Red Hot Infections in Pregnancy

What’s RED & HOT:
INFECTIONS in PREGNANCY
Helen Madamba, M.D. M.P.H.-T.M.
Mitzi Marie M. Chua, M.D.
http://www.epid.gov.lk/web/images/pdf/Influenza/Events/pregnant_women.gif

Session
Objectives
To determine the optimum
treatment for selected infections
commonly seen in pregnancy
 UTI
 HIV/AIDS
 Hepatitis B infection
 Human papillomavirus
 Syphilis
To integrate a management
approach based on the current
evidence and local applicability

“InfectionPackage”
forPrenatalCare
Routine tests for infections
during prenatal care
 Urinalysis, urine culture for
UTI
 HIV Counselling and Testing
 HBsAg for Hepatitis B infection
 Papsmear for Human
papillomavirus
 RPR or VDRL for Syphilis

Doyouroutinelyorderurine
cultureaspartofprenatalcare?
Question for our OBs in the audience
In ALL pregnant
patients, a urine
specimen should be
carefully collected for
urinalysis and
culturing during the
first prenatal visit or
at 12-16 weeks’ (9th-
17th, preferably 16th
week) gestation.
U.S. Preventive Services Task Force. Screening for asymptomatic bacteriuria in adults- U.S.
Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. 2008
Jul 1. 149(1)-43-7. [Medline].

Impactof
MaternalUTI
totheFetus
 Uterine hypoperfusion due to
maternal dehydration, maternal
anemia, and direct bacterial
endotoxin damage to the placental
vasculature  fetal cerebral
hypoperfusion
 Untreated upper UTIs associations:
 Low birth weight
 Prematurity; Premature labor
 Hypertension; preeclampsia
 Maternal anemia
 Amnionitis

UA–MSCC
 With one hand, spread the labia.
 With the other hand, use a castile soap–
moistened towelette to wipe the urethral
meatus downward toward the rectum,
then discard the towelette.
 Void the initial portion of the bladder
contents into the toilet.
 Catch the middle portion of the bladder
contents in the sterile collection
container, while keeping the labia spread
with the first hand.
RED-ytocollect?

UTI
Spectrum:
Acute cystitis
Asymptomatic bacteriuria (ASB)
Acute pyelonephritis
Management Pearls
Outpatient
Oral antibiotics
Inpatient, IV antibiotics
https://emedicine.medscape.com/article/452604-overview

Acute
Uncomplicated
Cystitis
A 27-year old, G1P0 13 weeks’
AOG, had urinary frequency and
terminal dysuria for 2 days. There
was no fever. There were also no
vaginal discharges.
WhatUTIcategory?
 A 27-year old, G1P0 13 weeks’ AOG, had
urinary frequency and terminal dysuria for 2
days. There was no fever. There were also
no vaginal discharges.
Diagnostics
 Urine culture/ sensitivity studies
 Significant pyuria (UA)
 >8 pus cells/mm3 of uncentrifuged urine, OR
 >5 pus cells/HPF of centrifuged urine
AND
 (+) leukocyte esterase and nitrite test on
dipstick
Strong recommendation, Moderate quality of evidence

Asymptomatic
Bacteriuria
 A 37-year old G3P2 16 5/7 weeks AOG
had a urine culture growth of >100,000
CFU Escherichia coli.
 On review of presentation, patient had no
complaints but culture was ordered by
attending OB after 2 urinalysis samples
showed pyuria.
WhatUTIcategory?

Howwillyou
followupthis
pregnantpatient
withASB?
Post-treatment diagnostic tests
 A follow-up urine culture should be done
one week after completing the course of
treatment.
Weak recommendation, Low quality of evidence

Hot‘n
confusing?
ANTIBIOTIC SELECTION
 If the patient is clinically responding to the present
treatment, no need to revise the antibiotic if resistance
to the empirically started antibiotic is reported on
urine culture. Adjust antibiotic therapy based on urine
culture results ONLY when there is no improvement in
the clinical signs and symptoms and laboratory results
or when there is worsening of the patient’s condition.
Strong recommendation, Low quality of evidence
MONITORING
 Pregnant patients with pyelonephritis, recurrent UTIs,
concurrent gestational DM, concurrent nephrolithiasis
or urolithiasis, and preeclampsia, should be
monitored at monthly intervals until delivery to ensure
that urine remains sterile during pregnancy. Strong
recommendation, Low quality of evidence
[NAG] … and monitor every trimester till delivery.

