Mod 3-4 Flashcards by Kristin Godsey

After 36 weeks, Rx this abx instead of Macrobid for UTI

Keflex

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17 OHCP (Makenna) for PTL is given between ___ - ____ weeks

16-36

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not recommended to prevent PTL

bed rest

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progesterone PO or IM is only recommended for _____ pregnancies

singleton

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abx for intraamniotic infection

gentamycin + ampicillin

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population at higher risk for ASB

women w/ sickle cell or sickle cell train

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if nitrites are in urine, bacteria is very likely:

e.coli

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leukocytes in urine mean the body is:

fighting infection

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for women with AS Hemoglobin, check _____ every trimester

urine culture

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with pPROM, do NOT:

check cervix

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Ffn is indicated during weeks ___-___

24-34

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fetal fibronectin is present < ___ weeks and >____ weeks

< 20 weeks; > 37 weeks

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both of these are used to predict PTL and used between 24-34 weeks

Partosure and Ffn

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cervical length < 15 mm =

high risk for PTB

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cervical length 15-29 cm =

intermediate risk for PTB

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cervical length >30 mm =

PTB unlikely

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ASB is most common in ______ women with _______

Black women w/ sickle cell trait

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Risk Factors for \_\_\_\_\_\_\_\_\_\_\_\_:
Multiparity
GDM
sickle cell trait
urinary tract congenital anomaly
hx recurrent UTI
low SES

UTI in Pregnancy

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routine screening at ______ weeks gestation is recommended for ASB

12-16

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gold standard test for ASB

urine culture

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single organism of > _______ cfus /mL is diagnostic for ASB

100,000

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pyeolonephritis can occur w/ bacterial counts as low as _________

20,000-50,000

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culture urine every trimester for these populations

GDM + sickle cell trait

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management for recurrent ASB

Nitrofurantoin 100 mg qHS x 21 days

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Abx that concentrates only in urinary tract and causes minimal resistance in Gram(-) organisms BUT may cause acute pulmonary reaction (rarely) that dissipates on its withdrawal

Nitrofurantoin

Can be caused by chlamydia (culture would be negative)

cystitis

May develop w/o antecedent covert bacteriuria

cystitis

``` Risk Factors for _________: Lower socioeconomic status Obesity urinary catheterization Immunosuppression diabetes sickle cell anemia neurogenic bladder Hx before pregnancy of recurrent or persistent UTI UTI associated w/ increased risk of pyelo, PTB, LBW, perinatal mortality Preeclampsia (Especially in 3rd trim) ```

cystitis

``` typical sx of ________: Typical: Dysuria, Urgency, Frequency Pyuria and Bacteriuria usually found Microscopic or frank hematuria possible Nocturia Suprapubic pain **Frequency and urgency not reliable indicators of UTI ```

cystitis

If there is a lower UTI with pyuria accompanied by a sterile urine culture - it may be from:

urethritis from chlamydia

treat urethritis from chlamydia with:

azithromycin

cystitis treatments are __-day treatments (90% effective)

``` Treatment for _________: Amoxicillin 500mg TID Ampicillin 250mg QID Cephalosporin 250mg QID Ciprofloxacin 250mg BID Levofloxacin 200 or 500mg daily Nitrofurantoin 50-100mg QID or 100mg BID TMP/SMZ 160/800mg BID ```

cystitis

rashes are most common with these diseases

zika, rubella, toxoplasmosis

caused by significant bacteriuria in presence of systemic symptoms

pyelonephritis

``` pathogens that cause ________: E. Coli Klebsiella Enterobacter Proteus gram(+) organisms: GBS or Staph aureus ```

pyelonephritis

pyelo is most common in ___ trimester

2nd

``` Risk Factors for ___________: Nullip Young age Lower socioeconomic status Obesity urinary catheterization ```

pyelonephritis

Leading cause of septic shock in pregnancy

pyelonephritis

``` Complications of ___________: maternal and fetal morbidity maternal sepsis acute renal failure acute respiratory distress PTB LBW FGR C/S ```

pyelonephritis

Sx of ____________: Fever CVA tenderness - unilateral or bilateral Significant bacteriuria Flank pain unilateral and right-sided more than half the time Fever and shaking chills w/ abrupt onset Aching pain in one or both lumbar regions Other - chills, myalgia, anorexia, nausea, vomiting, low back pain Anorexia, nausea, and vomiting may worsen dehydration Look sick/acutely ill

pyelonephritis

Diagnostics for __________: Urine sample for dip and culture ***preferred by cath Many leukocytes, frequently in clumps Numerous bacteria Dipstick - nitrites, WBC casts Blood culture if temp >39, limited clinical utility Bacteremia - 15-20% of cases Plasma creatinine - monitor acute kidney injury

pyelonephritis

NitrAtes are _______ in urine | NitrItes are ________ in urine

Nitrates=normal | Nitrites=abnormal, mean infection

__________/_________ to physcian is indicated for pyelonephritis

co-management/referral

Β-agonist tocolysis increases risk X4!! for respiratory insufficiency from pulmonary edema in:

