Common infection in pregnancy lecture.5.58pptx.pptx

Common infection in pregnancy lecture.5.58pptx.pptx

1. Common infection in pregnancy Department of Obstetrics and Gynecology, Faculty of medicine, Vajira Hospital

2. สามารถให้การวินิจฉัยป้องกัน และรักษาเบื้องต้นแก่โรคติดเชื้อที่พบบ่อยในหญิงตั้งครรภ์ได้ Objectives

3. UTIs ToRCH Toxoplasmosis Rubella Cytomegalovirus (CMV) Herpes simplex virus (HSV) Varicella zoster virus (VZV) Group B streptococcus (GBS) Outlines

4. Maternal and fetal immunology

5. Suppression of a variety of humeral and cell mediated immunological functions to accommodate the “foreign semiallogenic fetal graft” Pregnancy induced immunological changes

6. Passage infectious agent from the mother to fetus Placenta ( intrauterine) VZV, rubella, CMV, HIV, toxoplasmosis During labor/delivery ( intrapartum ) HSV, GBS , VZV,HIV Breast feeding (neonatal) HSV Vertical transmission

7. Urinary tract infections (UTIs)

8. Pregnancy induced urinary tract changes Asymptomatic bacteriuria Cystitis Pyelonephritis

9. Hypertrophy Dilatation Progesterone induced smooth muscle relaxation (before 14 weeks) Ureteral compression Rt >Lt (mid pregnancy) Increase vesicoureteral reflux Pregnancy induced urinary tract changes

10. Most common bacterial infection during pregnancy Organisms Normal perineal flora E. coli K. pneumoniae Enterobacter or Proteus Gram positive organism eg . GBS Urinary tract infections

11. Definition: persistent, actively multiplying bacteria within the urinary tract in asymptomatic women Diagnosis: clean-voided specimen containing > 10 5 organism/ml If not treated, 25% develop symptomatic infection during pregnancy Asymptomatic bacteriuria

12. Asymptomatic bacteriuria Single dose treatment Amoxycillin 3 g Ampicillin 2 g Cephalosporin 2 g Nitrofurantoin , 200 mg 3 – day course Amoxycillin 500 mg tid Ampicillin 250 mg qid Cephalosporin 250 mg qid Ciprofloxacin 250 mg bid Levofloxacin 250 mg OD Nitrofurantoin 50-100 mg qid , 100 mg bid

13. Asymptomatic bacteriuria Other Nitrofurantoin 100 mg qid 10 days Nitrofurantoin 100 mg bid 7 days Nitrofurantoin 100 mg at bedtime 10 days Treatment failures Nitrofurantoin 100 mg qid 21 days Suppression for bacterial persistence or recurrence Nitrofurantoin 100 mg hs for remainder of pregnancy

14. Dysuria , urgency, frequency Pyuria , bacteriuria , microscopic/gross hematuria Treatment as asymptomatic bacteriuria ( 3 day course)>>90% effective Cystitis

15. Most common serious medical complication of pregnancy Leading cause of septic shock during pregnancy Acute pyelonephritis

16. Develop frequency in 2 nd trimester > 50% unilateral and Rt side 25% bilateral Clinical finding Symptoms Fever, shaking chills Aching pain in lumbar regions Anorexia, nausea, vomiting Signs Tenderness on CVA Acute pyelonephritis

17. Hospitalize patient Investigation and monitoring Obtained urine and blood cultures CBC, serum Cr, electrolytes CXR if dyspnea /tachycardia Repeat CBC and chemistry studies in 48 hr Monitor V/S, urine output Plan of management

18. Supportive IV crystalloid for urine output ≥ 50 ml/hr Specific IV ATB Change to oral ATB when afebrile D/C when afebrile 24 hrs, consider oral ATB 7-10 days Repeat urine C/S 1-2 weeks after ATB therapy completed Plan of management

19. Empirical ATB Ampicillin 1 gm IV q 6 hr + gentamicin 240 mg IV OD Cefazolin 1 gm IV q 6 hr Ceftriaxone 2 gm IV OD Extended-spectrum ATB 95% of women are afebrile by 72 hrs Acute pyelonephritis

20. Persistent infection Urinary tract obstruction are considered Renal sonography is recommended Obstruction Abnormal ureteral / pyelocaliceal dilatation If stone are strongly suspected despite a non diagnostic sonographic examination, a plain abdominal radiograph will identified nearly 90%/single shot IVP MRI: intrarenal or perinephric abcess or phlegmon Acute pyelonephritis

