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RANZCOG 2024 - Antenatal > Infection in pregnancy > Flashcards

Infection in pregnancy Flashcards

1
Q

Discuss CMV in pregnancy
-Incidence (4)
-Risk factors (1)
-Mode of transmission (3)
-Transmission to fetus (5)

A
  1. Incidence
    -60-70% of women seropositive
    -Most common congenital infection
    -Most common cause of non-hereditary deafness
    -Birth prevalence 1%
  2. Risk factors
    -Frequent prolonged contact with children <3yrs
  3. Mode of transmission
    -Saliva, urine, genital secretions
  4. Transmission to fetus
    -Transmission to fetus - transplacental, genital tract
    -Transmission 30% if primary infection of mother
    -Transmission can occur in those with re-infection 1%
    -Risk is greatest with transmission in the first trimester
    -Burden of fetal disease from non-primary infection due to population already impacted
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2
Q

Discuss CMV in pregnancy
-Screening (3)
-Clinical presentation (4)
-Diagnosis (4)

A
  1. Screening
    -Universal screening is not recommended
    -Can consider in women pre-pregnancy who are high risk with IgG
    -All women should be given hygiene advice
  2. Clinical presentation
    -Most women are ASx
    -Fever, malaise, lymphadenopathy in primary infection
  3. Diagnosis
    Investigate if: Sx suggestive of CMV, exposure to CMV infected individual, Abnormalities on routine USS
    Serology
    -New infection = IgM and low avidity IgG (suggests infx within 3 months), or new seroconversion
    -Old infection = IgG or IgM + high avidity IgG
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3
Q

Discuss management of CMV
1. Treatment for mother (1)
2. Diagnosis of fetus (3)
3. Management of fetus (2)

A
  1. Treatment of mother
    -No specific treatment
    -CMV Ig - not shown to work but increases PTB. Evidence poor
    -Consider antivirals. Unclear evidence of reduced maternal-fetal transmission.
  2. Diagnosis of fetus
    -Refer MFM
    -Fetal USS but low sensitivity - 30-50%
    -MRI and USS complimentary
    -Amniocentesis approx 8 weeks after infection for PCR if >21/40. High false negatives if before this time and gestation.
    -Serial growth scans and assessment for growth, hydrops, structural abnormalities
  3. Management of fetus
    -If infection is confirmed offer TOP
    -Consider antivirals
    -Test the saliva or urine of all babies of mothers with CMV infection for CMV within the first 3 months of life
    -Hearing assessment at birth and long term
    -Discuss with paediatrician for ongoing management
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4
Q

Discuss CMV in pregnancy
-Fetal risks for infection (5)
-Fetal USS findings (10)

A
  1. Fetal risks
    -In primary infection to mother risk of transmission 30%
    -In reinfection to mother risk of transmission 1%
    -If infection is symptomatic 50% of babies have long term sequalae in either group
    -If Asx then 10% of babies have long term sequalae in either group
    -10% of babies die
    -Severity of outcome is the same regardless of primary or reinfection
  2. Fetal USS findings
    -Microcephaly, hydrocephaly, intracranial calcifications, ventriculomegaly
    -Ascites, abdo calcifications, hyperechoic bowel, hepatomegaly
    -Growth restriction, oligo/polyhydramnios, hydrops
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5
Q

Discuss CMV in pregnancy
-Outcomes of acute infection (6)
-Longterm sequalae (7)

A
  1. Outcomes of acute infection
    -Hepatitis, pneumonia, thrombocytopenia and purpura, anaemia, chorioretinitis, stillbirth, multiorgan dysfunction, hydrops
  2. Longterm sequalae
    -Sensorineural hearing loss
    -Visual loss
    -Microcephaly
    -Developmental delay
    -Seizures
    -Cytomegalic inclusion disease
    -CP
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6
Q

What are recommendations for CMV infection prevention (7) RANZCOG

A
  1. Do not share food, drinks, utensils with children <3yrs (avoid saliva and urine)
  2. Avoid putting child dummy/ soother in mouth
  3. Thorough hand washing 15-20 seconds after nappy change, laundry, feeding or bathing children
  4. Clean toys and surfaces that come into contact with a child’s saliva, urine
  5. Don’t share your child’s toothbrush
  6. Vaccination very hard to develop
  7. All pregnant women and women trying to conceive should be given info about CMV and preventive methods
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7
Q

