Pregnancy & Childhood Infections

Question 1

What are the problems with infections during pregnancy?

Answer 1

Pregnancy does not alter resistance to infection

some infections during pregnancy are more severe and can affect the foetus

Question 2

What may infections in pregnancy cause?

Answer 2

• Miscarriage
• congenital abnormalities
• fetal hydrops
• fetal death
• preterm delivery
• preterm rupture of the membranes

Question 3

What is meant by “fetal hydrops”?

Answer 3

A serious fetal condition defined as an abnormal accumulation of fluid in two or more fetal compartments

this includes Ascites, pleural effusion, pericardial effusion and skin oedema

Question 4

How can the foetus receive immunity?

Answer 4

Maternal antibodies cross the placenta and give passive immunity to the foetus

Question 5

What is a key message during antenatal counselling?

Answer 5

Avoid exposure to infections during pregnancy

i.e. vaccination (pertussis vaccine b/w 16 - 32 weeks)

Question 6

What screening is offered during pregnancy?

Answer 6

• Screening for HIV and syphilis and hepatitis B occurs early in pregnancy (by 10 weeks)
• it is reoffered before 20 weeks
• Hepatitis B, HIV and syphilis can all be passed from mother to baby during pregnancy and birth
• early detection aids specialist appointment and interventions/treatment to reduce the risk of transmission

Question 7

Why is screening for rubella in pregnancy no longer offered?

Answer 7

Screening for rubella in pregnancy is no longer offered

rubella is now very rare in the UK because of the high uptake of the MMR vaccine

Question 8

What is meant by the TORCH acronym for infections that can be transmitted from mother to baby during pregnancy (in utero)?

Answer 8

• Toxoplasmosis
• Others (syphilis, HIV, Coxsackie virus, Hepatitis B, Varicella zoster)
• Rubella
• Cytomegalovirus
• Herpes simplex virus

Question 9

How are the following pathogens acquired?

How are they transmitted to the baby?

Answer 9

• Cytomegalovirus - respiratory droplets / secretions
• Parvovirus B19 - respiratory droplets / secretions
• toxoplasmosis - ingestion of oocytes
• syphilis - sexually transmitted
• varicella zoster virus - respiratory droplets / secretions
• rubella - nasopharyngeal secretions
• zika virus - mosquito bite

Question 10

What do most of the TORCH infections cause?

Answer 10

They cause mild maternal morbidity, but have serious fetal consequences:

• abortion
• stillbirth
• prematurity
• IUGR
• congenital malformations - microcephaly, intracranial calcifications

Question 11

What is IUGR?

Answer 11

Intrauterine growth restriction

this is a condition in which an unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb

Question 12

What are other perinatal infections?

Answer 12

• Group B streptococcus
• listeriosis
• gonorrhoea
• chlamydia
• influenza
• human immunodeficiency virus
• hepatits b virus

HIV and HBV virus can be passed in utero and postnatal via breast milk

Question 13

What are the risks associated with transplacental passage of the influenza virus?

Answer 13

Teratogenesis has not been confirmed

premature delivery may occur (as in any febrile maternal illness), increasing the perinatal morbidity and mortality

the clinical syndrome in the mother is self-limited unless pneumonia occurs and the newborn manifests as any form of sepsis

Question 14

What is meant by the “perinatal period”?

Answer 14

The period immediately before and after birth

usually starts at the 20^th - 28^th week of gestation and ends 1 - 4 weeks after birth

Question 15

Why is screening for Group B Streptococci not recommended in the UK?

Answer 15

Until it is clear that antenatal screening for GBS carriage does more good than harm and that the benefits are cost-effective, routine screening is not recommended

Question 16

What is the likelihood of maternal GBS carriage in current pregnancy if a mother has had previous GBS carriage?

What 3 options does the mother have in this situation?

Answer 16

If there is history of previous GBS carriage, likelihood of maternal GBS carriage in current pregnancy is 50%

3 choices are:

1. To NOT have intra-partum antibiotics
2. To have intra-partum antibiotics
3. Screening at 35-37 weeks and offer antibiotics to those who have GBS colonisation

Question 17

When are intrapartum antibiotics administered?

Answer 17

Intra-partum refers to the time period between onset of labour and the delivery of the placenta

Question 18

What is chorioamnionitis?

How many pregnancies are affected by this?

Answer 18

Inflammation of the umbilical cord, amniotic membranes / fluid and placenta

it is a major cause of perinatal morbidity and mortality

affects 1-2% of term pregnancies and 20-25% of pregnancies with pre-term labour

Question 19

What are the symptoms of chorioamnionitis?

Answer 19

• Maternal fever
• uterine tenderness
• tachycardia
• purulent / foul amniotic fluid

obstetric complications + adverse outcomes for the neonate:

• sepsis
• pneumonia
• long term neurodevelopment disability

Question 21

what usually causes chorioamnionitis?

What is it associated with?

Answer 21

It is inflammation of the fetal membranes (amnion / chorion) due to a bacterial infection

it typically results from bacteria ascending from the vagina into the uterus

it is most often associated with prolonged labour

Question 22

What are the risk factors for intra-amniotic infections?