SAFE
Firsttrimester
ofpregnancy
Amoxicillin-clavulanate
Cephalosporins
Fosfomycin
https://www.medscape.com/viewarticle/891799
Thisone’sHOT!

AVOID
Firsttrimester
ofpregnancy
Nitrofurantoin
Cotrimoxazole
https://www.medscape.com/viewarticle/891799
ThisisNOThot!

Acute
Uncomplicated
Pyelonephritis
A 30-year old, G2P1 12 weeks’
AOG, presented with fever and
chills. On PE, she had right
costovertebral angle tenderness.
WhatUTIcategory?

✅
✅
✅
✅
✅
✅
✅
✅

Renal
Ultrasound
Unless an anatomic abnormality or
renal disease is suspected, initial
routine imaging studies are not
necessary.
Patients with suspected
pyelonephritis who are not
responsive to appropriate antibiotic
therapy after 48-72 hours should
also undergo imaging.
Willyouorder?

Acute
Uncomplicated
Pyelonephritis
The same 30-year old, G2P1 now
30 weeks’ AOG, presented with
fever, no chills. On PE, she had
right costovertebral angle
tenderness.
Urine culture revealed ESBL
Escherichia coli.
Referred to ID; patient covered
with ertapenem
WhatUTIcategory?

Prevention
Behavioral
Methods
 Avoid baths.
 Wipe front-to-back after urinating or
defecating.
 Wash hands before using the toilet.
 Use washcloths to clean the perineum.
 Use liquid soap to prevent colonization
from bar soap.
 Clean the urethral meatus first when
bathing.
Thisone’sHOT!

A21-yearold, G1P026weeksAOG,
(+)historyofIVdruguse,cameback
withCBC,U/A,andHBsAgresult.
HBsAgscreenisnon-reactive.
HIVscreenisreactive.
All pregnant patients routinely offered HIV testing.
https://www.hepmag.com/basics/hepatitis-b-
basics/pregnancy-hepatitis-b

 Prong 1. Primary prevention of HIV among
women of child-bearing age.
 Prong 2. Preventing unintended pregnancies
among women living with HIV.
 Prong 3. Preventing HIV transmission among
women living with HIV to her infant.
 Prong 4. Providing treatment, care and
support to women living with HIV, their
children and their families.
https://www.hsph.harvard.edu/population/aids/philippines.aids.09.pdf
Preventionof
Motherto Child
Transmissionof
HIVInfection

Prong1.Primaryprevention ofHIVamongwomenofchild-bearingage.
A – abstinence
B – be mutually faithful
C – check your status
D – don’t inject drugs
E – educate yourself and
others for early detection
Primary
Preventionof
HIVinfection

Prong2. PreventingunintendedpregnanciesamongwomenlivingwithHIV
Preventing
unplanned
pregnancies
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

Prong3.PreventingHIVtransmissionamongwomenlivingwithHIVtoherinfant
Prenataland
Intrapartum
Care
PhilippineObstetricalandGynecologicalSociety(Foundation)Inc
ClinicalPracticeRecommendationonPreventionofMothertoChild
TransmissionofHIVInfection
HIV Screening
Antiretroviral Drugs
Management of Delivery
Infant Feeding
Contraception
POGS Clinical Practice Recommendations on PMTCT

Preliminary Counselling Dialogue
Providers of obstetric care should
inform the patient that an HIV
screening test will be performed as
part of the recommended routine
antenatal package of tests of
infections (HBsAg, RPR/VDRL,
papsmear, urine culture)
HIVCounselling
andTesting