Discuss HIV in pregnancy
-Antenatal screening (2)
-Initial management of HIV positive women (5)

A
  1. Antenatal screening
    -Screen with ELISA
    -Diagnose with Western Blot
  2. Initial management of HIV woman
    -Post test counselling
    -Repeat test in 4 weeks if recent exposure or ongoing risk
    -Involve MDT - Physician, ID
    -Assess HIV RNA viral load, HIV resistance testing, CD4 count, routine labs
    -Test for other STI
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8
Q

Discuss HIV in pregnancy
-What is the risk of transmission to child if prevention strategies are taken?
-What is the risk of transmission to child if prevention strategies are not taken?
-What is the risk of risk of transmission through breastfeeding if prevention strategies are taken?
-What is the risk of transmission through breastfeeding if prevention strategies are not taken?

A
  1. MTCT with prevention strategies = <2%
  2. MTCT without prevention strategies = 20-50%
  3. MTCT in breastfeeding with prevention strategies = 1-5%
  4. MTCT in breastfeeding without prevention strategies = 20%
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9
Q

Discuss prevention strategies to reduce MTCT in women infected with HIV
-General points (6)
-Those with low viral load <50 copies/mL at 36 weeks (1)
-Those with viral load >400 copies /mL at 36 weeks (2)
-Those with viral load between 50-400copies/mL at 36 weeks (2)
-Management of late presenters

A
  1. General points
    -Routine screening of all pregnant women
    -MDT and specialist management
    -Commence on HAART or continue HAART.
    -If not requiring HAART for maternal health start by 24/40
    -Avoid breast feeding in all circumstances
    -Screen for other STIs and make sure smears UTD
  2. Those with viral load <50copies/mL at 36 weeks
    -Can have vaginal delivery
  3. Those with viral load (High)
    -Intrapartum zidovudine
    -CS
  4. Those with viral load (Moderate)
    -Consider intrapartum zidovudine
    -CS
  5. Late presenters
    -Start on HAART
    -CS
    -Intrapartum zidovudine
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10
Q

Discuss management of neonate with intrapartum HIV exposure (5)

A
  1. Antiretroviral prophylaxis within 6-12 hrs post delivery
  2. In low risk MTCT single agent prophylactic ARV for 4/52
  3. In high risk MTCT multi agent prophylactic ARV
  4. Test neonate with HIV PCR at regular intervals
  5. Follow exposed but unaffected children up for 5 years
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11
Q

Discuss HSV in pregnancy
-Risk of vertical transmission (2)
-Risk of transmission in recurrent herpes (4)
-Risk of transmission in primary herpes (2)

A
  1. Risk of vertical transmission
    -95% of exposure due to infected maternal secretions
    -5% due to intrauterine infection
  2. Risk of vertical transmission in recurrent herpes
    -If no shedding then <1%
    -If shedding 1-3%
    -If lesion 2%
  3. Risk of transmission in primary herpes
    -< 6 weeks until delivery 25-50%
    - >6 weeks until delivery - same as for recurrent herpes (1% if ASx)
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12
Q

Discuss HSV in pregnancy
-Antenatal management (4)
-Delivery considerations (4)

A
  1. Antenatal management
    -Establish if primary or secondary infection and type.
    -If partner has HSV but mother doesn’t then avoid sexual intercourse when active lesions, advise condoms, avoid sex after 30/40
    -If previous HSV - valaciclovir from 36/40
    -If primary infection - treat with aciclovir or valaciclovir and offer valaciclovir from 36/40
  2. Delivery considerations
    -If previous herpes and no lesions CS not indicated
    -If previous herpes and lesions offer CS
    -If primary herpes diagnosed late in pregnancy or in labour offer CS
    -In VB avoid FSE, FBS, instrumental delivery
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13
Q

Discuss impact to baby infected with HSV at birth

A
  1. Localised infection - meningoencephalitis, conjunctivitis, keratitis, chorioenteritis, vesicular skin lesions, stomatitis, laryngeal lesions
  2. Disseminated disease
    -Rare but high mortality
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14
Q