pyelonephritis

Endotoxin-induced hemolysis leading to transient anemia is common in:

pyelonephritis

Management of ___________: Hospitalize Obtain urine and possibly blood cultures Labs: CBC w/ diff, serum creatinine, electrolytes Repeat in 48 hours Creatinine also important if giving nephrotoxic drugs Frequent vitals Cooling blanket and Tylenol for fevers Monitor urine output - consider catheter -- UO >/=50mL/hr w/ IV fluids IV antibiotics - change to PO when afebrile IV- amp & gent, cefazolin or ceftriaxone, or extended-spectrum Chest x-ray w/ dyspnea or tachypnea Discharge when afebrile 24 hrs - consider antimicrobial therapy for 7-10 days Repeat urine culture 1-2 wks after antimicrobial therapy completed Outpatient tx may be an option w/ carefully selected pts up to 24 wks No clinical improvement in 72 hrs and persistent fevers - consider/eval for urinary tract obstruction or other complications Recurrence 30-40% - may need suppressive therapy for rest of pregnancy

pyelonephritis

Labs for ____________: CBC w/ diff, serum creatinine, electrolytes Repeat in 48 hours

pyelonephritis

~50% of those that give birth prematurely do not have an identified _________

risk factor

``` Risk Factors for ___________: ---Maternal Factors Age<17 and >35 African-American ethnicity Genetic variants Low prepregnancy body weight BMI<19.8 Low socioeconomic status Short interpregnancy interval <18 months Stress - depression, anxiety, PTSD Smoking in pregnancy Substance abuse - cocaine, crack, heroin, tobacco ---Fetal factors Congenital anomalies Fetal growth restriction Infection Isoimmunization w/ hydrops Maternal medical and reproductive history Previous preterm birth - MOST SIGNIFICANT RISK FACTOR Prior cervical surgery - cone, D&C Mullerian tract abnormalities Short cervical length measured on TVUS ---Current pregnancy factors Cervical insufficiency - short cervix Infections during pregnancy Intrauterine infection Polyhydramnios Multifetal gestation Maternal disorders - PIH, HELLP, placenta previa Pyelonephritis Vaginal bleeding during more than one trimester ```

PTL

``` There is conflictin evidence that these are risk factors for ___________: Asymptomatic bacteriuria lower UTIs genital tract infections periodontal disease vaginal bleeding ```

PTL

``` Differential Dx for _________: Many! Physiologic changes of pregnancy and normal discomforts like backache and pelvic pressure Braxton hicks ctx Dehydration Lax vaginal tone Round ligament pain Infection Abruption Trauma Appendicitis, cholecystitis, pyelonephritis ```

PTL

Detected in cervicovaginal secretions in those w/normal pregnancies w/intact membranes before 20 weeks and at term Reflects stromal remodeling of the cervix before labor

Fetal fibronectin

fFN is abnormal between ___-___ weeks | ** could mean inflammation/uterine activity

24-34

screening ___________ patients for fFN does not improve outcomes

asymptomatic

Even when used w/ TVUS cervical length universal screening for _____ has poor predictive value

fFN

In symptomatic patients, fFN has ______ positive predictive value, _____ negative predictive value

poor positive predictive value | better negative predictive value

best predicts who will NOT give birth w/in the next 7-14 days

fFN

______ screening for cervical length is not affected by obesity, cervix position, or shadowing from fetal presenting part

TVUS

TVUS is __________ as routine screening for PTL] **SMFM - screening for women w/ prior PTB ACOG - only says to “consider screening”

NOT indicated

Suggested to be done along with fFN for symptomatic women

TVUS

TVUS in symptomatic patients: if cervix < ___ mm - send fFN

Not a good predictor of PTL alone to guide treatment - use in combo with other things

TVUS

perform TVUS if cervix < ___ cm dilated

perform TVUS if cervix __-__ cm dilated with no change in 30-60 min

2-3

if TVUS shows cervical length is intermediate (16-29 mm) but fFN is negative, midwife should:

send patient home

considered ineffective strategies for dealing with PTL

IV hydration and Bedrest

indicated for women with hx of PTB

17-OHP-C weekly IM injections

17-OHP-C weekly IM injections is recommended over __________

vaginal progesterone

17-OHP-C not evidence-based for __________ gestations

multiple

when patient is taking progesterone for hx of PTL and cervical length ___ or less mm, midwife should:

refer to OB

current singleton pregnancy with prior singleton PTB, give 17 OHP-C starting at __ weeks until ___ weeks, **regardless of cervical length

16-24

history of PTB-- start checking _________ at 16 weeks

cervical length

with NO history of PTB, ____________ progesterone works just as well as cerclage

vaginal

tocolytics generally not recommended after _____ weeks

tocolytics not recommended in women with _____ because it does not improve neonatal outcomes

PPROM

limit use of tocolytics to ____ hours to allow for corticosteroid administration

do not use tocolytics beyond ___ weeks even to allow for corticosteroids

medications that have best clinical efficacy as tocolytics with lower incidence of toxicity and maternal S/E

Procardia (nifedipine) | Indocin (indomethacin)

no longer recommended for acute tocolysis

terbutaline

tocolytic that should be reserved for clinical situation where nifedipine and indomethacin are contraindicated or fetal/newborn neuroprotection is the goal

Mag Sulfate

tocolytics are risk for pulmonary edema and are ineffective in ____________

multiple gestations