21. ToRCH infection

22. Protozoal infection Toxoplasma gondii Eating raw or undercooked meat infected with tissue cyst Contact with oocyst from cat feces in contaminated litter soil water Toxoplasmosis

23. Acute infection No symptoms Some cases; fatigue, fever, muscle pain, MP rash, posterior cervical lymphadenopathy Maternal infection Preterm*4 Not associated with IUGR Fetal infection higher in the 3 rd trimester Severity of fetal infection greater in early pregnancy Toxoplasmosis

24. Clinical manifestations Asymptomatic (70 – 90%) Signs present at birth Classic triad Chorioretinitis Intracranial calcification Hydrocephalus Hepatosplenomegaly Jaundice A nemia Toxoplasmosis

25. IgG confirmed before pregnancy >> no risk congenital infected fetus Investigation Maternal serology: IgG , IgM Prenatal diagnosis DNA amplification techniques (PCR) Sonographic evaluation Intracranial calcification, hydrocephaly, liver calcification, placental thickening, hyperechoic bowel Diagnosis

26. Spiramycin Reduce risk of congenital infection Pyrimethamine + sulfaiazine + folic acid Eradicate parasites in the placenta and fetus Management

27. Cooking meat to safe temperature Washing fruits and vegetables Cleaning cooking surfaces and utensils that contain raw meat, poultry, seafood or unwashed fruit and vegetables Wearing gloves when changing cat litter Avoid feeding cats raw or undercooked meat Prevention

28. spirochete, Treponema pallidum Infection can result in stillbirth hydrops fetalis prematurity associated long-term morbidity women with untreated early syphilis  40% of pregnancies spontaneous abortion incidence : 8.2 to 10.1 cases per 100,000 live births Transplacental transmission typically occurs during the second half of pregnancy Syphilis

29. Primary syphilis Chancre, painless, raised, red, firm border, smooth base Resolve 2-8 weeks 2 nd syphilis Disseminated and affect multiple organs systems Develop 4-10 weeks after chancre Diffuse MP rash, plantar and palmar targetlike lesions, patchy alopecia Clinical manifestation

30. Latent syphilis Not treat primary or 2 nd syphilis Reactive serology testing, resolve clinical manifestation Early latent ≤ 12 months, late latent > 12 months Late syphilis Slowly progressive disease affecting any organ system but rarely seen in reproductive aged women Clinical manifestation

31. Screening in the 1 st prenatal visit Symptomatic Dark field examination direct immunofluorescent antibody staining of lesion exudates Asymptomatic VDRL/RPR>>express as titers >>reflex disease activity (increase during early syphilis,>1:32 in 2 nd syphilis Following treatment of primary and 2 nd syphilis 3-6 months to confirm 4 fold drop in titers TPHA test generally remain positive throughout life Diagnosis

32. uncommon before 18 weeks Prenatal diagnosis is difficult Hydrops fetalis Ascites Hepatomegaly Placental thickening Prenatal diagnosis by PCR from amniotic fluid Congenital Syphilis

33. Clinical manifestations  Late congenital manifestations  : scarring related to early frontal bossing, short maxilla, high palatal arch Hutchinson triad Hutchinson teeth [blunted upper incisors] interstitial keratitis eighth nerve deafness saddle nose, and perioral fissures Syphilis

34. Category Treatment Early syphilis Benzathine penicillin G 2.4mU IM single dose –some recommend a 2 nd dose 1 week later >1 year duration Benzathine penicillin G 2.4mU IM weekly*3 doses Neurosyphilis Aqueous crystalline pen G 3-4 mU IV q 4 hrs for 10-14 days Aqueous procaine penicillin 2.4 mU IM daily+ probenecid 500 mg oral 1*4 10-14 days Treatment

35. Rubella (German measles)

36. Signs & symptoms Mild febrile illness Generalized MP rash Face to trunk and extremities Arthralgia , arthritis Head and neck lymphadenopathy Conjunctivitis Infection in the 1 st trimester>>significant risk for abortion and severe congenital malformation Viremia preceeds clinical signs about 1 wk Infectious during viremia and through 5-7 days of the rash Clinical manifestations

37. 1 or more of the following Eye defects: cataracts and congenital glaucoma Heart disease: PDA, PAS Sensorineural deafness: most common single defect CNS defects: microcephaly , developmental delay, mental retardation, meningoencephalitis Pigmentary retinopathy Neonatal purpura (blueberry muffin) Hepatosplenomegaly and jaundice Radiolucent bone disease Congenital rubella syndrome (CRS)