Discuss listeria infection in pregnancy
-Incidence (1)
-Transmission (4)
-Presentation (2)
-Investigations (2)
-Management (2)

A
  1. Incidence 1:100,000 - 15% in pregnant women
  2. Transmission
    -Food born infection
    -Much more likely to get infection in pregnancy as T cell immunity impaired (20x)
    -Fetal infection by transplacental or ascending infection
    -Transmission highest in 3rd trimester
    -Facultative anaerobe
  3. Presentation
    -Flu like illness, febrile. Sore throat, abdo pain, diarrhoea.
    -33% of women asx
  4. Investigations
    -Blood and genital cultures
  5. Management
    -Amoxicillin 1g IV 14/7 if symptoms. Add in Gent if severe
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15
Q

Discuss the fetal effects from maternal listeria infection
-Mortality rate of infection in 2/3 trimester (1)
-Antenatal impact (3)
-Neonatal impact if born alive (2)
-Clinical features suggestive of infection (4)
-Management for neonatal where there is confirmed or suspected listeria infection (2)

A
  1. Mortality rate
    -40-50%
  2. Antenatal impact
    -Miscarriage in first trimester
    -Amnionitis - brown stained liquor
    -PTL
  3. Impact if born alive
    -Granulomatosis infantiseptica = Early onset infection 0-7 days - 20-60% mortality from pneumonia mainly
    -Late onset infection - 7 days to 6 weeks - 10-20% mortality from meningitis mainly
  4. Clinical features
    -Placental, pharyngeal, skin granulomas
    -Rash
    -Pneumonitis
    -Purulent conjunctivitis
  5. Management of neonate
    -Swab placenta / cord / histopathology
    -Take bloods and consider CSF for micro
    -CXR and FBC
    -Treat with ben pen and gent for 48hrs then stop if well continue for at least 2 weeks
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16
Q

Discuss prevention methods for listeria infection

A
  1. Avoid high risk foods
    -Unpasteurised milk or food made from unpasteurised milk
    -Pate or dips, soft cheese
    -Precooked and chilled, smoked or raw seafood
    -Precooked meats
    -Preprepared salads
  2. Safe food handling
    -Wash hands
    -Cook meat and fish
    -Keep food separate in fridge
    -Wash fruit and vege
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17
Q

Discuss parvovirus infection in pregnancy
-Incidence (2)
-Virus type and pathophysiology (2)
-Transmission (2)
-Risk factors for transmission (3)
-Clinical features (8)

A
  1. Incidence
    - 1-5% of pregnancies affected
    -40% of women are susceptible. 60% immune
  2. Virus type and pathophysiology
    - DNA virus
    -Pathophysiology. Attacks rapidly dividing cells with particular affinity for haemapoetic system resulting in anaemia in both mother and fetus
  3. Transmission
    -Respiratory droplets
    -Haematogenous spread through placenta and to fetus (15-30% of cases)
  4. Risk of transmission
    -55% from own child
    -20-30% from occupational exposure - early childhood and teachers
    -Increased risk if exposed to children 4-11yrs
  5. Clinical features
    -Incubation 4-14 days
    -Fever, malaise, arthralgia
    -Lymphadenomyopathy
    -Facial rash (slapped cheek), lace like rash on trunk
    -Aplastic anaemia
    -IgM rises fast and lasts for > 3months, IgG rises soon after IgM
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18
Q

What are the maternal effects of parvovirus infection during pregnancy (4)

A
  1. Aplastic crisis in women with haemoglobinopathies
  2. Reversible PET from mirror syndrome of hydropic fetus
  3. Chronic anaemia in immunocompromised women
  4. First trimester miscarriage 10%
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19
Q

What are the impacts to the fetus during infection of parvovirus?
-Impact on fetal development (1)
-Chance of infection (1)
-Chance of fetal loss (2)
-Main impact and outcome of this (3)
-Long term effects (1)

