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Obstetrics > Infections > Flashcards

Infections Flashcards

1
Q

CMV - IgM + - what % have infection?

A

25%

Can persist for months after primary infection, and recur with reactivation

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2
Q

Symptoms primary CMV

A

Usually asymptomatic

May have a viral illness

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3
Q

Risk factors for CMV acquisition

A

Child care workers (12% seroconversion/y)

parents with children in day are

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4
Q

CMV general population seroconversion

A

2%/y

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5
Q

Prenatal diagnostic testing

A

Amnio for CMV PCR
at least 6 weeks after primary infection
Sensitivity ~100% >21/40

USS low sensitivity and specificity `

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6
Q

USS features of CMV

A 
Microcephaly 
Ascites
Oligo/poly
Abdominal/intracranial calcification
hydrocephalus
Hydrops
IUGR
Hepatomegaly
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7
Q

Prevention of CMV transmission

A
  1. No role of IVIG in prevention
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8
Q

Management of confirmed foetal CMV infection

A
  1. TOP, with the knowledge it is difficult to predict the severity of infection based on PCR and USS
  2. IVIG - better clinical outcomes for babies at 1 year in one non-randomised trial
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9
Q

CMV - risk of transmission with seroconversion

  • risk of symptomatic CMV
  • risk of sequelae
A

30%

  • with transmission: (overall 10-20% risk long term squeal of congenitally infected child)
  • 10% symptomatic > 50% sequelae
  • 90% asymptomatic > 10% sequelae
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10
Q

Clinical signs of symptomatic CMV

A
  • high early mortality
  • microphaly
  • seizures
  • chorioretinitis
  • developmental delay
  • sensorineural hearing loss
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11
Q

Newborn Ix for CMV

A
  • Examination
  • Serology
  • Urine/salive PCR

> if + then opthal and radiological (USS and MRI)

> Rx w oral valganciclovir

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12
Q

Practices for reducing infection with CMV

A
  1. Assume children <3y in your care have CMV
  2. Thoroughly wash hands with soap and water after touching child/toys/nappies/feeding/bathing etc
  3. Don’t share cups, plates, utensils, toothbrushes or food
  4. Do not kiss the child on or near the mouth
  5. Do not share a bed w the child
  6. Do not share towels or washcloths
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13
Q

Prevalence rubella

A

1/100 000 pregnancies

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14
Q

Symptom rubella infection

A

50% asymptomatic
Vague coryzal symptoms
Examthem: maculopapular, face>trunk, resolves face>trunk
+/- polyarthralgia
+/- tender lymphadenopathy
Forchemers spots (rose like) on soft palate

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15
Q

Diagnosis of rubella infection

A

4x increase in IgG titre (usually 2/52)
IgM +
Culture +
Amnio/CVS PCR

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16
Q

Diagnosis of neonatal congenital rubella infection

A

IF IgM + at birth > retest 1/12

Infant Rubella IgG higher for longer than expected (maternal IgG lasts ~6/52)

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17
Q

Chance of foetal infection across gestations (Rubella)

A

T1 80%
T2 30%
T3 100%

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18
Q

Congenital rubella infection vs congenital rubella syndrome

A 
Infection:
- MC
- SB
- Birth defects
- Asymptomatic
- IUGR
Syndrome:
= constellation of birth defects 
- hearing impairment
- congenital heart defect
- cataracts/glaucoma
- pigmentary retinopathy
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19
Q

Rx rubella in pregnancy

A

Prevention - vaccine prepreg
Supportive care
Rx of complications e.g. steroids for thrombocytopenia
Manage the foetus: discuss TOP (esp <16/40), no direct in utero Rx

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20
Q

Manifestations of congenital infection EARLY

A
  • Hearing loss 60%
  • Heart defects 45% (PDA, pulmonary stenosis)
  • Microcephaly 25%
  • Cataracts 25%
  • IUGR 25%
  • hepatosplenomegaly/jaundice/purpura/pneumonitis
  • meningoencephalitis
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21
Q

Manifestations of congenital rubella infection LATE

A
  • Hearing loss
  • Intellectual disability
  • DM
  • Thyroid dysfn
  • Progressive pan-encephalitis
  • Immune defects
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22
Q

Neonatal follow up after rubella infection

A
  • Clinical attendants at birth should be rubella immune
  • IX: IgM, Urine PCR, culture urine and throat swab (can take weeks)
  • Opthal, cardiac and hearing assessments at birth
  • Regular clinical assessment
  • May be infectious for 1y of life
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23
Q

Risk of congenital defects by gestational age (Rubella)

A

T1 ~85%
13-16/40 ~35%
>16/40 - rare

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24
Q

HSV seroprevalence

A

HSV 1= 60%

HSV 2 = 20%

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25
Q

Risk of HSV transmission if in genital tract in labour (recurrent)

A

HSV 1 15%
HSV 2 <0.01%
Overall 1-3%

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26
Q

HSV - difference between primary and non-primary first infection?

