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Infections in pregnancy
 

Infections in pregnancy

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Infections in pregnancy

Infections in pregnancy

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    Infections in pregnancy Infections in pregnancy Presentation Transcript

    • Infections in Pregnancy Dr. B. K. Iyer
    • General Principles
      • Pregnancy does not alter resistance to infection
      • Severe infections have greater effects on the fetus
      • Maternal antibodies cross the placenta and give passive immunity to the fetus
      • Fetus becomes immunologically competent from the 14th week
    • Fetus and Infection
      • Indirect effect - O2 transport, nutrient exchange
      • Direct effect - invasion of placenta and infection of fetus
          • Viruses more than bacteria
          • rarely effect fetus unless maternal infection is severe
            • exception: Rubella, CMV, Herpes Simplex
    • Fetus and Infection
      • Infections cause
      • - miscarriage
      • - congenital anomalies
      • - fetal hydrops
      • - fetal death
      • - preterm delivery
      • - preterm rupture of the membranes
    • Viral Diseases
      • Rubella
      • Parvovirus
      • Cytomegalovirus
      • Varicella Zoster
      • Herpes
      • Hepatitis
      • HIV
      • Rubeola
    • Measles (Rubeola)
      • Paramyxovirus
      • Incubation - 10-14 days
      • Respiratory droplet inoculation
      • Fever, rash, cough, rhinorrhea, conjunctivitis and Koplik’s spots
      • Pneumonia (2nd bacterial) main cause of death
      • Encephalomyolitis, SSPE, Hepatitis
    • Measles (Rubeola)
      • No increased maternal or fetal deaths
      • Risk of preterm delivery
      • No specific syndrome
      • Neonatal measles and pneumonia if active disease in mother
      • Increased PNM in developing countries
    • Measles (Rubeola)
      • Prevention vaccine (95% recipients protected)
      • Treatment antipyrexials
      • cough suppresants
      • Antibiotics for bacteria
      • Suppress uterine contractions
      • ? Immune serum globulin
      • Isolation precautions
    • Rubella
      • Togavirus (RNA virus)
      • Incubation - 14-21 days
      • Respiratory droplet inoculation
            • only modestly contagious
      • Fever, rash (3 days), cough, arthralgias, post auricular and suboccipital lymphadenopathy
      • Usually mild, overt clinical symptoms 50-75% of cases
      • Encephalitis, bleeding diathesis & arthritis are rare complications
    • Rubella and the Fetus
      • Purpura, Splenomegaly, jaundice, meningoencephalitis, thrombocytopenia are transient
      • Congenital cataracts, Glaucoma, heart disease, deafness, microcephaly and mental retardation are permanent abnormalities
      • Diabetes, thyroid abnormalities, precocious puberty & Progressive panencephalitis (late)
    • Rubella
      • Vaccination (95% seroconversion)
      • @ 15 months and early adulthood
      • Immune status checking in teenagers, pre-college and pre-pregnancy
      • Antenatal testing
      • Serology testing for presumed exposures (paired Sera)
      • No in-utero therapy
    • Parvovirus
      • Human parvovirus B19 (DNA virus)
      • - erythema infectiosum in childhood
      • - chronic arthropathy
      • - chronic bone marrow failure (immunodefic)
      • - aplastic crisis (Sickle disaease)
      • Incubation 4-14 days
      • Respiratory droplet spread
      • High fever, “Slapped cheek syndrome’
      • non specific rash, no symptoms
    • Parvovirus and fetus
      • Hydrops (anaemia, myocarditis)
      • Adults 60% sero-positive
      • 1/3 fetuses affected in acute infection
      • Fetal loss rare with appropriate treatment
      • Assess serology - IgG, IgM, paired serology
      • Serial ultrasound, intrauterine transfusion
    • Varicella
      • Varicella-Zoster virus (DNA)
      • Incubation - 10-20 days
      • Respiratory droplet inoculation
      • Fever, malaise, pruritic rash (maculopapular with vesicles)
      • Pneumonia (+/- bacterial), encephalitis, myocarditis, pericarditis and adrenal insufficiency especially in adults
    • Varicella and pregnancy
      • Mild immunocompromise of pregnancy increases risk
      • 10% develop pulmonary complications - main cause of mortality
      • Fetal effects
      • Preterm delivery
      • Varicella syndrome
      • Neonatal varicella (VZ first 2 months)
    • Varicella Syndrome
      • Cutaneous scarring
      • Limb hypoplasia
      • Missing/hypoplastic digits
      • Limb paralysis/muscle atrophy
      • Psychomotor retardation