A
  1. Impact on development
    -Not teratogenic
  2. Chance of infection
    -Infection risk 50% of cases
  3. Chance of fetal loss
    -If infection before 20/40 risk of loss - 10%.
    -If infection after 20 weeks risk of loss <1%
  4. Main impact
    -Haemolytic anaemia and haemapoetic arrest
    -Non-immune hydrops (<10%) from high output cardiac failure from haemolytic anemia (3%) Average onset 5 weeks post infection
  5. Outcome of non-immune hydrops
    -30% of those with hydrops spontaneously resolve
    -30% die without IUT
    -30% get resolution with IUT of those 6% die
    -Death from hydrops or it’s treatment 1:170
  6. Long term effects
    -None
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20
Q

Discuss investigations for parvovirus (4)

A
  1. IgM -ve and IgG -ve = susceptible or not yet sero-converted so retest in 2-weeks
  2. IgM-ve and IgG+ve = past infection - immune
  3. IgM +ve and IgG -ve = recent infection
  4. IgM can rapidly clear in hydrops so if 8 weeks post infection consider PCR to confirm
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21
Q

Discuss management of parvovirus in pregnancy (7)

A
  1. Urgent MFM referral
  2. Ultrasound for hydrops 2 weekly for 12 weeks
  3. Amniocentesis not indicated
  4. TOP should not be offered as no long term poor outcomes if survives
  5. Weekly scans for MCA-PSV fortnightly 12 weeks
  6. If evidence of fetal anaemia or hydrops for fetal blood sampling +/- IUT
  7. IOL at 37 weeks as MCA PSV becomes very unreliable after this
22
Q

Discuss prevention of parvovirus infection for pregnant women (3)

A

-Not practicable to avoid exposure at home
-Exclusion from work if early childhood or teacher during parvovirus epidemics not recommended
-Antenatal screening not recommended

23
Q

Discuss rubella in pregnancy
-Type of organism (1)
-Incidence of unvaccinated/ susceptible women (1)
-Risk of infection in susceptible women (1)
-Mode of transmission (2)
-Clinical features (4)

A
  1. Type of organism
    -Virus
  2. Incidence of unvaccinated / susceptible women
    - 1-2% of young adult women
  3. Risk of infection if susceptible
    -2:1000 / 1:500
  4. Mode of transmission
    -Contact with infected person - can be asx
    -Spreads to URT and then through blood to organs including placenta
  5. Clinical features
    -Fever, malaise, lymphadenopathy
    -Blanching maculopapular rash - starts at neck and face then to trunk
24
Q

Discuss screening and diagnosis of rubella
-Screening (3 points)
-Diagnosis (4 points)

A
  1. Screening
    -Routine screening antenatally for IgG
    -If non-immune (<10 IU/mL) vaccinate post delivery
    -If indeterminante <15IU/mL consider revaccination post delivery
  2. Diagnosis
    -IgM +ve IgG +ve = possible recent infection - repeat to confirm
    -IgM -ve and IgG -ve = susceptible. Repeat if concern fro recent infection
    -IgM +ve and IgG -ve = possible recent infection repeat. If no seroconversion likely false IgM +ve - vaccinate post delivery
    -IgM -ve and IgG +ve = past infection or vaccination
25
Q

Discuss risks to the fetus exposed to rubella
-Risk of transmission to fetus according to timing of infection(3)
-Risk of adverse fetal outcome according to timing of infection (4)
-Clinical risks to fetus (9)

A
  1. Risk of transmission to fetus according to timing
    < 12 weeks - 80% risk of infection
    13-16 weeks 55% risk of infection
    >17 -22 weeks 36% risk of infection
    >22 weeks high risk of infection but congenital abnormalities rare
    (U shaped curve for infection with gestation)
  2. Risk of adverse outcomes according to timing of infection
    <12 weeks 85% risk of adverse outcomes
    13-16 weeks 35% risk of adverse outcomes
    17-22 weeks minimal risk only deafness
    >20 weeks no increased risk
  3. Clinical features of rubella infection
    -Fetal growth restriction
    -CNS - Meningioencephalitis
    -Eyes - Cataracts, retinopathy, microphthalmia, glaucoma
    -Ears - sensorineural deafness
    -CVS - PS and PDA
    -Blueberry muffin spots on skin
    -Hepatosplenomegally
    -Developmental delay, endocrinopathies
26
Q

Discuss management of rubella in pregnancy
-Management during pregnancy
-Management of the neonate