A

Primary - HSV 1 and 2 serology negative

Non-primary = seropositive for other serotype

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27
Q

Risk of HSV transmission for primary HSV?

A

If maternal seroconversion well before efelivery e.g. prior to 30-24/40, then as for recurrent.
No maternal seroconversion - 25-50%

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28
Q

Can you get in utero HSV infection?

A

Yes
Rare
<1%
Can cause abortion, PTB and IUGR

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29
Q

Scalp clip with known genital HSV?

A

No

Increases transmission RR 6.8!

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30
Q

Indications for CS with HSV?

A
  • New HSV diagnosed in labour
  • Primary HSV diagnosed late in pregnancy
  • After maternal discussion with recurrent lesions in labour
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31
Q

Exposed neonate (primary or systemic infection), or neonate with symptoms (skin lesions, seizures, sepsis, low plt, deranged LFTs, DIC, resp distress, corneal ulcers)

A

Ix: LP, LFTs, FBE, HSV PCR blood, surface swabs

Immediately commence IV Aciclovir20mg/kg TDS

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32
Q

Recurrent genital HSV lesins in labour

A

Leave membranes intact as long as possible
Avoid FBS
Avoid instrumental delivery
Expedite delivery

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33
Q

Listeria - organism

A 
Bacteria
Listeria monocytogenes
Aerobic, facultative anaerobe
Motile
B-haemolytic
Gram + rod
Tumbling motility by light microscopy
Grows well at refrigeration temperatures 
Predilection for the placenta and CNS
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34
Q

Listeria - Symptoms

A 
Febrile flu like illness
Malaise / HA / Backache
Abdo pain
Pharyngitis
Conjunctivitis
Diarrhoea
ARDS
Asymptomatic (1/3)
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35
Q

Ix Listeria

A

Blood culture

Genital tract gram stain and culture

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36
Q

Rx Listeria

A

Amoxycillin/Ampicillin 2g Q6H IV x14/7
Gent x 14/7
(Pen allergy Trimethoprim/Sulphamethoxazole - not in T1, w folate)

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37
Q

Incidence Listeria

A

0.3/100 000

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38
Q

Foetal mortality w maternal Listeriosis T2/3?

A

~50%

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39
Q

Asymptomatic individuals with consumption of food implicated in outbreak of Listeria - Rx?

A

Yes (suggested)

Amoxyl 2-3g/d

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40
Q

Incubation Listeria

A

Broad
1-67 days
Preg average 6/52

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41
Q

Neonatal symptoms of Listeriosis

A

Granulomatosis infantiseptica - placenta, cord or post pharyngeal granulomas, small skin granulomas, pustular skin rash
MEc liquor < 34/40
Pneumonitis
Purulent conjunctivitis

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42
Q

Neonatal Ix and Rx

A

Culture: placenta, swabs, blood cultures, urine and CSF
CXR
FBE
Rx: Amoxycillin and Gent (14-21 days dependent on culture results)

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43
Q

Perinatal listeriosis

A

Early onset <7/7

  • often fulminant disease
  • mort 20-60%

Late onset 7/7-6/52

  • usually meningitis or sepsis
  • mort 10-20%
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44
Q

Symptoms of Malaria infection

A 
Parasitaemia peaks T2
Fever (may be periodic) / Chills/ Sweats
Myalgia
Fatigue
Nausea
Janudice
Diarrhoea
Abdo pain
Cough
Pregnancy:
- MOre severe disease
- More hypoglycaemia and ARDS
- More splenomegaly
- More anaemia (may protect against placental malaria)
45
Q

Risks of Malaria to pregnancy

A 
MC
IUGR
PTB
PNM
Congenital infection
Maternal anaemia/death
46
Q

Management Malaria in pregnancy

A
  1. PRevention
  2. Hb and Plts
  3. Falciparum (80%) - Quinine and Clindamycin, or Artensunate (complicated)
  4. Vivax - Chloroquinine
47
Q