Preliminary Counselling Dialogue
The fact that you are pregnant
is an evidence of unprotected
penetrative sexual contact
which is a mode of
transmission for HIV.
HIVCounselling
andTesting

AdvantagesofOptionB+
Earlier treatment for woman’s health
and avoiding risks of stopping and
starting triple ARVs especially in
settings of high fertility
Simple message to communities
“once ARV started, it is
taken for life.”
Anti-retroviral
(ARV)Drugs

• An elective cesarean
delivery is scheduled at 38
weeks AOG
• Emergency CS is done for
those in labor and with
ruptured membranes <4 hours
unless delivery is imminent
POGS Clinical Practice Recommendation on PMTCT of HIV Infection. November 2015.
Managementof
Delivery

Vaginal delivery maybe done
when the risk of maternal to child
transmission is low:
• those who had ARV treatment
• HIV viral load <1000 copies/ml
• if with ruptured membranes, the time
elapsed should be <4 hours to
delivery
POGS Clinical Practice Recommendation on PMTCT of HIV Infection. November 2015.
Managementof
Delivery

INFORMED
CONSENT
NO MIXED FEEDING
EXCLUSIVE breastfeeding
or
AFASS replacement feeding
InfantFeeding
REDHOTFEEDING!

initiate/continue ARV medications
replacement feeding: acceptable,
feasible, affordable, sustainable and
safe (AFASS)
risks, follow up and other options
for replacement feeding
relieve breast engorgement
InfantFeeding
REDHOTFEEDING!

A24-yearold, G7P7(7007) 3days
postpartum,breastfeedinginthe
ward. MHOcallstoinformthat
patientistheirprenatalclient.
HIVscreenisreactive.
REDHOTSURPRISE!

Continue exclusive breastfeeding
Initiate/continue ARV medications
for both mother and patient for as
long as breastfeeding up to two (2)
years
InfantFeeding
REDHOTFEEDING!

Prong4. Providingtreatment,care
andsupporttowomenlivingwithHIV,
theirchildrenandtheirfamilies.
Sexualand
reproductive
healthand
rights(SRHR)
Framework of WHO recommendations and good
practice statements to advance the sexual and
reproductive health and rights of women living
with HIV

Life goes on beyondHIV
Anti-retroviral
(ARV)Drugs

A19-year old, G1P016weeks
pregnant, camebackwithCBC,
U/A,and HBsAgresult.
HBsAgscreenisreactive.
HBs Ag screen seems always done.

Whatdoyou
do?
Additional testing (ALT, HBV
DNA, or imaging for HCC
surveillance if indicated)
Determination of need for antiviral
therapy
Women who meet standard
indications for HBV therapy should
be treated.

Getaviralload!
Pregnant women positive for
HBsAg should be tested for hep B
virus deoxyribonucleic acid (HBV
DNA) to guide the use of antiviral
medication to prevent perinatal
transmission.
Red-hotCOST!

Individualize
therapytoreduce
theriskof
perinatal
transmission.
The American Association for the
Study of Liver Diseases (AASLD)
suggests antiviral therapy for
pregnant women with HBV DNA
>200,000 IU/mL.
Quality and Certainty of Evidence: Low
Strength of Recommendation: Conditional

Theironyof“strengthof
recommendation”
AASLD recommends against the
use of antiviral therapy to reduce
the risk of perinatal transmission
of HBV in HBsAg-positive
pregnant women with an HBV-
DNA level <200,000 IU/mL.
Quality and Certainty of Evidence: Low
Strength of Recommendation: Strong

Whatto
give?
The only antivirals studied in
pregnant women are lamivudine,
telbivudine, and tenofovir (TDF).
TDF preferred to minimize the risk
of emergence of viral resistance
during treatment
Red-hotchoices

Timing&
Duration
Antiviral therapy started at 28-32
weeks’ gestation in most studies.
Discontinued at time of delivery or
up to 4 weeks postpartum
 At time of birth to 3 months
postpartum in most studies
With discontinuation of treatment,
women should be monitored closely
for up to 6 months after delivery for
hepatitis flares & seroconversion.