A
  1. Management during pregnancy
    Vaccination contra-indicated
    No treatment available to reduce risk of fetal infection
    If infection in first trimester offer TOP
    If infection in second trimester offer amnio / CVS
    -Test PCR, culture and fetal IgM. Risk of false +ve with maternal contamination
    -Test at least 6 weeks post infection. Best performed after 20 weeks
    If infection in third trimester give reassurance
  2. Management of the neonate
    -Test for serum IgM
    -PCR urine, throat swab
    -Culture conjunctiva, urine, throat swab
    -Breast feeding not contraindicated
    -Make sure caregivers are immune or vaccinated
    -Infants are infectious for up to 12 months. Should have isolation while in hospital
    -Offer opthalm, cardiology, hearing assessments
    -Regular 3-6 monthly checks for first few months to yrs of life
27
Q

Discuss syphilis in pregnancy
-USS findings of congenital syphilis (5)

A
  1. Hydrops fetalis (Non-immune)
  2. Hepatosplenomegaly
  3. Polyhydramnios
  4. Placental thickening
  5. Skin thickening
28
Q

Discuss syphilis in pregnancy
-Screening (2)
-Diagnosis (4)

A
  1. Screening
    -Screen at first antenatal bloods and then at 28/40 + 36/40 in high risk women, birth + 6/52 PP (variable by epidemiology in location)
    -Screening tests are treponemal - TPPA/TPHA (Says had or has had - won’t change with treatment)
  2. Diagnosis
    -If positive for TPPA, TPHA, EIA then do VRDL/RPR
    -VRDL/RPR +ve and TPPA/TPHA/EIA +ve = syphilis infection
    -VRDL/RPR +ve and TPPA/THPA/EIA -ve = could be too early in infection. Retest in 4 weeks. If still -ve then VRDL/RPR likely false +ve
    -VRDL/RPR -ve and TPPA/THPA/EIA +ve = latent / past infection
29
Q

Discuss risks of infection to fetus in the following types of syphilis.
-Primary
-Secondary
-Latent
-Tertiary
-Types of abnormalities (5)

A
  1. Primary - high
  2. Secondary - moderate
  3. Latent - Low
  4. Tertiary - negligible
  5. Types of abnormalities
    -MSK - saddle nose, limbs deformities
    -Dermatological rashes
    -Neurological - hearing loss, CP, Hydrocephalus
    -Dental abnormalities
    -Hutchinson’s triad: deafness, teeth, interstitial keratitis
30
Q

Discuss management of syphilis in pregnancy (5 points)

A
  1. Treat with benzathine pen as would outside of pregnancy
    -One dose in primary and secondary 1.8g 2.4 million units
    -3 doses in latent infection 1.8g / 2.4 million units weekly 3 weeks
  2. Repeat VRDL or RPR monthly
  3. A > 4 fold drop in titre confers successful treatment
  4. Retreat if there is a rise in titre
  5. Consider admission for fetal monitoring if women receiving treatment after 26 weeks for Jarisch-Herxheimer reaction
31
Q

Discuss syphillus management of the neonate following delivery
-Testing (3)
-Treatment if tests are positive (3)
-Monitoring if tests are negative (1)

A
  1. Testing
    -Serology RPR and IgM
    -Full clinical exam for rash, boney tenderness, hepatomegaly, eye lesions
    -Placental histopathology
  2. Treatment
    If any of the tests are positive then:
    -Bloods, X-rays and CSF
    -Ben Pen 50mg/kg for 10 days
    -Follow-up serology until non-reactive on 2 occasions
  3. Monitoring
    If all tests negative for infection
    -Repeat serology at 3 and 6 months. If negative then not infected
32
Q

Discuss Jarisch-Herxheimer reaction
-What causes it (1)
-Incidence (1)
-How does it manifest (5)
-How should it be managed (3)

A
  1. Causes
    -Seen in the first 24hrs following treatment of syphilis where large amounts of organisms die and release endotoxins
  2. Incidence
    -45% of those treated for syphilis
  3. Manifestations
    -Fever, myalgia, tachycardia, chills, haemodynamic instability
    -TPTL, CTG abnormalities
  4. Management
    -Admit for fetal monitoring if >26 weeks
    -Fluids
    -Resolves in days to weeks
33
Q