``` Contraindications for ____________: ruptured membranes nonreassuring fetal status intraamniotic infection preeclampsia IUFD lethal fetal anomaly maternal bleeding w/ hemodynamic instability chorio ```

Tocolytics

give for fetal lung maturation prior to 34 weeks (consider up to 36.6 weeks)

corticosteroids (bethamethasone and dexamethasone)

give 12 mg IM q24 hours x2

bethamethasone

give 6 mg IM q12 hours x4

dexamethasone

give one course of corticosteroids when risk of PTB in ___ days if patient is less than ____ weeks

7; 34

If no previous course of corticosteroids, midwife may consider one course if imminent risk at less than _____ weeks

36.6

may repeat corticosteroid course when previous course was given ___ days earlier and at risk of PTB at < ____ weeks

7; 34

Do we give regularly scheduled repeat course of corticosteroids?

``` fetal adverse effects of ____________: ***if taken longer than 48 hours: oligohydramnios in utero constriction of ductus arteriosus necrotizing enterocolitis in premies patent ductus arteriosus in NB ```

Indomethacin (Indocin (NSAID)

``` maternal adverse effects of __________: pulmonary edema cardiac dysrythmia myocardial ischemia SOB chest pain hyperglycemia hypokalemia palpitations hypotension tachycardia tremor ```

terbutaline (beta blocker)

use Mag Sulfate in patients ____-_____ weeks

24-34 weeks

avoid use of Mag Sulfate with _________

calcium channel blockers (Nifedipine/Procardia)

Mag Sulfate can leach ________ out of mom and baby which leads to fractures

calcium

less than ___% of women w/ clinical PTL go on to give birth within 7 days

``` Current suggested guidelines to diagnose _____: >/=6 ctx/hr Cervical dilation >3cm 80% effaced ROM Bleeding ```

PTL

MOA: binds to β-2 adrenergic receptors → chain rxn → decreased intracellular calcium → myometrial receptors blocked *receptors can become desensitized w/prolonged use → decreased effectiveness

beta blockers terbutaline ritodrine

MOA: Directly blocks calcium ion influx through cell membrane and release of intracellular calcium from the sarcoplasmic reticulum → inhibited myometrial contraction

calcium channel blocker (Nifedipine)

MOA: | COX inhibitor reduces prostaglandin production by cost

NSAIDs Indomethacin

probably competes w/ calcium at cell membrane which reduces calcium available for myometrial ctx

Mag Sulfate

fetal adverse effects of __________: Tachycardia neonatal hypoglycemia

beta blockers (terb)

Contraindications for __________: tachycardia sensitive cardiac disease poorly controlled HTN and/or diabetes

beta blockers (terb)

terbutaline may cause PP _________

hemmorrhage

BBW: Not for tocolysis for >72 hours d/t maternal cardiac complications; PO NOT recommended due to lack of proven effectiveness

terbutaline

ACOG says this can be used for short term inpatient us but it no longer recommended for acute tocolysis

terbutaline

``` maternal adverse effects of __________: peripheral vasodilator transient nausea flushing headache palpitations hypotension dizziness tachycardia ```

calcium channel blockers (Nifedipine)

fetal adverse side effects are secondary to maternal hypotension for this medicatio

calcium channel blockers (Nifedipine)

``` Contraindications of ____________: preload-dependent cardiac disorder left ventricular dysfunction CHF hemodynamic instability ```

Calcium Channel Blockers

Do not use concurrently w/ terbutaline or mag sulfate

calcium channel blockers (Nifedipine)

maternal adverse effects of ____________: | nausea, vomiting, reflux, gastritis, platelet dysfunction

NSAIDs (Indomethacin)

``` Contraindications of ____________: platelet dysfunction bleeding diathesis, hepatic dysfxn GI ulcerative disease, asthma if sensitive to aspirin ```

NSAIDs (Indomethacin)

* Not reccommended for more than 48 hrs of continuous use | * Not reccommended for >/=32 wks

NSAIDs (Indomethacin)

``` maternal adverse effects of ___________: flushing nausea blurred vision headache lethargy muscle weakness hypotension ~~ Rarely: pulm edema, resp or cardiac arrest ```

Mag Sulfate

fetal effects of ____________: neuroprotective ↓FHR variability ↓neonatal tone

Mag Sulfate

Contraindications of ____________: impaired renal function myasthenia gravis cardiac conduction defects

Mag Sulfate

Do not use concurrently w/ nifedipine

Mag Sulfate

Toxicity - loss of ________ reflexes, UO < ____ mL/hr, resp rate < __/min

patellar; 30; 12

toxicity of Mag increases w/ serum creatinine > ___mg/dL

1.0