Immune-active
hepatitis
 Elevation of ALT >2 the ULN or evidence of
significant histologic disease
 ULN for ALT in healthy adults is reported to be
29-33 U/L for males and 19-25 U/L for females. A
ULN for ALT of 35 U/L for males and 25 U/L for
females is recommended to guide management
decisions.
PLUS
 Elevated HBV DNA above 2,000 IU/mL
(HBeAg negative) or above 20,000 IU/mL
(HBeAg positive).
 Treatment should be based on
recommendations for nonpregnant women.
Butdonotethat–

Breastfeeding
NOT contraindicated
Antivirals minimally excreted in
breast milk &unlikely to cause
significant toxicity
Insufficient long-term safety data
in infants born to mothers who
took antiviral agents during
pregnancy and while breastfeeding
HotOtherMatters

Wedon’tmiss
this,dowe?
The CDC continues to recommend
hepatitis B vaccination and
hepatitis immune globulin
regardless of birth weight within
12 hours of birth for infants born to
hepatitis B-infected mothers.
Red-hotINTERVENTION

Doyouroutinelyvaccinate
pregnantwomenaspartof
prenatalcare?
• Tetanus-
diphtheria-
pertussis
• Influenza vaccine
• Pneumococcal
vaccine
• Hepatitis B
POGS Clinical Practice Guidelines on Immunization for Filipino Women 2011

Whichvaccinesare
contraindicatedinpregnancy?
Live attenuated
vaccines are
contraindicated
in pregnancy.
• HPV vaccine
• Varicella zoster
• Measles, mumps
and rubella

Tetanus-diphtheria-pertussis
(Tdap)vaccine
No previous tetanus
immunization of
unknown status:
• 3 doses of Td
vaccine given one
month apart,
starting second
trimester
• 3rd dose given
postpartum as
Tdap
Level 1 Grade A

Tetanus-diphtheria-pertussis
(Tdap)vaccine
Last Td/Tdap
vaccination more
than 10 years ago:
• Td booster in
second or 3rd
trimester of
pregnancy
Level 1 Grade A

Influenzavaccine
All pregnant and
breastfeeding
women should
receive the
inactivated flu
vaccine
(Level I, Grade A)

Pneumococcalvaccine
Pneumococcal
vaccination should be
recommended to
pregnant and
breastfeeding women
who are at high-risk
for invasive
pneumococcal disease.

Pneumococcalvaccine
Pneumococcal
vaccination should
preferably be
administered during
the 2nd or 3rd trimester
of pregnancy as a
general safety
precaution.

HepatitisBvaccine
• Hepatitis B vaccine
may be administered
to a pregnant women
who is otherwise
eligible for it.
• HBsAg-negative
pregnant women not
previously
vaccinated

HPV screening
 In 2003, the FDA approved a screening test that
can be done in conjunction with a Pap test to
determine if you have the HPV virus. The HPV
DNA test can detect high risk types of HPV, such
as types 16 and 18, before any abnormal cells can
be detected on the cervix.
 This screening is recommended for women over
the age of 30, who are at an increased risk of a
chronic HPV infection turning into pre-cancerous
cells.
 Men can carry and transmit the HPV infection
without ever having symptoms. At this time,
there is no test to detect HPV in men.

36year oldelderly primigravid
consults forprenatal checkup
complaining ofcauliflower-like
massesonthevulva.
HPV causes genital warts.