Discuss toxoplasmosis in pregnancy
-Organism type (1)
-Incidence (1)
-Mode of transmission (3)
-Clinical presentation (3)

A
  1. Organism type - protozoan
  2. Incidence - 2:1000
  3. Transmission
    -Toxoplasmosis oocytes in cat faeces
    -Ingestion from exposure to cat faeces or from poorly cooked meat of grass fed animals
    -Haematogenous spread through body including placenta
  4. Clinical presentation
    -Fever, malaise, lymphadenopathy
    -Severe disease is rare
34
Q

Discuss fetal effects of toxoplasmosis infection
-Risk of infection according to timing of exposure (3)
-Risk of adverse outcome according to timing of exposure (3)
-Types of adverse outcomes (7)

A
  1. Risk of infection according to trimester
    First trimester - transmission risk 10% (low)
    Second trimester - transmission risk 30% (intermediate)
    Third trimester - transmission risk >50% (High)
  2. Risk of adverse outcome
    First trimester - adverse outcome risk 85% (high)
    Second trimester - adverse outcome risk 20% (intermediate)
    Third trimester - adverse outcome risk 10% (Low)
  3. Adverse outcomes
    -Chorioretinitis
    -Hydrocephaly
    -Intracranial calcifications
    -Hepatosplenomegaly
    -Lymphadenopathy
    -Pneumonia
    -Thrombocytopenia
35
Q

Discuss investigations for toxoplasmosis in pregnancy
-Screening (1)
-Diagnosis (6)

A
  1. Screening
    -Not recommended
  2. Diagnosis
    IgM -ve and IgG -ve = susceptible
    IgM -ve and IgG +ve = past infection
    IgM +ve and IgG +ve = possible recent infection. IgM can stay +ve for months to yrs and so needs further testing
    -If IgG and IgM positive then do IgG avidity (High avidity suggests old infection, low avidity suggests new infection.
    -Can do IgA if positive suggests recent infection
    -Can test antenatal bloods and look for seroconversion
36
Q

Discuss management of pregnancies with toxoplasmosis infection (6)

A
  1. Refer to MFM
  2. Undertake risk assessment depending on trimester of infection
  3. USS/MRI for abnormalities (Low sens)
  4. Amniocentesis at 18-20 weeks and 4 weeks post infection for T. gondii on PCR in amniotic fluid. (High sens and spec)
  5. If USS and PCR negative then:
    -Treat mother with spiramycin if <18/40 or pyrimethamine and sulfadiazine if >18/40
  6. If USS or PCR positive then:
    -Offer termination
    -Treat mother with pyrimthamine and sulfadizine
37
Q

Discuss management of a neonate exposed to toxoplasmosis in utero
-Testing (6)
-Treatment if tests are abnormal (2)
-Monitoring if tests are normal (1)

A
  1. Testing
    -If mother has confirmed toxo then neonate needs testing
    -IgM, IgG and IgA, Toxo PCR - placenta and CSF
    -Placental histology
    -Full examination
    -Cerebral MRI/ USS
    -Opthal and audiological evaluation
  2. Treatment
    -Pyrimethamine and sulfadiazine
    -Monitor hearing, eyes and neurodevelopment throughout infancy and childhood
  3. Monitoring
    -Repeat IgM and IgA at 3 months and IgG at 6 and 12 months
38
Q

Discuss prevention of toxoplasmosis infection in pregnancy (5)

A
  1. Avoid cat faeces
  2. Garden with gloves on
  3. Avoid undercooked meat
  4. Avoid unpasteurised milk
  5. Wash fruit and vegetable
39
Q

Discuss varicella zoster in pregnancy
-Incidence (2)
-Mode of transmission (3)
-Clinical features (7)

A
  1. Incidence
    -3:1000
    -90% of women are immune
  2. Mode of transmission
    -Via respiratory droplets
    -Contact with vesicle fluid
    -Infectious 48hrs prior to rash and until last vesicle crusts over
  3. Clinical features
    -Malaise, fever, myalgia
    -Vesicular pruritic rash
    -Pneumonia and encephalitis
    -Zoster = shingles, Varicella = chickenpox (Primary infx)
40
Q