      • Convulsions
      • Microcephaly
      • Cerebral atrophy
      • Chorioretinitis/ chorioretinal scarring/optic disc hypoplasia
      • Cataracts
      • Horner’s Syndrome
      • Early childhood Zoster
    • Cytomegalovirus
      • DNA virus
      • Congenital infection - 1%
      • 5-10% of those infected show clinical illness at birth
      • Neonatal MR - 20-30%
      • 90% of survivors get late complications
      • 5-15% with no demonstrable disease at birth get some abnormality (deafness)
    • CMV Congenital Infection
      • Hepatomegaly }
      • Spleenomegaly }
      • Jaundice }TORCH
      • Thrombocytopenia }Syndrome
      • Petechiae }
      • Microcephaly }
      • Intrauterine growth retardation }
    • CMV Congenital Infection (Late)
      • Venticulomegaly
      • Cerebral atrophy
      • Mental retardation
      • Psychomotor delay
      • Seizures
      • Learning difficulties and language delay
      • Chorioretinitis / Optic atrophy
      • Intracranial calcifications
      • Long bone radiolucencies, dental abnormalities
      • Pneumonitis
    • CMV Congenital Infection
      • Prolonged virus shedding
      • No vaccine
      • No treatment
      • Risk group advice
    • Herpes Simplex
      • Disseminated disease in pregnant woman - death from hepatitis, encephalitis
      • Miscarriage (severe disease)
      • No congenital syndrome known
      • Intrapartum infection
          • disseminated disease - chorioretinitis, meningitis, encephalitis, mental retardation, seizures and death
          • Primary infection >>>secondary infection
          • HSV II - 75%; HSV I - 25% cases
    • Hepatitis B
      • Intrauterine infection - 5%
      • Intrapartum infection - 95%
      • Congenital infection - 90% chronic carriers
      • About 1% mothers are potential risks for their newborns
      • Newborns should receive passive (HBIg) and active immunization (vaccine x 3 doses) - protective in over 90% of cases
    • Hepatitis C
      • Risk of transmission to fetus 6-30%
      • Increased if other infections such as HIV
      • No treatment
      • Value of C Section is uncertain
      • Avoid invasive procedures
    • HIV
      • Infection rates variable
      • Risk of vertical transmission 20-40%, mostly peri-partum
      • Screening and treatment can almost completely reduce vertical transmission
      • C Section reduces risk of transmission x 4-fold
      • Viral counts <1000 - negligible risk to fetus
    • Bacterial Infections
      • Bacteruria*
      • Vaginal infections (BV, TV, Candida)
      • Group B Streptococci*
      • Gonorrhoea*
      • Chlamydia*
      • Toxoplasmosis*
      • Listeria
    • Bacteruria
      • Asymptomatic
      • 5-8% of all pregnancies (2% Non-preg)
      • Urinary stasis, tract dilatation
      • 30% symptomatic UTI (Pyelonephritis)
      • Diagnosis
      • Treatment
      • Subsequent care (MSU v Prophylaxis)
    • Group B Streptococci
      • 25% women are carriers
      • 50% of babies born will be colonized
      • 1-2% will have Grp B Strep infection
      • 1:1000 babies
      • Pneumonia (early), Meninigitis (Late)
      • Screening v Risk factor prophylaxis
    • Gonorrhoea
      • Neissseria Gonorrhoea (1-6% pop)
      • Pre-term labour, PPROM, Chorioamniionitis, Endometritis
      • Gonococcal opthalmia neonatorum (40%)
      • 80% asymptomatic
      • Screening needed?
      • Cephtriaxone IM stat
    • Chlamydia
      • 5-7% reproductive population
      • Pre-term labour, PPROM, Chorioamniionitis, Endometritis
      • Conjunctivitis (18-50%), Pneumonia (18%)
      • Most are asymptomatic
      • Screening needed
      • Azithromycin 1 gram stat
    • Syphilis
      • T.Pallidum
      • <1:1000 pregnant women
      • Can infect trans placenta from 15 th week
      • Second stage by birth if not treated
      • Screening – VDRL, RPR
      • Diagnostic tests – TPI, FTA-Abs
      • High dose Penicillin's
    • Toxoplasmosis
      • Toxoplasma Gondii (Protozoa)
      • Cat faeces, raw/undercooked meats
      • TORCH syndrome
      • Chorioretinitis, Encephalitis, Neonatal Jaundice
      • Serology =/- PCR
      • Sulfonamides + Pyrimethamine
    • Intra-Amniotic Infection
      • 1-2% all deliveries
      • Clinical Diagnosis – fever, uterine tenderness, Leucocytosis
      • Histologic chorioamnionitis more common
      • Ascending infection, rarely haematogenous
      • Polymicrobial
      • Increased PTD, PNMR, C Palsy, Endometritis
      • Treatment – Antibiotics and delivery
    • Miscellaneous
      • Malaria
      • Mycoplasma
      • HPV
      • Tropical diseases