HPV Infection
~100 types of HPV
infection, 40 can infect
genital area
Most sexually active
persons become infected
with HPV at leat once in
their lifetime.
Red-hotMYSTERIES

HPV Infection
Oncogenic, high-risk HPV
infection causes most cervical,
penile, vulvar, vaginal, anal
and oropharyngeal cancers
and pre-cancers
Non-oncogenic low-risk HPV
infection causes genital warts
and recurrent respiratory
papillomatosis
Red-hotMYSTERIES
CDC Sexually Transmitted Diseases Guidelines, 2015

KeyMessages
forCounselling
Most sexually active people get
HPV at some time in their lives,
although most never know it.
It is not possible to determine
which partner transmitted the
original infection.
Types of HPV that cause genital
warts are different from the types
that cause cancer.
Red-hotMESSAGES

Special
Considerations
Podofilox, podophyllin,
sinecatechins, imiquimod should
not be used in pregnancy
Anogenital warts can proliferate
and become friable during
pregnancy
Resolution might be incomplete or
poor until pregnancy is complete.
Red-hotMESSAGES

Managementof
Delivery
Cesarean delivery should not be
performed solely to prevent
transmission of HPV infection to
the newborn
Cesarean delivery is indicated if
pelvic outlet is obstructed or if
vaginal delivery would result in
excessive bleeding.
Low risk for recurrent respiratory
papillomatosis

Doyouroutinelyscreenfor
HPVaspartofprenatalcare?
Cervical cancer
screening should be
part of routine
prenatal care.
• Papsmear
• Visual inspection
with acetic acid
(VIA)
• HPV testing
Society of Gynecologic Oncologists of the Philippines (Foundation) Inc.
Clinical Practice Guidelines for the Obstetrician-Gynecologist 2010

AmIatriskfor
cervicalcancer?
 HPV infection is the necessary cause of
cervical cancer.
 Parity of 7 or more
 Long-term use of OCPs
 Smoking
 Co-infection of HPV with Chlamydia
trachomatis or herpes simplex virus
 HIV infection
REDflags-risks

AmIatriskfor
cervicalcancer?
 Early age at first intercourse
 Lifetime number of sexual partners
 Early age at first full term pregnancy
 Uncircumcised male partner
 No prior screening
 Low socioeconomic status
REDflags-risks

Primary
Preventionof
cervicalcancer
 Total abstinence prevents HPV infection.
 Lifetime mutual monogamy prevents
HPV infection.
 Consistent and correct use of barrier
protection decreases cervical cancer
incidence.
 Vaccination against HPV 16/18 is
efficacious against persistent HPV
infection and ≥ CIN 2+.
REDHOTINTERVENTION

Secondary
Preventionof
cervicalcancer
 Regular gynecologic examinations and
cytologic test (Pap smear) with treatment
of precancerous abnormalities
 Liquid based cytology
 Visual inspection with acetic acid is an
acceptable alternative to Pap smear.
REDHOTINTERVENTION

Secondary
Preventionof
cervicalcancer
 Screening should begin approximately 3
years after onset of vaginal intercourse
but not earlier than 21.
 Annual screening with conventional
cervical cytology until age 30 years.
 At or after age 30 years, a woman who
has had 3 consecutive normal results
may undergo screening ever 2 to 3 years
REDHOTINTERVENTION

Secondary
Preventionof
cervicalcancer
 Annual gynecologic examination is
recommended regardless of the frequency
of screening.
 Women immunized against HPV 16/18
should be screened same as non-
immunized women.
 A pap test should be obtained twice in
the first year after diagnosis of HIV
infection and if results are normal,
annually thereafter.
REDHOTINTERVENTION

 In 2003, the FDA approved a screening test that can be
done in conjunction with a Pap test to determine if you
have the HPV virus. The HPV DNA test can detect
high risk types of HPV, such as types 16 and 18, before
any abnormal cells can be detected on the cervix.
 This screening is recommended for women over the age
of 30, who are at an increased risk of a chronic HPV
infection turning into pre-cancerous cells.
 Men can carry and transmit the HPV infection without
ever having symptoms. At this time, there is no test to
detect HPV in men.

Doyouroutinelyordersyphilis
screenaspartofprenatalcare?
All pregnant
women should be
screened for
syphilis early in
pregnancy.

