Infectious diseases - Herpes + Chlamydia

Question 1

What are the classifications of neonatal herpes?

Answer 1

1) Disease localised to skin and eye/mouth
2) Localised CNS Disease (encephalitis alone)
3) Disseminated infection with multi organ involvement

Question 2

What proportion is disease localised to the eye/mouth?

What % develop neurological or ocular morbidity?

Answer 2

30%

<2% with antiviral (best prognosis)

Question 3

With local CNS disease
- what % develop neurological morbidity?

• What % mortality?

Answer 3

Neuro: 70%

Mortality: 6%

Question 4

With disseminated infection with multi organ involvement
- What % develop neurological morbidity?

• What % mortality?

Answer 4

Neuro: 17%

Mortality 30%

Question 5

Type 1 HSV– typically causes oro-labial herpes

What % T1 causes genital herpes?

Answer 5

1/3

Question 6

What factors influence vertical transmission of HSV

Answer 6

• Primary/recurrent
• Prescence of maternal antibodies
• Duration of membrane rupture before delivery
• Use of fetal scalp electrode

Question 7

How to manage 1st episode in 1st/2nd trimester?

Answer 7

Supportive measures (paracetamol and topical lidocaine)
Take viral PCR
Baldder catheterisation if signs retention
Acyclovir
Advise GUM clinic
Watch for signs of encephalitis/disssemintated infection
Offer suppression from 36 weeks

Manage expectantly - can have VD along does not deliver within 6 weeks

If disseminated infection occurs - higher risk of mortality

Question 8

What can aciclorvir cause in the neonate when given to the mother?

Answer 8

Transient neonatal neutropenia

Question 9

Does HVS in 1st/2nd increase risk miscarriage/congential abnormality?

Answer 9

No

Question 10

How to manage 1st episode in third trimester?

Answer 10

• Commence acyclovir 500mg TDS until deliver
• Should deliver by CS, especially if within the last 6 weeks

Question 11

The neonatal transmission risk if 1st episode in last 6 weeks?

Answer 11

41%

Question 12

Risk of neonatal transmission if recurrent infection at time of delivery?

Answer 12

0-3%

Question 13

If primary infection at onset of labour?

Answer 13

Take viral swap + inform neonates

Offer CS within 4 hours of SROM

If wants VD - IV aciclovir 5 mg/kg every 8 hours) and IV Abx to the neonate (20 mg/kg every 8 hours)

No invasive pressures: FSE/ARM/instrumental delivery

Question 14

When should suppressive acilovir be given in recurrent infections?

Answer 14

36 weeks

Question 15

When should supportive measures be given in HIV+ve and recurrent infection.

Mode of delivery?

Answer 15

32 weeks

MOD in line with BHIVA HIV guidelines

Question 16

How to manage neonates born by CS with primary infection in 1st trimester?

Answer 16

Inform neonates
Swabs not required, no treatment required
PN education - reduce risk of PN transmission

Question 17

How to manage neonates born by vaginal delivery and primary infection in 3rd trimester

Answer 17

• Inform neonates
• Swabs - skin, conductiva, oropharynx reaction
• IV acyclovir 20mg/kh 8 hourly
• Can breastfeed
• Educate parents - early sings of infection (poor feeding, leathery, lesions fever)
• Strict infection control measures

Question 18

How to manage neonates if recurrent HSV +/- active lesion

Answer 18

Maternal IgG protective, risk infection is low
- inform neonates
- normal PN care
- educated parents

Question 19

PPROM and active primary HSV

Answer 19

Limited evidence
CS if delivery within 6 weeks
consider initial management with IV acyclovir 5mg/kg
Consider steroids

Question 20

What type of pathogen is chlamydia?

Answer 20

Obligate intracellular organism

Question 21

What is the prevalence of chlamydia in pregnant women?

Answer 21

2-7%

Question 22

What % of neonates delivered vaginally to a mother infected with chlamydia are colonised?

Answer 22

50-60%

Question 23

Babies exposed to chlamydia, what are the most common fetal risks and how often do they occur?

Answer 23

Conjunctivitis - 50%, presented within 2 weeks
Pneumonia - 20%, within 2 months

Question 24

What test is most sensitive for detecting chlamydia? Where is it collected from in males/females/

Answer 24

Nucleic acid amplification tests (NAATs)
Men - 1st void urine
Women - vaginal swab

Question 25

What are the 3 treatment regimes for pregnancy women with chlamydia (NICE)?

Answer 25

• Azithromycin 1g PO 1 day, then 2 days 500mg PO
• Erythromycin 500mg QDS 7days or 500mg BD for 14 days
• Amoxicillin 500mg TDS 7 days

Question 26

What is the treatment options for chlamydia in non-pregnancy persons >13years (NICE)

Answer 26

1st line
Doxycycline 100mg BD, 7 days (cannot use pregnancy or BF)

2nd line
- Azithromycin 1g PO 1 day, then 2 days 500mg PO

3rd line
Erythromycin 500mg QDS 7days or 500mg BD for 14 days
Ofloxacin 200mg BD 7 days or 400mg OD 7 days (CI pregnancy, children or growing adolescents)

Question 27

What is the comments cause of vaginal discharge/infection in sexually active women?

Answer 27

Bacterial vaginosis - 20% pregnant women

Question 28

What causes bacterial vaginosis?

Answer 28

Alteration in vaginal microbiome - less Lactobacillus and increase in G. vaginalis / Bactrroides sp / Mobiluncus

Question 29

What associations does bacterial vaginosis have in pregnancy?

Answer 29

• Preterm labour
• Chorio
• Post partum endometritis

Question 30

What cells are seen on wet mount discharge in BV?

Answer 30

Clue cells

Question 31

Treatment of bacterial vaginosis in pregnancy (if symptomatic) NICE

Answer 31

1. Avoid contributing factors (smoking, vaginal douching, soaps in bath)
2. PO metronidazole 400mg BD for 5-7days

If women does not want tablets
3. Vaginal metronidazole gel 0.75% OD for 5 days or clindamycin cream 2% for 7 days

Repeat testing at 1 month if still symptomatic