>50 % of women also have GC </li></ul><ul><li>PTL and LBW when associated with other STIs’. </li></ul>
  61. 61. Detection <ul><li>Symptoms – frothy, thin, odorless, yellow-green discharge in copious amounts, pruritis, dysuria, strawberry cervix, painful intercourse, postpartum endometritis </li></ul><ul><li>Test – wet prep (saline solution) Look under microscope for white cells and erythrocytes </li></ul><ul><li>Ph> 4.5 </li></ul>
  62. 62. Treatment <ul><li>Clotrimaxole vaginal cream @hs x 7 days for first trimester </li></ul><ul><li>Flagyl 2 gm po x 1 dose (Avoid alcohol) </li></ul><ul><li>May breastfeed </li></ul><ul><li>Use condoms and treat sexual partners </li></ul>
  63. 63. Toxoplasmosis <ul><li>Agent – Toxoplasmosis gondii (protozoan) </li></ul><ul><li>Mode of transmission –eating raw or undercooked meat, vegetables, fruit, drinking unpasteurized milk, ingesting cysts found in cat feces, transplacentally </li></ul><ul><li>Detection </li></ul><ul><li>- IFAT (Indirect Flourescent Antibody Test)- </li></ul><ul><li>from maternal tissue or serum for IgM or IgG </li></ul><ul><li>- ELISA </li></ul>
  64. 64. Maternal/Fetal Effects <ul><li>Fetal – congenital toxoplasmosis, IUGR, enlarged liver and spleen, anemia, jaundice, neurologic damage, microcephaly, hydrops, deafness, low IQ </li></ul><ul><li>* 10-24 wks highest risk period </li></ul><ul><li>Maternal – 90% asymptomatic, mono-like symptoms, lymph swelling , PTL, miscarriage, 15-30 % of pregnant women will have + antibodies from previous exposure </li></ul>
  65. 65. Treatment <ul><li>Spiramycin 1 gm q 8 hrs, Pyrimethamine 25 mg po qd, with sulfadiazine 1 gm po qid. Must be given with Folinic acid 6 mg IM or po 3 x per week </li></ul><ul><li>May reduce neonatal incidence by 50% </li></ul><ul><li>Watch maternal platelets </li></ul><ul><li>At birth infant is tx with Pyrimethamine and Sulfadiazine </li></ul><ul><li>May breastfeed </li></ul><ul><li>Isolate </li></ul>
  66. 66. Prevention <ul><li>Cook meats thoroughly </li></ul><ul><li>Wash kitchen utensils </li></ul><ul><li>Wash hands </li></ul><ul><li>Wash fruits and vegetables </li></ul><ul><li>Avoid contact with cat liter boxes, sand boxes, garden soil </li></ul>
  67. 67. Rubella <ul><li>RNA virus. Member of Togaviridae family </li></ul><ul><li>Incubation period – 10-14 days </li></ul><ul><li>Mode of transmission – Respiratory secretions, airborne, transplacentally </li></ul><ul><li>If infected in 1 st trimester 50 -90% of infants will have severe congenital anomalies or death </li></ul><ul><li>2 nd or 3 rd trimester – subtle to no effects </li></ul>
  68. 68. Rubella <ul><li>Detection – HAA antibody test. If < 1:8 patient will be non-immune </li></ul><ul><li>20 % of the population is not immune to rubella </li></ul><ul><li>Prevent pregnancy at lease 28 days post vaccination </li></ul><ul><li>ISG (immune serum globulin ) may be given to decrease fetal effects </li></ul><ul><li>Viral culture on infant </li></ul><ul><li>Strict isolation – no caretakers who are pregnant </li></ul>
  69. 69. Maternal/Fetal Effects <ul><li>Maternal – Maculopapular rash starting on the face and migrating downward. Rash lasts 3- 5 days, fever, malaise, post-auricular and occipital adenopathy </li></ul><ul><li>Viral shedding for 15 days </li></ul><ul><li>Spontaneous abortion, hydrops </li></ul><ul><li>Watch for sinusoidal FHR pattern </li></ul><ul><li>May breastfeed after viral shedding period </li></ul>
  70. 70. Rubella
  71. 71. Herpes Simplex Virus (HSV) <ul><li>Type I (Oral) and Type II (Genital) </li></ul><ul><li>Transmitted by direct contact with lesion </li></ul><ul><li>– primary lesion occurs in 2-20 days </li></ul><ul><li>- vesicles rupture within 1-7 days and form ulcers that take an average of 12 days to heal </li></ul><ul><li>Routes of transmission - vaginal birth, ascending infection especially with ROM, transplacentally if primary infection </li></ul>
  72. 72. HSV <ul><li>Pregnant women infected with the virus for the first time can shed the virus for 8-100 days or for recurrent infection 6-40 days </li></ul><ul><li>15-35 % women of childbearing age are HSV II + </li></ul><ul><li>Period of remission and occurrence </li></ul><ul><li>Oral sex can mix lesions </li></ul>
  73. 73. Detection <ul><li>Tissue (Viral) culture of open lesion for giant body cells (Znack prep) </li></ul><ul><li>ELISA </li></ul><ul><li>Positive PAP smear </li></ul><ul><li>Western blot </li></ul>
  74. 74. Maternal Effects <ul><li>Maternal – Painful papules that change to fluid filled vesicles/ulcers in clusters that crust over and heal. Located on vulva, vagina, cervix, labia, perineum </li></ul><ul><li>Severe pain, burning, itching, low grade fever malaise, numbness, tingling, enlarged lymph nodes or may be asymtomatic, predisposition to cervical cancer </li></ul><ul><li>Deliver within 4 hrs of ROM if active lesion – must do C/S </li></ul>
  75. 75. Fetal Effects <ul><li>Miscarriage if transplacental transmission, </li></ul><ul><li>Neonatal mortality 50-60 % if primary infection during pregnancy </li></ul><ul><li>Neurologic & opthalmic sequela </li></ul><ul><li>Microcephaly, bulging fontanels </li></ul><ul><li>Systemic infection in 70% </li></ul><ul><li>RDS, pneumonia </li></ul><ul><li>Intracranial calcifications, skin lesions, </li></ul><ul><li>Seizures, tremors, lethargy, </li></ul>
  76. 76. Herpes Disease Progression <ul><li>500,000 people are infected with genital herpes each year and another 10 million have recurrent lesions </li></ul><ul><li>One in five pregnant women have had an HSV infection </li></ul><ul><li>Herpes can become dormant- once it gets into the dorsal root ganglia antiviral drugs are useless </li></ul><ul><li>Recurrent outbreaks are triggered by stress, illness, exposure to ultraviolet light, tissue damage or suppression of the immune system </li></ul>
  77. 77. HSV
  78. 78. Neonatal HSV
  79. 79. Treatment <ul><li>Mother – Acyclovir 800 mg bid x 5 days </li></ul><ul><li>or Valtrex 500 mg for 14 days in 3rd trimester </li></ul><ul><li>Infant – Acyclovir 30-60 mg / kg day for 10-21 days for neonates </li></ul><ul><li>Treat sexual partners </li></ul><ul><li>No AROM </li></ul><ul><li>NO FSE, vacuum extractor </li></ul><ul><li>May breastfeed as long as lesion is not on the breast. Must use excellent hand washing </li></ul>

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