Answer 22

• Most common after prolonged rupture of membranes
• amniocentesis / cordocentesis
• cervical cerclage
• multiple vaginal examinations
• bacterial vaginosis

Question 23

What is the pathogenesis of intra-amniotic infections like?

Answer 23

Bacteria present in the vagina cause infection by ascending through the cervix

Haematogenous (via blood) infection is rare e.g. Listeria monocytogenes

Question 24

What organisms can cause intra-amniotic infections?

Answer 24

• Group B Streptococcus
• Escherichia coli
• Genital Mycoplasma (Mycoplasma hominis & Ureaplasma urealyticum)

it is caused by polymicrobial infections

Question 25

What is involved in the management of intra-amniotic infections?

Answer 25

**Intrapartum antimicrobials** and delivery of the foetus antimicrobials should be administered at the time of diagnosis (not after delivery)

Question 26

What is puerperal endometritis?

Answer 26

A uterine infection (lining of the womb) during puerperium which affects 5% of pregnancies It is typically caused by bacteria ascending from the lower genital or GI tract it can occur up to 6 weeks following birth

Question 28

What is the major risk associated with puerperal endometritis?

Answer 28

Puerperal sepsis is a major cause of maternal death it can cause sepsis, pelvic abscesses and peritonitis in the mother

Question 29

What are the risk factors for puerperal endometritis?

Answer 29

* Caesarean section * prolonged labour * prolonged rupture of membranes * multiple vaginal examinations

Question 30

what are the clinical features of puerperal endometritis?

Answer 30

* Fever - 38.5C in first 24h post-delivery or \>38.0C for 4 hours 24+ hours after delivery * uterine tenderness * purulent, foul-smelling lochia * increased white cell count * general malaise, abdominal pain

Question 31

What are the causative organisms for puerperal endometritis?

Answer 31

The causative organisms are frequently mixed: * *Escherichia coli* * *Beta-haemolytic Streptococci* (Group B) * anaerobes

Question 32

What is involved in the diagnosis and treatment of puerperal endometritis?

Answer 32

**Diagnosis:** * the role of transvaginal endometrial swabs is controversial **treatment:** * broad spectrum intravenous antimicrobials * these are continued until the patient has been apyrexial for 48h * for polymicrobial infections, **clindamycin + gentamicin** are used

Question 33

What are the most common infections in children?

Answer 33

Neonatal sepsis Common childhood infections - respiratory tract infections, UTIs, meningitis Rashes associated with systemic disease

Question 34

What are the main causes of maternal and neonatal mortality?

Answer 34

**Maternal mortality:** * haemorrhage * indirect causes * hypertension * sepsis * other direct causes * abortion * embolism **neonatal mortality:** * complications from preterm birth * intrapartum related * sepsis / meningitis * pneumonia * congeital * other * tetanus * diarrhoea

Question 35

What are the risks associated with early onset sepsis (EOS) in neonates? When does this start?

Answer 35

early-onset neonatal sepsis (usually within 72 hours) is a major cause of mortality and morbidity in new-born babies high mortality, particularly in premature and low birth weight babies death occurs in 1 in 4 babies that develop it, even when they are given antibiotics

Question 36

What causes early onset sepsis in neonates? Under what circumstance does it have higher mortality?

Answer 36

It is caused by organisms from the maternal genital tract typical to have multisystem involvement / pneumonia higher mortality, particularly in infections that are evident within the first 24 hours

Question 37

What are the major causative pathogens of neonatal late-onset sepsis?

Answer 37

* Coagulase negative staphylococci * *staphylococcus aureus* * *escherichia coli* * *klebsiella* spp. * *enterobacter* spp. * *pseudomonas* spp. * *candida* spp.

Question 38

What are the commonest symptoms reported in early education settings?

Answer 38

1. Respiratory symptoms 2. fever 3. gastroenteritis 4. earache 5. rash

Question 39

In which groups of children are infections more common? Why are infections more common in children?

Answer 39

**Affected groups:** * young infants * children with special health care needs / impaired immune systems * children with long-standing prosthetic devices **Why are infections common?** * frequent hand-to-mouth behaviours * still learning appropriate hygiene skills e.g. washing hands, covering coughs * some children are not fully immunised * children have close physical contact

Question 40

What are the vast majority of infections in children?

Answer 40

90% of infections are mild, self-limited and require no treatment

Question 41

What are the 3 main upper respiratory tract infections in children?

Answer 41

* Common cold * acute tonisillitis * acute otitis media

Question 42

What is a "sore throat"? What causes it?

Answer 42

Any of various inflammations of the tonsils, pharynx or larynx, characterised by pain on swallowing 70-80% of cases are viral 20-30% of cases are caused by Group A beta-haemolytic Streptococcus

Question 43

What is otitis media? What are the typical symptoms?

Answer 43

Inflammation of the middle ear +/- presence of middle ear effusion * unusual irritability * difficulty sleeping * tugging or pulling at one or both ears * fever * fluid draining from the ear * loss of balance * unresponsive to quiet * sounds or other signs of hearing difficulty

Question 44

What are the bacteria that cause acute otitis media?

