Effects of infections in pregnancy

Question 1

Infections harmful to mother

Answer 1

Influenza

Question 2

Infections harmful to foetus

Answer 2

Toxoplasmosis
HSV
Syphilis
Parvovirus B19
CMV
Rubella

Question 3

Infections harmful to both mother and foetus

Answer 3

Hep A/E/B/C
VZV
HIV

Question 4

Acronym for harmful to foetus

Answer 4

ToRCHeS
Toxoplasmosis
Other
Rubella
Cytomegalovirus (CMV)
Herpes simplex virus (HIV , hep)
Syphilis

Question 5

Diagnosing infection in pregnancy

Answer 5

Serology
IgG signifies past infection
PCR- detection of viral or bacterial DNA or RNA

Question 6

Cytomegalovirus (CMV)

Answer 6

Very common- 50% adults past exposure

Transmission can be via saliva, blood, sex, organ transplant or mother- anytime during pregnancy

Question 7

Congenital CMV Cause

Answer 7

Primary infection more likely to cause it
Most likely in 1st trimester
Intrauterine- 1st, 2nd or 3rd trimester
Intra-partum
Post partum e.g. breast milk

Question 8

Congenital CMV facts

Answer 8

7 per 1000 births

Question 9

Congenital CMV diagnosis

Answer 9

Maternal serology- CMV IgG and IgM

Neonatal urine/saliva for CMV DNA PCR

Question 10

Congenital CMV symptoms

Answer 10

Intra uterine growth retardation
Hepatosplenomegaly
Microcephaly
Sensorineural deafness

Question 11

CMV + deafness

Answer 11

Commonest congenital cause of sensorineural hearing loss

Question 12

Varicella Zoster Virus (VZV)

Answer 12

80-90% adults immune
V infectious- droplet/airborne
Mother- worse the later
Foetus- complicated

Question 13

VZV CNS complications

Answer 13

VSV encephalitis/meningitis

Question 14

Least contagious to most contagious R0

Answer 14

Hep C –> ebola –> HIV –> SARS –> Mumps –> measles

Question 15

VZV diagnosis

Answer 15

Swab of vesicle fluid- viral PCR

Maternal serology

Question 16

VZV Management

Answer 16

Varicella Zoster ImmunoGlobulin
Vaccination
TREATMENT- (val)acyclovir (safe during pregnancy)

Question 17

VZV treatment

Answer 17

(val)acyclovir

Safe during pregnancy

Question 18

VZV in children

Answer 18

Chicken pox

Question 19

VZV in adults

Answer 19

Shingles

Question 20

Congenital Varicella syndrome

Answer 20

Higher risk in 2nd trimester
Skin lesions (73%)- leading to limb hypoplasia
CNS (62%)- microcephaly, hydrocephaly, neurodevelopmental delay
Cataracts/other eye problems
GI, genitourinary + cardiac abnormalities
Miscarriage

Question 21

Neonatal varicella

Answer 21

Mother has VZV around time delivery
–> most severe if 5-2 days before delivery
V severe/fatal
Neonate should receive VZIG and acyclovir

Question 22

Herpes Simplex Virus

Answer 22

V common

>90% adults HSV 1 antibodies by 40

Question 23

Neonatal HSV Infection

Answer 23

Most acquire infection perinatally
Nearly all infants manifest disease
Mortality 65% untreated
Mortality 25% if treated with acyclovir

Question 24

Rubella

Answer 24

German measles
>95% population have antibodies
Uncommon
Outside of pregnancy- self-limiting, rash, lymphadenopathy, arthralgia
Diagnosis- serology/oral fluid PCR

Question 25

Congenital rubella

Answer 25

``` Risk to pregnancy dependant on gestational age- highest when below 11/40 weeks- 90% 20% risk if below 20 weeks Microcephaly Heart disease Petechiae and purpura Eye anomalies ```

Question 26

MMR

Answer 26

Measles Mumps Rubella

Question 27

Parvovirus B19

Answer 27

``` Cellular target is RBCs Diagnosis- maternal serology/PCR, foetal ultrasound 0-20 weeks- 9% risk of foetal loss 9-20 weeks- 3% risk of hydrops fetalis >20 weeks- negligible ```

Question 28

Hydrops fetalis

Answer 28

Caused by heart failure secondary to poor RBC production or aplasia Due to parvovirus B19 Treated by intrauterine cord blood transfusion

Question 29

Toxoplasmosis

Answer 29

Infection due to Toxoplasma gondii Natural host is cat Humans are intermediate host through ingestion of oocyst- cat faeces or infected meat Infection is lifelong

Question 30

Toxoplasmosis MOA

Answer 30

Evades immune detection as intracellular pathogen Cysts in different tissues- favours muscle, brain etc. Reactivation causes problems in immunocompromised e.g. HIV

Question 31

Toxoplasmosis risk acquirement odds ratio

Answer 31

Cat ownership- 0.7 Gardening- 2 Eating raw meat- 2.6 Eating cured meat- 2.9

Question 32

Congenital toxoplasmosis

Answer 32

Risk to foetus highest during first trimester IUGR, hydrocephalus, cerebral calcification, microcephaly, hepatosplenomegaly Diagnosis- maternal serology/amniotic fluid PCR

Question 33

Congenital toxoplasmosis

Answer 33

Spyramicin | Pyrimethamine/sulfadiazine/folinic acid

Question 34

Congenital toxoplasmosis

Answer 34

No vaccine | Avoid gardening, don't handle cat litter, avoid uncooked or cured meats

Question 35

Syphilis

Answer 35

Spirochete Treponema pallidum STI Diagnosis- clinical syndrome + serology- treponemal and non treponemal specific Highest risk of transmission during 2st trimester or peripartum Can be associated with miscarriage/still birth/prematurity

Question 36

Syphilis treatment

Answer 36

Penicillin

Question 37

Congenital syphilis- Early, 0-2 years

Answer 37

``` Rash Rhinorrhoea Osteochondritis Perioral fissures Lymphadenopathy GN ```

Question 38

Congenital syphilis- Late, >2 years

Answer 38

``` Hutchinson's teeth Clutton's joints High arched palate Deafness Saddle nose deformity Frontal bossing Desquamations Snuffles- syphilitic rhinitis, mucus which is full of T.pallidum ```

Question 39

Hutchinson's Triad

Answer 39

Due to congenital syphilis Deafness Hutchinson's teeth Interstitial keratitis- inflamed cornea

Question 40

Antenatal infection screening

Answer 40

``` At 12/40 weeks HBV HIV Syphilis CMV/toxoplasma/VZV ``` Rubella no longer part of antenatal screening from April 2016

Question 41

Sepsis

Answer 41

Leads to premature labour or IUGR

Question 42

UTI

Answer 42

Higher risk of outflow obstruction | Gestational diabetes

Question 43

Peripartum sepsis

Answer 43

Infection of retained products of conception, chorioamnionitis

Question 44

Group B strep

Answer 44

Risk of neonatal sepsis

Question 45

Termination >24 weeks

Answer 45

Only if substantial risk that child born would be severely handicapped

Question 46

Ethics around antenatal screening

Answer 46

Allows early detection of high risk pregnancies Serology can be difficult to interpret Retrospective testing for TORCH infections may lead to --> future diagnostic procedures e.g. amniocentesis --> decisions regarding continuation of pregnancy --> often no treatment available