20year oldG2P1
complained of
vulvar ulcers
RPRreactive
TPPApositive

Syphilis
Infection
Primary syphilis infection – ulcers or
chancre at the infection site
Secondary syphilis – skin rash,
mucocutaneous lesions,
lymphadenopathy
Tertiary syphilis – cardiac,
gummatous lesions, tabes dorsalis,
general paresis
Latent syphilis infection – those
lacking manifestations, detected by
serologic testing
 Early latent syphilis – acquired within the preceding year
 Late latent syphilis – acquired more than a year prior
 Syphilis of unknown duration

DiagnosticTests
forSyphilis
Darkfield examination from lesion
exudates  definitive method for
diagnosing Treponema pallidum
A presumptive diagnosis of
syphilis requires use of two tests:
Nontreponemal test like VDRL
or RPR
Treponemal test like FTA-ABS,
TP-PA, TP-EIA or rapid
treponemal assays

SyphilisScreening
• For patients with poor prenatal care, RPR test screening and treatment should
be performed at the time pregnancy is confirmed
• Pregnant women with reactive treponemal screening tests should have
additional quantitative nontreponemal testing to monitor treatment response.
• For women at high risk of infection, serologic testing should be performed
twice, at 28-32 weeks AOG and at delivery
• Any woman with fetal death after 20 weeks AOG should be tested for syphilis.

Syphilisduring
Pregnancy
Risk for antepartum fetal infection or
congenital syphilis at delivery is
related to the stage of syphilis during
pregnancy, with the highest risk
occurring with the primary and
secondary stage.
Quantitative maternal nontreponemal
titer, especially if >1:8, might be a
marker of early infection and
bacteremia.

SyphilisScreening
•If a treponemal test (e.g., EIA or CIA) is used for antepartum
syphilis screening, all positive EIA/CIA tests should be reflexed to
a quantitative nontreponemal test (RPR or VDRL).
•If the nontreponemal test is negative, then the results are
considered discrepant and a second treponemal test (TP-PA
preferred) should be performed, preferably on the same specimen.
•If the second treponemal test is positive, current or past syphilis
infection can be confirmed.

SyphilisScreening
•If the second treponemal test is negative, the positive EIA/CIA is
more likely to represent a false-positive test result in low-risk
women with no history of treated syphilis.
•If the woman is at low risk for syphilis, (-) signs or symptoms,
partner (-) syphilis, and is likely to follow up, repeat serologic testing
within 4 weeks.
•If both the RPR and TP-PA remain negative, no further treatment is
necessary.
•If follow-up is not possible, women without a history of treated
syphilis should be treated according to the stage of syphilis.

Preferred
Regimen
Penicillin is the only drug
recommended for treatment of
pregnant women with syphilis.
 Pregnant women allergic to penicillin should be desensitized and treated with
penicillin.
 Primary, Secondary, Early Latent (<1 year
duration)
 1st line: Benzathine penicillin G 2.4MU IM
x 1 dose
 Late latent (including unknown duration)
 1st line: Benzathine penicillin G 7.2 MU
total, administered as 3 doses of 2.4 MU IM
each buttock at 1-week intervals

Management
Pearls
 When syphilis is diagnosed during the second
half of pregnancy
 Include a sonographic fetal evaluation for
congenital syphilis
 Sonographic signs of fetal or placental syphilis
(i.e., hepatomegaly, ascites, hydrops, fetal anemia,
or a thickened placenta) indicate a greater risk for
fetal treatment failure
 Women treated for syphilis during the second half
of pregnancy are at risk for premature labor
and/or fetal distress if the treatment precipitates
the Jarisch-Herxheimer reaction.
 Advise to seek obstetric attention after treatment
if they notice any fever, contractions, or decrease
in fetal movements.

Missed doses are not acceptable for
pregnant women receiving therapy
for late latent syphilis. Pregnant
women who miss any dose of
therapy must repeat the full course
of therapy.
All women who have syphilis
should be offered testing for HIV
infection.
Management
Pearls

Red Hot Infections in Pregnancy

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