``` possible risks of ___________: Neonatal hypoglycemia Adverse effects on neurodevelopment Increased cerebral palsy incidence Late gestation (>34 weeks) - higher neonatal and perinatal mortality in the overall population w/ increased use of steroids. potential adverse effects on neurodevelopmental outcomes found in animal studies showing a reduction in brain growth at later gestations ```

Corticosteroids

avoid calcium channel blockers in _________ disease

liver

calcium channel blockers can cause ____ tension

hypo

Maternal risks of ___________: Intraamniotic infection (15-25%) Postpartum infection ( 15-20%) Abruptio placentae complications (2-5%)

PPROM

``` Fetal Risks of __________: Respiratory distress- most common Sepsis Intraventricular hemorrhage Necrotizing enterocolitis With intrauterine inflammation- increase risk of neurodevelopmental impairment ```

PPROM

treatment options for PPROM @ < 24 weeks

expectant management or IOL

may be considered as early as 20.0 weeks in PPROM

antibiotics

these treatments are not recommended in PPROM if pregnancy is not viable

Mag Sulfate for fetal neuroprotection, corticosteroids, tocolysis or GBS prophylaxis

treatment for PPROM @ 24.0-33.6 weeks

expectant management

recommended treatment to prolong latency with PPROM (if no contraindications)

antibiotics

treatments for __________: Antibiotics Single course corticosteroids GBS prophylaxis as indicated

PPROM 24.0-36.6 weeks

Estimated that ___-___ % of term deliveries are complicated by a clinically apparent intraamniotic infection. Increases after 40 weeks completed gestation

2-5

``` Risk Factors for _________: Prolonged ROM Long labors Manipulative vaginal or intrauterine procedures Frequent Cervical exams Dehydration ```

Intra-Amniotic Infection

Categories of __________: Isolated Maternal Fever Suspected Confirmed

Intra-Amniotic Infection

category of intra-amniotic infection based on clinical criteria which include maternal intrapartum fever, and one or more of the following maternal leukocytosis, purulent cervical drainage, or fetal tachycardia.

suspected

category of Intra-Amniotic Infection based on a positive amniotic fluid test result (gram stain, glucose level, or culture results consistent with infection) or placental pathology demonstrating histologic evidence of placental infection or inflammation

confirmed

category of Intra-Amniotic Infection either a single oral temp of 39 C or greater, or an oral temperature of 38 - 38.9 C that persists then the temperature is repeated after 30 min.

isolated maternal fever

diagnosis of _______________________ is made - when maternal temperature is greater than or equal to 39.0 C OR - when maternal temp is 28- 28.9 C and one additional clinical risk factor is present.

suspected intraamniotic infection

``` Maternal complications of ____________: Maternal morbidity Dysfunctional labor (requiring increased intervention) PP uterine atony with hemorrhage Endometritis Peritonitis Sepsis ARDS Rarely death ```

intraamniotic infection

``` Neonatal complications of ____________: Neonatal pneumonia Meningitis Sepsis Death ```

intraamniotic infection

Administration of __________ antibiotics is recommended whenever an intraamniotic infection is suspected or confirmed

intrapartum

intraamniotic infection is rarely an indication for:

C section

maternal temp elevation greater than 38 C (100.4 F) in women who use epidural analgesia during labor. Occurs in a subset of laboring women after epidural administration and is noninfectious in origin

epidural fever

epidural fever will not improve if given _________

Tylenol

epidural fever will somewhat improve if given ______________ but will impact chorio

corticosteroids

polymicrobial clinical syndrome resulting from replacement of the normal hydrogen peroxide producing Lactobacillus sp. in the vagina with high concentrations of anaerobic bacteria (e.g., Prevotella sp. and Mobiluncus sp.), G. vaginalis, Ureaplasma, Mycoplasma, and numerous fastidious or uncultivated anaerobes.

Bacterial Vaginosis

Sx of ___________: Vaginal irritation and itching Dyspareunia Gray or white discharge Fishy odor that is often most noticeable after vaginal penetration during sexual activity 75% are asymptomatic Speculum--appears thin white/gray homogenous discharge + irritated vaginal mucosa and introitus and possibly cervicitis

Bacterial Vaginosis

Diff Diagnosis for ____________: | Vulvovaginal candidiasis

Bacterial Vaginosis

Diagnostics for ____________: - Gram stain with use of Nugent scoring system is the gold standard for diagnosis (rarely available) - Saline and KOH slides to determine pH - Whiff test