ABCD of Malaria prevention

A

Awareness of risk (highest risk papua/solomons/vanauatu/subsaharan africa)
Bite prevention (insecticide, repellant (50% deet) nets, clothes)
Chemoprophylaxis (dependent on area of travel and trimester - Mefloquine safe)
Diagnosis and treatment must be prompt

48
Q

Symptoms of severe malaria

A 
Coma
Hypoglycaemia (secondary to hyperinsulinaemia - common with Quinine)
Shock
Pulmonary oedema (ARDS)
Convulsions
renal failure
Coagulopathy
Renal failure
Metabolic acidosis
Severe anaemia
49
Q

Risk of congenital Malaria?

A

Most when infection around the time of delivery
8-33%
Send the placenta
All babies thick and thin films within first 28 days

50
Q

Hep C Incidence Oz

A

1-2%

51
Q

Hep C risk of sexual transmission

A

<5%

52
Q

Which Hep C genotypes respond best to treatment?

A

3,4,5 - 55% response
0,1,2 - 30% response

Rx w Interferon and rubaviron

53
Q

What is the risk of vertical transmission of Hep C?

A

5% overall

RNA - <1%
RNA + 11%
RNA + and HIV 16%

Active drug users at higher risk of transmission

54
Q

What are the implications of HCV RNA - ?

A
  • Low level viraemia
  • False + Ab test
  • Past cleared infection
  • Still must test the infant at 18/12
55
Q

How should you test the baby from a HCV infected mother?

A

Abs at 12/12 - most uninfected babies will be negative

If AB + check RNA and LFTs

56
Q

Can you treat HCV in pregnancy?

A

No - Rx is contraindicated

Should refer for consideration of post partum treatment

57
Q

What factors increase the risk of vertical transmission of HCV?

A
  • RNA +
  • high viral load
  • HIV co-infection
  • PROM
  • Invasive procedures
58
Q

Can women w HCV breastfeed?

A

Yes

If cracked nipples consider discarding milk while waiting for them to heal

59
Q

What is the risk of vertical transmission of HIV?

A

~45% without treatment

<2% with treatment

60
Q

PRevalence HIV

A

Geography dependent

England 0.1%

61
Q

What symtoms may occur with HIV infection?

A 
Primary:
- Fatigue
- Lymphadenopathy
- Fever
- Rash
Other:
- Persistent generalised lymphadenopathy
- Weightloss
- Fevers
- Diarrhoea
- Encehalopathy
62
Q

What are some opportunistic infections w HIV?

A
  • Pneumocyctis
  • Cerebral Toxo
  • CMV retinitis
  • TB
  • Mycobacterium avium
  • Karposi
  • NHL
  • Cryptococcus
63
Q

Outline features of pretest counselling

A
  • Confidentiality
  • Ascertain risk factors and timing of potential exposure
  • Ascertain details on previous testing
  • Outline why the test is done
  • Outline contact tracing requirements
  • Implications of results
  • Confirm results will be given in person
64
Q

Effect of pregnancy on HIV:

A
  • No major effect on progression, incl to AIDS
  • Opportunistic infections may be less aggressively investigated or treated, esp if HIV status unknown
  • Normal pregnancy associated with a reduction in cell medicated immunity - there is a decrease in number but NOT a decrease in % of CD4 cells
65
Q

Effect of HIV on pregnancy:

A
  • Increased risks: MC, PTB, IUGR (esp w advanced disease)

- No increase in congenital anomalies

66
Q

HIV - factors that increase MTCT:

A
  • High viral load
  • Serovenoversion during pregnancy
  • Advanced maternal disease
  • Poor immunological status (low CD4)
  • PROM (>4h doubles the risk)
  • Preterm labour
  • Vaginal delivery
  • Antepartum invasive procedures (CVS, Amnio, FBS)
  • Intrapartum invasive procedures (epis, FSE, instrumental)
  • Prem
  • Low BW
  • Breastfeeding and mixed breast/bottle feeding
  • Smoking
  • Choreoamnionitis
67
Q

Management of HIV in pregnancy:

A
  • Other sexual health screening
  • MDT
  • Cotrimoxazole and Folate IF CD4<200, AIDS or previous pneumocystis
  • HAART for: maternal wellbeing, or from 24/40 if from PMTC, stay on if already on. (Zidovudine and lamivudine +/- 3rd agent
68
Q

Risks in pregnancy of HAART

A

Protease inhibitors increase GDM
Increased risk PET/IUGR
Immune reconstitution inflammatory syndrome (IRIS) (paradoxical worsening of a condition on commencement of HAART esp VZV, HSV)

69
Q

Intrapartum management

A
  • CS reduces transmission, but unknown if benefit after one of labour or SROM
  • May consider VD if undetectable VL 4-6/52 prior to delivery
  • Early cord clamping and bath the baby may reduce transmission
  • Bottle feed
  • Universal precautions
70
Q

Which patients with HIV get intrapartum Zidovudine?