Discuss maternal risks of varicella zoster virus during pregnancy (5)

A
  1. Increased risk of complications - pneumonia, hepatitis, encephalitis compared with children
  2. Disease more severe in pregnancy - 10% risk of pneumonia
  3. Maternal mortality <1% if antiviral treatment
  4. Incidence 3:1000
  5. Delivery with viremia can increase PPH secondary to thrombocytopenia and hepatitis
41
Q

Discuss fetal risks of varicella zoster virus during pregnancy
-Risk of abnormalities according to timing of infection (4)
-Features of varicella zoster syndrome (5)
-Risk of neonatal infection (2)

A
  1. Risk of abnormalities according to timing
    -Trimester one - 0.5%
    -Trimester two 12-28 weeks - 1.5%
    -Trimester three >28 weeks. Not at risk
    -<7 days pre delivery risk is high
  2. Features of FVS (Fetal varicella syndrome)
    -Skin scarring in dermatomal distribution - 78%
    -Eyes - micro-opthalmia, chorioretinitis, cataracts - 60%
    -CNS - microcephaly, cortical atrophy, mental retardation - 50%
    -Limbs - hypoplasia of limbs - 68%
    -Low birth weight and PTB 50%
  3. Neonatal varicella infection
    -At risk if born 7 days before or 2 days after maternal infection developed
    -Neonate has no immunity (no IgG from mother) so at risk of disseminated disease
42
Q

Discuss management of exposure to varicella zoster viral infection in pregnant women (5 points)

A
  1. Assess hx of maternal exposure - > 5mins face to face, same room for >15mins (RCOG)
  2. Assess if previously had VZV or immunised
  3. If unclear then check antenatal serology
  4. If serology negative or results not back within 4 days then:
    -Give VZIG if exposure within 96hrs (Attenuates illness and decreases risk of FVS)
    -RCOG states effective if given up to 10 days from appearance of rash in index case
    -If >4days give aciclovir PEP 800mg PO 5 times a day for 7 days if high risk for severe infx
  5. Women should be managed as potentially infectious up to 28 days and should be isolated from other pregnant women
43
Q

Discuss management of varicella zoster virus infection in pregnant women (7 points)

A
  1. All women with chickenpox in pregnancy need medical review
  2. If complications or immunocompromised manage in hospital with IV aciclovir and supportive therapy
  3. If no complications and <24hrs since onset of rash give aicilovir 800mg 5 times a day and monitor at home
  4. If no complications and >24hrs since rash monitor at home only
  5. Safety net for complications and monitor in hospital if these develop
  6. Refer to MFM
  7. Aim to not delivery the baby within 7 days of onset of rash
44
Q

Discuss management of the fetus exposed to VZV
-Diagnosis

A
  1. Refer to MFM
  2. Detailed USS for anomalies at least 5 weeks since infection
  3. Repeat USS until delivery
  4. Can consider fetal MRI
  5. Fetal VZV serology is unhelpful
  6. Amniocentesis is not routinely advised if USS is normal as the risk of FVS is low but a negative PCR can be reassuring
  7. Risk of FVS is very high when both USS and PCR are positive
45
Q

Discuss management of the neonate when the mother has VZV
-If baby born > 7days after maternal VZV
-If baby born within 7 days to 2 days after delivery of maternal VZV
-If maternal VZV 3-28days after baby born

A
  1. Maternal VZV > 7days before delivery
    -VZIG is not required for neonate
    -Consider VZIG if baby <28 weeks or <1000g
    -No isolation from mother required
    -Breast feeding encouraged
  2. Maternal VZV <7days prior or <2 days post delivery
    -Immediate VZIG
    -No isolation from mother
    -Breast feeding encouraged
  3. Maternal VZV 3-28 days post delivery
    -VZIG required if baby is <28/40 or <1000g
    -No isolation from mother
    -Breast feeding encouraged
46
Q

Discuss Zika virus and pregnancy
-Organism (1)
-Transmission (4)
-High risk areas (5)
-Clinical manifestation (7)
-Public health measures (2)