Bacterial Vaginosis

Components of _____________: 1. Presenece of a thin homogenous discharge that adheres to vaginal walls 2. Presence of clue cells on the normal saline prepared slide 3. pH of the vainga or vaginal dischare is 4.5 or higher 4. Positive Whiff test which signals the release of an amine fishy odor when vaginal discharge contacts alkaline KOH

Amsel's Criteria

BV is diagnosed when 3 of the 4 ______________ are present

Amsel's Criteria

BV is associated with an increase instance of _________

Preterm Birth

Preventions for ____________: Routine probiotics especially Lactobacillus crispatus can be helpful in establishing a normal vaginal flora and reducing recurrence Abstain from vaginal intercourse during treatment Wash all objects before they touch the vagina Use condoms

Bacterial Vaginosis

Approximately 50-80% of adults have this infection. It is the most common viral infection in newborns in the U.S. with approximately 30,000 new cases occurring each year.

Cytomegalovirus (CMV)

in the herpes virus family that shares a characteristic ability to establish lifelong latency. After initial infection, which may cause few symptoms, this virus becomes latent, residing in cells without causing detectable damage or illness.

Cytomegalovirus (CMV)

Transmission routes for ____________: - direct contact with saliva or urine, especially from babies and young children - commonly found in daycares - sexual contact - breast milk to nursing infants - transplanted organs and blood transfusions

Cytomegalovirus (CMV)

``` Sx of ____________: Fever Sore throat Fatigue Swollen glands ```

Cytomegalovirus (CMV)

Occassionally, ______ can cause Epstein-Barr or Hepatitis

Cytomegalovirus (CMV)

Babies born with ____________ can have **hearing loss** (most common) brain, liver, spleen, lung, and growth problems

Cytomegalovirus (CMV)

Differential Dx for _______________: Other human herpes virus Other viral diseases complicating pregnancy

Cytomegalovirus (CMV)

Preferred testing for CMV in newborns:

saliva or urine

Testing for CMV in adults:

blood

For babies with signs of congenital CMV infection at birth, treatment with _______________ may improve hearing and developmental outcomes

antivirals--primarily valganciclovir

There is limited information on the effectiveness of ____________ to treat infants with hearing loss alone.

antivirals--primarily valganciclovir

the most common serologic test for measuring CMV antibodies (IgG + IgM)

ELISA

A positive test for CMV ______ indicates that a person was infected with CMV at some time during their life but does not indicate when a person was infected. ***only applies for persons ≥12 months of age when maternal antibodies are no longer present.

IgG

Measurement of CMV IgG in paired samples taken 1 - 3 months apart can be used to diagnose ________ infection

primary

seroconversion (1st sample IgG negative, 2nd sample IgG positive) for CMV is clear evidence for ________________ infection

RECENT primary

The presence of CMV _____ cannot be used by itself to diagnose primary CMV infection because it can also be present during secondary CMV infection

IgM

CMV IgM positive results in combination with low IgG avidity results are considered reliable evidence for _________ infection

primary

Following primary CMV infection, IgG antibodies have _____ binding strength (avidity) then over 2-4 months mature to _____ binding strength (avidity)

LOW then HIGH

standard laboratory test for diagnosing congenital CMV infection

polymerase chain reaction | (PCR) on saliva

_______ is usually collected and tested for confirmation after the CMV saliva PCR because most CMV seropositive mothers shed CMV virus in their breast milk which can cause a false-positive CMV result on saliva collected shortly after the baby has breastfed.

urine

collect a saliva sample from baby to test for CMV at least __ hour(s) after breastfeeding and within ____ weeks of birth

1 hour within 3 weeks of birth

testing of newborns for CMV is not routinely performed, though some states perform targeted CMV testing of newborns who fail the ___________

hearing screen

most CMV infections in pregnancy women are __________

asymptomatic

most newborns will not be infected by ________ (only 20% will)

CMV

Management of CMV in pregnancy if pregnant woman has CMV AND fetus has evidence of IUGR or anomaly

refer to OB

most maternal _____ infections do not result in fetal infection

CMV

the later the gestation, the _____ likely CMV is to affect infant

LESS

Prevention of ____________: handwashing avoid kissing

CMV infection

percentage of women colonized with GBS in pregnancy

25%

The rate of GBS in newborns are decreasing and is less than _____% per 1,000 newborns in term infants. Associated mortality rate for GBS disease in a full term infant is ___-___%

0.5% | 4 - 6%

``` Risk Factors for _________ transmission: African American Positive culture bacteriuria in pregnancy Previous infant with sepsis Previous chorioamnionitis PPROM ROM greater than 18 hours Maternal fever in labor Preterm birth/low birth weight ```

GBS

``` Maternal Sx of ______: Febrile mother Significant and persistent fetal tachycardia Odor to amniotic fluid Uterine tenderness (late sign) ```

GBS

``` Newborn Sx of _______: Fever Pallor and poor tone Respiratory distress Slow irregular pulse Difficulty feeding ```

GBS

Differential Dx for ___________: Streptococcus B carrier state complicating pregnancy Strep of the newborn due to streptococcus, Group B