A
  • those w high viral load at 36 weeks (>50 copies/ml, between 50-400/ml may consider, >400 definitely)
  • Late presenters (get additional raltegravir or nevi rapine depending on VL)
71
Q

Are there foetal risks of ART?

A
  • No described adverse events
  • No HIV embryopathy described
  • Efavirenz and Didanosine are terotogenic, stavudine shouldn’t be prescribed in pregnancy
72
Q

How should be treat the baby?

A

Dependent on high vs low risk MTCT

  • low risk: Zidovudine
  • High risk: multi drug therapy, + PJP prophylaxis until HIV infection excluded

Start as soon as possible after birth
For 2-4 weeks depending on gestation at birth
Test the baby (W DNA or RNA PCR) at 6 weeks and 3 months, at least 2 weeks after prophylaxis has stopped
Only test w Ab > 18/12

73
Q

Who should we test for TB?

A

HIV +
Close contact w TB
Recent arrival from area of high prevalence
Symptomatic

74
Q

How should we test for TB?

A

Tuberculin skin test (unaffected by pregnancy)
IGRA (interferon gamma release assay)
Physical examination

75
Q

Signs of TB

A
  • Any chest sign - most commonly upper lobe crackles , can have tracheal deviation secondary to fibrosis and scarring, dullness to percussion over the clavicle
  • Lymphadenopathy
  • Erythaema nodosum
  • Extrapulmonary infection: LN, bone, liver, spleen, bone marrow, caecum, CNS, eye
76
Q

Effect of pregnancy on TB

A
  • No evidence of increased disease progression
  • Congenital TB via umbilical cord is rare
  • Neonatal TB via maternal airborne transmission is a concern in developing countries
77
Q

Management of TB in pregnancy

A

Similar to non-pregnant
MDT
Active TB in pregnancy should be treated immediately
Active dx w supervised course of more than 1 drug that the organism is sensitive to (RIPE):
Rifampicin > Vit K secondary to cytochrome induction
Isoniazid > Pyridoxine to reduce peripheral neuritis
Pyrazinamide
Ethambutol

> Monitor LFTs

Send the placenta for culture and histopath

78
Q

How should the baby of a TB + mother be treated?

A

Normally the mother is not infectious within 2 weeks of treatment
Sputum + mothers > Rx baby w Isoniazid (or drug that the organism is sensitive to ) usually for 6 months
Give the baby the BCG vaccine
Women should continue to breastfeed

79
Q

Symptoms of neonatal TB

A 
Resp distress
Poor feeding
Hepatosplenomegaly
Fever
Lymphadenopathy
80
Q

Which babies should get the BCG vaccine

A

Aboriginal babies
Born to mothers w TB
Infants of migrant parents
Those travelling to area of high incidence of TB

81
Q

Streptomycin in pregnancy?

A

No!
cat D
Known teratogen
May cause congenital deafness

82
Q

Risk factors for GBS

A
  • 18/24
  • GBS bacturia (correlation with more heavily colonised baby and high risk of EOGBS)
  • Previous GBS affected baby
  • Intrapartum fever >38 degrees
83
Q

Early onset GBS incidence

A

1/1000 all pregnancies
Untreated GBS + 1/200
70% of infants born to GBS + mothers are colonised
90% symptomatic within 12h of birth

84
Q

Culture screening versus risk factor based screening

A

RR 0.46 for prevention of EOGBS.
(This was a retrospective cohort study)
CDC, ACOG and RANZCOG support
RCOG does not support (? not cost effective)

85
Q

Anorectal collection of GBS swab - increased detection?

A

Yes
25%
Request sensitivities if penicillin allergic

86
Q

Rate maternal anaphylaxis to penicillin

A

1/100 000

Less severe reactions in 7-10%

87
Q

Penicillin hypersensitivity

A

Cephazolin 2g IV, then 1g Q8H
Anaphylaxis
Clindamycin 600mg IV Q8H (30% resistance) or Vancomycin

88
Q

Reduction in EOGBS w chemoprophylaxis

A

1.5/1000 > 0.3/1000

Late onset GBS has remained unchanged (>1/52)

89
Q

What are the infective stages of Toxoplasmosis?