A
  1. Organism - single stranded RNA virus
  2. Transmission
    -From mosquito bites
    -Sexual or haematogenous
    -Vertical
    -Transplacental
  3. High risk areas
    -South and central America
    -Central Africa
    -India
    -Asia
    -South Pacific
  4. Clinical manifestation
    -Rash, arthralgias, conjunctivitis, headache, myalgias
    -Encephalitis
    -GBS
    -Symptom onset 2-13 days post exposure
  5. Public health measures
    -Notifiable disease in NZ and Australia
    -Notify if fetal abN found
47
Q

Discuss Zika virus in pregnancy
-Fetal effects (12)
-Fetal USS abnormalities (4)
-Timing of transmission to fetus
-Timing for adverse effects

A
  1. Fetal effects
    -Microcephaly, venticulomegaly, cerebral calcifications, lissencephally, cerebellar hypoplasia, arthrogryposis
    -Macular pigmentation, atrophic lesions, retinal damage
    -Optic nerve abnormalities
  2. Fetal ultrasound abnormalities
    -Microcephally (HC >3SD from mean)
    -Cerebral ventricular megally
    -Thalami and brainstem abnormalities
    -Eye abnormalities - intraoccular calcifications, cataracts
  3. Timing of transmission
    -No trimester transmission specific rates
  4. Timing for adverse effects
    -More likely worse in first trimester
48
Q

Discuss testing for Zika virus in pregnancy (4 points)

A
  1. No evidence for routine testing for asx individuals
  2. If wanting to get pregnant before 6 months following time in high risk area can have IgM testing
  3. If symptomtic test for dengue and Zika NAAT in serum and urine. Testing for IgM Zika not recommended
  4. No role for semen testing although present up to 180 days
49
Q

Discuss management and prevention of Zika infection in pregnancy
-Prevention (4)
-Management (7)

A

1 Prevention
-Avoid pregnancy after 6 months following travel to high risk areas
-Avoid getting bitten by mosquitos
-Use condoms for 3 months following partner travel to affected area
-No current vaccination
2. Management
-Notifiable disease
-Refer to MFM
-No specific treatment for mother
-Fetal monitoring for growth and intracranial anomalies every 4 weeks
-If intracranial anomalies do fetal MRI
-Amniocentesis - do if abnormalities to determine if Zika related as poor outcomes
-Delivery doesn’t change outcomes

50
Q

Discuss Malaria in pregnancy
-Organism (1)
-Transmission (3)
-Endemic areas (4)

A
  1. Organism
    -Protozoan
  2. Transmission
    -Carried on mosquito - anopheles
    -Plasmodium falciparum most common
    -Sequestered in liver then transferred to RBC
  3. Endemic areas
    -Oceania - most common
    -Africa
    -South and central America
    -South Asia
51
Q

Discuss risks of Malaria in pregnancy
-To mother (7)
-To fetus (4)

A
  1. To mother
    -Malaria is an emergency in pregnancy
    -For women who do not have endemic exposure outcomes are worse with both fetus and mother
    -Severe febrile illness
    -Severe anaemia from haemolysis
    -Cerebral malaria
    -Placental parasitemia - higher in endemic exposed women
    -Maternal mortality 50% if severe
  2. To fetus - caused from placental disease with hypoxia
    -Miscarriage
    -Still birth
    -PTD
    -IUGR
52
Q

Discuss management of malaria in pregnancy
-Prevention (3)
-Management (11)

A
  1. Prevention
    -Avoid endemic areas when pregnant
    -Avoid exposure to mosquito bites
    -Take chemoprophylaxis - mefloquine once a week is safe in pregnancy
  2. Management
    -Aim for prompt diagnosis and treatment
    -Diagnosis by microscopy and rapid detection test
    -MDT approach with ICU involvement if severe
    -Given clindamycin or Quinine while waiting for diagnosis (also use for 7/7 in treatment of uncomplicated malaria)
    -Give IV Artesunate
    -Screen for anaemia, hypoglycemia, pulmonary oedema
    -Manage fever with cooling cares and antipyrexials
    -Consider thromboprophylaxis
    -If recover then GS
    -Malaria not an indication for IOL if uncomplicated
    -Screen neonates within 28 days of delivery

RANZCOG 2024 - Antenatal (12 decks)

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