GBS

Diagnositics for __________: - culture at 35-37 weeks gestation - Positive in urine culture during pregnancy - Previous infant with GBS disease - CBC - Cultures at birth when there no GBS results are amnion/placenta, infants axilla, groin or ear fold

GBS

can be harmless or it can lead to infections such as UTI, pneumonia, or sepsis in mother

GBS infection

Sx of newborn ________: - newborn sepsis - pneumonia - (less frequently) meningitis (more commonly seen in late-onset disease)

GBS infection

Reasons for __________ with GBS: - IP fever greater than 100.4 - Positive GBS in preterm labor or PROM - Signs of Chorioammnionitis - Transfer of care or birth location due to symptoms - GBS positive mom with abnormal FHR pattern - Symptomatic infant

Referral

Preventitions for ________: --Probiotic therapy with Lactobacilli during pregnancy: Yogurt with live active cultures Naturally fermented live culture foods such as Kombucha, kimchi, kefir Culturelle tablets --Herbal remedies such as: Astragalus root tea, tincture or capsule to build immunity Echinacea for 2-3 weeks only Tea of lemon balm and oregano, 2-3 cuts daily Raw garlic no more than 1 clove per weeks 2-3 weeks before birth --Chlorhexidine vagina wash --Waterbirth

GBS

Without immunization shortly after birth, as many as ___% of infants born to Hep B infected mother will become infected

90%

Transmission of _________: Blood or Body Fluids **Vertical transmission can occur during pregnancy

Hep B

Risk Factors for _________: - Health care professionals - Hemodialysis patients - IV drug use - Sexual contacts, multiple sex partners - STIs - Household contacts - Employment in prison system or facility for developmentally delayed - International travelers or immigrants from high-prevalence area

Hep B Infection

``` Sx of _________: Malaise and lethargy Fever and chills RUQ pain Jaundice Nausea and vomiting ***At least half of all initial are asymptomatic ```

Hep B Infection

``` Differential Dx for ________: Hepatitis A Hepatitis C Cholestasis of pregnancy Cholelithiasis ```

Hep B Infection

Diagnostics for __________: screen in ALL pregnant women Liver functions test - elevation in acute phase HBsAg - detected 1-12 weeks postinfection

Hep B

HBsAg is detected __-__ weeks after infection

1-12

Positive HBsAg means:

current or chronic infection of Hep B

Positive HBsAB/ anti-HBs means:

Hep B immunity (after infection or vaccination) | Recovered after Hep B

Negative HBsAg means:

susceptibility to Hep B

Negative HBsAB/ anti-HBs means:

infection of Hep B

Postive HBcAb (hepatitis core antibody)/ anti-HBc means:

past or present infection of Hep B | chronic Hep B infection

Postive IgM Antibody to Hep B Core Antigen/ IgM anti-HBc means:

Acute Hep B infection

appears positive 6-14 weeks after Hep B infection and disappears with 6 months of acute disease

IgM Antibody to Hep B Core Antigen/ IgM anti-HBc

mothers and infants can have _______ or ________ Hep B infections

acute or chronic

Management of ______________: -Adequate rest -Herbs for immune support Milk thistle tea Dandelion tea tincture or capsule Turmeric Green tea -Provide education on transmission -Postpartum follow up for referral to GI -Preterm birth is increased with hepatitis B infections! -Refer to infectious disease and specialties -Pediatric consultation when maternal infection present

Hep B Infections

_________ risk is increased with Hep B infections in pregnancy

Preterm birth

Prevention of ___________: Administration of immunization series for at-risk uninfected women Refrain from sharing household items such as toothbrushes and razors Other family members should be tested and vaccinated if non-immune Cover cuts and skin lesions Use of condoms/ safe sex Abstinence from alcohol consumption Wash hands before eating and after toileting Avoid contact with blood or body fluids Avoid undercooked food in endemic areas

Hep B

Hepatitis anti-virals that can be given during pregnancy:

Hep A + Hep B (NOT Hep C!!!)

Breastfeeding is not contraindicated during _________ unless taking antiviral therapy

Hep B or Hep C infection

If screening HBsAg is POSITIVE, order these tests:

HBeAg (Hep B e-antigen) HBV DNA concentration ALT

If HBeAg is POSITIVE or... HBV DNA concentration > 20,000 or... ALT > 19 then midwife should:

refer to specialist immediately!