A

i. Oocyte - in cat faeces, infective after 1-5 days
ii. Tachyzoite
iii. Bradyzoite - in undercooked meat/soil/fruit and veg - contained in cysts this not penetrable by ABs. Need to wait until develop into bradyzoites

90
Q

Incidence of Toxo infection in pregnancy

A

1-8/1000 (highest France)

91
Q

What are the symoptoms of maternal Toxo infection

A

May be asymptomatic

Can have fever, malaise, fatigue, headache +/- lymphadenopathy

92
Q

Toxo - risk of foetal infections

A 
increases with GA
Preconceptin 0% (unless immunocompromised)
T1 15% >likely severe outcomes
T2 45% > intermediate risk outcomes
T3 70% > usually mild infection
93
Q

What are some USS findings of Toxo

A

Hyperechoic lesions/calcifications
VM - usually symmetrical and bilateral
Changes can be rapidly progressive
NOT SB/IUGR

94
Q

Diagnosis of Toxo infection

A
  1. Serology - 2 weeks apart. IgM last 10/12. Can check IgG avidity +/- IgA.
  2. Amnio PCR > 4/52 after infection
  3. Placental histopath (cysts, deciduitis, villous sclerosis, chronic vascular thromboses, +/- free trophozoites)
95
Q

Rx Maternal Toxo

A

Controversial if any Rx reduces MTCT
Foetal infection should be treated as it reduces the serious neurological squealer and death.
NNT mat inf 18
NNT foetal inf 3

Spiramycin 1g PO TDS > doesn’t cross placenta and thus won’t treat an infected foetus
OR
Pyrimethamine and Sulphonamide (+ Folate)

96
Q

Prevention of Toxo

A 
Avoid unfiltered water
Avoid travelling S America (more severe infection)
Wash fruit and veg
Cook meat thoroughly
Avoid cat faeces
Excellent hand hygiene
97
Q

What is the classic triad of neonatal Toxo?

A

Chorioretinitis
Hydrocephalus
Intracranial calcifications

98
Q

What examinations should be performed on the newborn with clinical suspicion of toxo?

A 
Physical exam
- chorioreitinitis
- seizures-
- fever
- hepatosplenomegaly
- pneumonitis
- anaemia
- jaundice 
- lymphadenopathy
Eye exam
LP 
Cranial imaging for calcifications and hydroceph
Hearing exam
Follow up serology
99
Q

Rx neonatal toxo

A

examination and Ix

If infection, even if asymptomatic Rx w pyrimethamine for 6/12 (+ folate)

100
Q

What is the prevalence of VZV sero+?

A

95%

101
Q

What is the risk of embryopathy w VZV infection in pregnancy

A

Low

28/40 no reports

102
Q

What are the symptoms of congenital varicella?

A 
Limb hypoplasia
Skin spots
Nerological abnormalitis
Structural eye damage
MEntal retardation 50%
103
Q

What is the infectious period for varicella?

A

From 48h prior to rash up to when the lesions are crusted over

104
Q

What is defined as ‘significant exposure’ to varicella?

A

Same household
Face to face for 5 minutes
same room 1h

105
Q

How do you manage significant exposure to varicella?

A

No PHx chichenpox
Unknown or neg IgG -
- 96h consider oral acyclovir if at risk (second half of pregnancy, smoker, immunocompromised, EO complications > IV)

The patient remains infectious for up to 1/12 after ZIG

106
Q

What are defined as maternal complications of VZV?

A
  • Pregnant women more prone to complications and excess morbidity
  • New lesions ater 6 days
  • ongoing fevers after 6 days
  • haemorrhagic rash or bleeding
  • respiratory symptoms
  • neurological sympotms
107
Q

What is the role of amnio in VZV infection?

A

Generally not advised - low risk of congenital effects

- Use USS (5/52 post infection) or MRI to guide prognosis

108
Q

How accurate is a hx of chicken pox for serology?

A

97-99%

Possibly less accurate in women born or raised overseas

109
Q

How should you manage maternal VZV at term?

A 
Delay delivery 5-7 days to allow transfer of antibodies
Organise neonatal opthal exam at birth
Rx ZIG (no benefit once chicken pox occur)

Obstetrics (3 decks)

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