Answer 44

* Streptococcus pneumoniae * haemophilus influenzae * M. Catarrhalis * streptococcus pyogenes * staphylococcus aureus

Question 45

What are the most common lower respiratory tract infections in children?

Answer 45

* Pneumonia * acute bronchitis * bronchiolititis respiratory viruses are the leading cause in children under 5 years

Question 46

What are the most common organisms which cause acute respiratory infections in children?

Answer 46

* Respiratory syncytial virus * *mycoplasma pneumoniae* * *streptococcus pneumoniae* * adenovirus * *haemophilius influenzae* * influenza A and B * haemophilus parainfluenzae H. Influenzae is now quite rare due to immunisation

Question 47

What is the definition of bronchiolitis?

Answer 47

Inflammation of the bronchioles / small airways in children younger than 2 years (usually 3-6 months of age) it is a seasonal viral illness characterised by fever, nasal discharge and dry, wheezy cough on examination there are fine inspiratory crackles and/or high-pitched expiratory wheeze

Question 48

What are the causes of bronchiolitis?

Answer 48

1. Respiratory syncytial virus (RSV) 2. metapneumovirus 3. adenovirus 4. para-influenza virus 5. influenza 6. rhinovirus

Question 49

What are the bacterial and viral pathogens which cause pneumonia in neonates?

Answer 49

**Bacterial pathogens:** * ​group B streptococcus * gram negative bacilli ( E. coli, K. Pneumoniae, Proteus spp.) * staphylococcus aureus **Viral pathogens:** * RSV * herpes simplex virus * cytomegalovirus * adenovirus

Question 50

What are the main pathogens which cause pneumonia in children aged 1-3 months?

Answer 50

**Bacterial pathogens:** * s. Pneumoniae * h. Influenzae type B **viral pathogens:** * RSV **other:** * C. Trachomatis

Question 51

What are the main pathogens which cause pneumonia in children aged 4 months - 5 years?

Answer 51

**Bacterial pathogens:** * s. Pneumoniae * h. Influenzae type b **viral pathogens:** * parainfluenza virus 1 and 3 * adenovirus * influenza virus A and B

Question 52

What are the pathogens that cause pneumonia in children aged 5 years and older?

Answer 52

**Bacterial pathogens:** * s. Pneumoniae **others:** * M. Pneumoniae * C. Pneumoniae

Question 53

What is the presentation of pneumonia in children?

Answer 53

Acute febrile illness, possibly preceded by typical viral upper respiratory tract infection younger children rarely cough and may present with grunting tachypnoea and chest retractions

Question 54

What are the symptoms of pneumonia in children?

Answer 54

* Breathlessness (poor feeding) * irritability * sleeplessness * cough, chest or abdominal pain in older patients * audible wheezing is rare in LRTI, but can occur

Question 55

What is pertussis (whooping cough)?

Answer 55

A highly contagious respiratory disease caused by *Bordetella pertussis* bacteria it is known for uncontrollable, violent coughing which often makes it hard to breathe

Question 56

What are the 3 stages of clinical illness in pertussis?

Answer 56

**Catarrhal phase:** * cold-like - coryza, conjunctival irritation, occasional slight cough * lasts 7-10 days **Paroxysmal phase:** * long duration (2-6 weeks) with no fever * series of rapid, forced expirations followed by gasping inhalation (whooping sound) * post-tussive vomiting * very young infants may present with apnea or cyanosis in the absence of cough **convalescent phase**

Question 57

How is pertussis transmitted? How is it diagnosed?

Answer 57

It is transmitted person-to-person through aerosolised respiratory droplets humans are the sole reservoir **Diagnosis:** * culture & PCR in early stages * serology if illness \> 3 weeks

Question 58

How does meningitis present in children?

Answer 58

There is a non-specific clinical presentation in newborn & infants * fever * irritability * lethargy * poor feeding * high pitched cry, bulging AF * convulsions, opisthotonus

Question 59

What organisms cause meningitis in neonates and young children?

Answer 59

**Neonates:** * Group B streptococcus * escherichia coli * Listeria monocytogenes **\> 1 month - 5 years:** * Streptococcus pneumoniae * Neisseria meningitidis

Question 60

What is viral meningitis? What is it caused by?

Answer 60

It is the most common infection of the CNS especially in \< 1 year caused by enteroviruses, HSV, influenza, EBV, adenovirus and CMV there are mononuclear lymphocytes in CSF

Question 61

What is the morbidity and mortality involved in meningococcemia?

Answer 61

Mortality - 5-10% (90% if DIC) Morbidity - 10% (deafness, neurological problems, amputations) Peak incidence \< 4 years

Question 62

What are the symptoms of meningococcaemia?

Answer 62

* Fever * non-specific malaise * lethargy * vomiting * meningism * respiratory distress * irritability * seizures * maculopapular rash common in early disease

Question 63

what is meningococcaemia?

Answer 63

A severe form of blood poisoning that affects the entire body the hallmark sign of meningococcaemia is a rash that does not fade under pressure the rash can appear anywhere on the body due to damaged blood vessels allowing blood to leak into the skin