If HBeAg is NEGATIVE or... HBV DNA concentration < 20,000 or... ALT < 19 then midwife should:

refer to specialist after delivery

If HBsAg is NEGATIVE but patient is "at-risk", the midwife should:

- consider vaccination during pregnancy | - repeat HBsAg at delivery

Transmission of _______: Blood Vertical transmission can occur during pregnancy

Hep C

``` Sx of ____________: Malaise and lethargy Fever and Chills RUQ pain Jaundice Nausea and vomiting Asymptomatic ```

Hep C

``` Risk Factors for _________: -IV drug use - ever -Sexual contacts -HIV positive women -Hemodialysis patients -Blood or organ recipient before 1992 -Evidence of liver disease -Body tattoos non sterile -Ingestion of raw shellfish -International travel -Day care workers -Immigrants from: Asia Africa Pacific Islands Haiti Middle East Eastern Europe Central/South America Rural Mexico ```

Hep C

``` Diagnostics for ________: Screening for ALL pregnant patients (guidelines just changed) Liver function tests Antibody test ***If Positive, consider RNA test) ```

Hep C

Anti-HCV (Hep C Antibody) is reliable ___-___ weeks after initial infection

5-6

Management of _________: Refer (to specialists) with acute disease Collaborate for NB care Consult with Peds prior to birth

Hep C Infection

Administer Hep Bantiviral therapy to pregnant women with high _________

viral loads

``` Prevention of ___________: Refrain from sharing household items Cover cuts and skin lesions Use of condoms Emphasize abstinence from alcohol consumption Vaginal birth is recommended ```

Hep C Infection

RNA retrovirus (RNA virus that replicates via production of DNA that is inserted into the host cell genome)

HIV

Transmission of __________: Breastfeeding - exposes infant to the virus Infected blood and bodily secretions Risk of acquisition is increased if woman has STDs such as herpes, gonorrhea, or genital ulcers

HIV

Early screening for _______ allows early diagnosis and administration of ARV medication which can decrease the incidence of perinatal transmission of

HIV

``` Sx of early stage _________: First stage- Acute retroviral syndrome (within the first few weeks after infection) Fever Malaise Skin rash Nausea Diarrhea Headache Sore throat Lymphadenopathy (similar to mono symptoms) ```

HIV

Sx of 2nd stage _______: | asymptomatic during a period of clinical latency can be up to 8 years or longer

HIV

``` Sx of 3rd stage ________: Fever Weight loss Diarrhea Cough Shortness of breath Opportunistic infections Intense illnesses and infections more severe than would be expected for age or health status ```

HIV

Active AIDS when CD4 cell count falls below ___ and symptoms of advanced infection appears

200

``` Sx of late stage ______: CD4 count < 200 Oral candidiasis Shingles Abnormal Pap tests and STIs More susceptible to cancer Opportunistic infections ```

HIV

``` Diagnostics for ______: Rapid test ELISA test Western blot test Antiretroviral ARV drug resistance testing ```

HIV

Refer pregnant woman with:

HIV infection

Greatest risk for vertical transmission of _____ is during birth

HIV

Can deliver vaginally if HIV viral load is < _____

1000

``` Prevention of _______: Abstinence or consistent condom use No sharing of needles Smoking cessation Do not breastfeed ```

HIV

causes 66% of all cervical cancers

HSV Types 16 and 18

causes 90% of genital warts

HSV Types 6 and 11

preferred HSV tests for persons who seek medical treatment for genital ulcers or other mucocutaneous lesions

cell culture and PCR

HSV PCR sensitivty declines as:

lesions dissipate

HSV treatment for positive pregnancy women should be started at ____ weeks

risk for HSV transmission is highest for infants whose mothers contract it in:

late pregnancy

newborns whose mothers acquired HSV late in pregnancy should receive:

acyclovir

pregnant person with high viral load can be considered for ______ therapy

HBIG

women who acquire HSV late in pregnancy should be co-managed with:

MFM + infectious dx specialist

asymptomatic viral shedding is more common with HSV Type __ and mostly happens during first ___ months after contraction

2; 12

HSV-2 increases risk of contracting:

HIV

listeriosis infections symptoms are often:

asymptomatic or nonspecific

``` Sx of _________: **often asymptomatic flu-like illness with fever myalgia, Backache headache often preceded by diarrhea or other gastrointestinal symptoms ```

Listeriosis

Diagnostics for _________: Primarily by blood culture Placental cultures should be obtained in the event of delivery ***Stool cultures should not be used

Listeriosis

can cause miscarriage, stillbirth, or preterm labor

Listeriosis

Fetal effects of ___________: Fetal and neonatal infections can be severe, resulting in fetal loss, preterm labor, neonatal sepsis, meningitis, and death Can cause lifelong health problems for the baby, including intellectual disability, paralysis, seizures, blindness, or problems with the brain, kidneys, or heart

Listeriosis

Antimicrobial regimen of choice is high-dose intravenous ampicillin (at least 6 g/day) X at least 14 days.Frequently, gentamicin is added to the treatment regimen because it has demonstrated synergism with ampicillin

Listeriosis

To prevent ________, women should avoid: Hot dogs, lunch meats, cold cuts (when served chilled or at room temperature; heat to internal temperature of 74°C [165°F] or steaming hot) Refrigerated pâté and meat spreads Refrigerated smoked seafood Raw (unpasteurized) milk Unpasteurized soft cheeses such as feta, queso blanco, queso fresco, Brie, queso panela, Camembert, and blue-veined cheeses Unwashed raw produce such as fruits and vegetables (when eating raw fruits and vegetables, skin should be washed thoroughly in running tap water, even if it will be peeled or cut)