38. Neonatal manifestations growth retardation radiolucent bone disease Hepatosplenomegaly Thrombocytopenia purpuric skin lesions “blueberry muffin” ( extramedullary hematopoiesis ) hyperbilirubinemia Rubella

39. Neonates with congenital rubella syndrome may shed virus for many months Extended rubella syndrome >>progressive panencephalitis and type 1 DM at 2 nd or 3 rd decade of life Congenital rubella syndromes

40. Symptoms and signs Serological analysis IgM antibody; 4-5 day after clinical onset IgG antibody; peak at 1-2week after rash onset Diagnosis

41. Confirmed maternal rubella infection in 1 st half of pregnancy Sonography Fetal growth restriction Ventriculomegaly Intracranial calcification Microcephaly Micropthalmia Cardiac malformations Meconium peritonitis Hepatosplenomegaly Rubella RNA in chorionic villi , amniotic fluid, fetal blood Confirm of fetal infection

42. Supportive care Droplet precaution for 7 days after onset of rash Management

43. MMR vaccine Live attenuated vaccine Avoid 1 month before or during pregnancy Prevention

44. Cytomegalovirus

45. Most common congenital viral infection in develop world From seropositive mothers 0.2 - 1.5% Cytomegalovirus

46. Primary infection Latent infection Recurrence – reactivation Clinical manifestation

47. Primary maternal infection during pregnancy leads to transmission 40% Intrauterine Intrapartum Breast feeding Daycare Recurrence maternal infection 0.5-1% fetal transmission Transmission methods

48. Primary infection Asymptomatic infection 90% 15% mononeucleosis like syndrome Fever Pharyngitis Lymphadenopathy Polyarthritis Reactivation Asymptomatic Clinical manifestation

49. Clinical manifestations Symptomatic infection Approximately 5 – 20% Cytomegalic inclusion disease Growth restriction Microcephaly Intracranial calcification Chorioretinitis motor disability Sensorineal deficits Jaundice Hepatosplenomegaly Hemolytic anemia Thrombocytopenic purpura Cytomegalovirus

50. Hearing loss Neurological deficits Chorioretinitis Psychomotor retardation Learning disabilities Late onset sequelae

51. CMV IgM , IgG Imaging studies Amniotic fluid studies Diagnosis

52. Management Symptomatic treatment Prevention No vaccine Good hygine and hand washing Management & Prevention

53. HSV

54. HSV type 1 Nongenital infections ≥50% new cases of genital herpes in adolescent and young adults HSV type 2 Genital infections Transmitted by sexual contacts HSV

55. 1 st episode primary infection 1 st episode nonprimary infection Reactive disease Asymptomatic viral shedding Clinical manifestations

56. Not associated with spontaneous abortion or stillbirth Associated with preterm labor HSV and pregnancy

57. 35% localized to eye or mouth 30% CNS disease with encephalitis 25% disseminated disease with involvement of multiple major organs Neonatal infection Kimberlin DW,clin Microbiol Rev 2004

58. Clinical diagnosis –insensitive and non specific Virological tests Cell culture PCR assayss Type – specific serological tests ELISA Immunoblot tests Diagnosis CDC.MMWR 2006

59. Management Primary infection Symptomatic recurrent infection Daily suppression Acyclovir 400 mg oral tid 7-10 days Valacyclovir 1 gm oral bid 7-10 days Acyclovir 400 mg oral tid 5 days Acyclovir 800 mg oral bid 5 days Valacyclovir 500 mg oral bid 3 days Valacyclovir 1 gm oral OD 5 days Acyclovir 400 mg oral tid Valacyclovir 500 mg oral bid From 36 week until delivery

60. C/S is indicated Active genital lesions Prodomal symptoms Any recurrence during pregnancy Acyclovir or valacyclovir suppression initiated at 36 weeks Peripartum shedding prophylaxis

61. Most newborns with perinatally acquired HSV appear normal at birth HSV infection in newborns usually develops in one of three patterns: Localized to the skin, eyes, and mouth (SEM) Localized CNS disease Disseminated disease involving multiple organs HSV

62. Varicella zoster virus

63. Primary infection Varicella or chicken pox Contagious from 1 day prior to onset of rash until the lesion crusted over Adults are more severe 5% infected pregnant develop pneumonitis (mortality 1-2%) Reactivated infection Herpes zoster or shingles No more frequent or severe in pregnant women Contagious if blisters are broken Clinical manifestations

64. Signs and symptoms Vesical base scraping Tzanck smear Tissue culture Direct fluorescent antibody testing VZV IgG , IgM Diagnosis