Listeriosis

Parvovirus also known as:

Fifth Disease

Transmission of _________: Respiratory droplets Blood and blood-derived products ‘vertically’ from pregnant woman to fetus

Parvovirus

``` Sx of ________: The characteristic rash is often described as ‘slapped cheeks’ (Lacy red rash on the cheeks, legs, belly and neck) Arthralgia Arthritis Fever **Can be asymptomatic ```

Parvovirus

Diagnostics for _________: Direct evidence of infection is obtained by detection of B19V-DNA using PCR B19V specific IgM antibodies become detectable in serum 7–10 days after infection, sharply peak at 10–14 days, and then decline within 2 or 3 months. IgG antibodies gradually increase from 14 days after infection and reach a plateau level after 4 weeks of gradual increase

Parvovirus

Both fetal cord blood and amniotic fluid samples are suitable for diagnosis of:

Parvovirus

Risk of fetal complications of ________ is believed greatest when infection occurs in the first 22 wks

Parvovirus

vertical transmission of _______ occurs 1–3 weeks after maternal infection, suggesting that fetal infection occurs during the maternal peak viral load

Parvovirus

Fetal effects of _________: Fetal infection may resolve spontaneously without any sequelae, or lead to severe consequences such as nonimmune hydrops fetalis (NIHF) due to severe fetal anemia, (highest frequency during 8–20 weeks of gestation) thrombocytopenia, hyperechogenic bowel, myocarditis, possibly central nervous system damage encephalopathy, cerebral migratory abnormalities neonatal encephalitis Intrauterine fetal demise (IUFD) (occurs mostly 20-24 weeks of gestation)

Parvovirus

a potent inhibitor of erythropoiesis

Parvovirus

if partner has been exposed to Zika, midwife should advise:

use condoms or abstinence

Midwifery Management of _________: weekly ultrasounds if hydrops/anemia develops, immediate referral

Parvovirus

Prevention of ___________: Regular washing of hands with soap and hot water Careful disposal of tissues or other items that carry bodily fluids Covering your mouth when sneezing, coughing, etc. Limited exposure to those who have Fifth disease

Parvovirus

Transmission of _______: | nasal secretions

Rubella

Rubella transmission peaks in:

late winter/Spring

``` Sx of __________: Fever Maculopapular rash, beginning on the face and spreading to the trunk and extremities Arthralgias Arthritis Head and neck lymphadenopathy Conjunctivitis May be asymptomatic or very mild symptoms ```

Rubella

Rubella infection in pregnant woman is:

very mild

Fetal effects of __________: Congenital rubella syndrome- Worse the earlier in the pregnancy the exposure occurs Eye defects- cataracts and congenital glaucoma Congenital heart defects- patent ductus arteriosus and pulmonary artery stenosis Sensorineural deafness- the most common single defect Central nervous system defects- microcephaly, developmental delay, mental retardation, and meningoencephalitis Pigmentary retinopathy Neonatal purpura Hepatosplenomegaly and jaundice Radiolucent bone disease Neonates born with congenital rubella may she the virus for many months and thus be a threat to other infants and susceptible adults who contact them Extended syndrome- progressive panencephalitis and type 1 diabetes

Rubella

Management of __________: Droplet precautions for 7 days after the onset of the rash Referral is warranted due to the high risk in the fetus

Rubella

Prevention of ____________: Vaccination- at least 1 month prior to pregnancy; do not give during pregnancy but can give postpartum even when breastfeeding Prenatal serological screening for rubella is indicated for all pregnant women

Rubella

``` Sx of ___________: Most Maternal infections are subclinical Fatigue Fever Headache Muscle pain Maculopapular rash Posterior cervical lymphadenopathy --If host is immunocompromised, reaction can be severe Encephalitis Retinochoroiditis Mass lesions ```

Toxoplasmosis

GBS screening: ____ - _____ weeks

36.0 - 37.6

Fetal effects of ___________: Associated with severe neonatal infections -Neonates usually have generalized disease: Low birthweight Hepatosplenomegaly Jaundice Anemia Possibility of primary neurological disease with intracranial calcifications with hydrocephaly or microcephaly Many develop chorioretinitis and exhibit learning disabilities The classic triad (chorioretinitis, intracranial calcifications, and hydrocephalus) is often accompanied by convulsions

Toxoplasmosis

Toxoplasmosis Severity of fetal infection depends on gestational age at the time of maternal infection Risks for fetal infection _________ with pregnancy duration The severity of fetal infection is _________ in early pregnancy

increase; increased

False positives occur in presence of blood, or semen, alkaline antiseptics, or BV

Nitrazine

False negative with prolonged membrane rupture or minimal residual fluid

Nitrazine

Mod 3-4 Flashcards

(279 cards)