Infections during pregnancy

ceratin bacterial, viral, fungal, protozoal and parasitic infections prevails in pregnancy. diagnosis and management

1. DEEPTHY P.THOMAS II YEAR MS C NURSING GOVT.COLLEGE OF NURSING ALAPPUZHA INFECTIONS DURING PREGNANCY

2. TYPES BACTERIAL INFECTION VIRAL INFECTIONS FUNGAL INFECTIONS PARASITIC AND PROTOZOAL INFECTIONS

3. BACTERIAL INFECTIONS GROUP B STREPTOCOCCAL INFECTION (GBS) Organism Streptococcus agalactiae

4. Risk factors Risk factors for early onset neonatal GBS include: Positive prenatal culture for GBS this pregnancy Preterm birth of less than 37 weeks of gestation PROM for longer than 18 hours. Intrapartum maternal fever greater than 38°C

5. screening

6. Management The CDC recommends intrapartum antimicrobial prophylaxis for Preterm labour before 37 weeks of gestation Duration of ruptured membranes longer than 18 hours. Intrapartum temperature greater than 100.4°F

7. pencillin G Ampicillin . Cefazolin .

8. TUBERCULOSIS IN PREGNANCY

9. Risk factors for TB Positive family history or past history Low socioeconomic status Area with high prevalence of tuberculosis HIV infection Alcohol addiction Intravenous drug abuse.

10. Clinical features: Cough Weight loss Sleep sweats Evening pyrexia Malaise and Fatigue enlarged lymph nodes or pleural rub

11. Diagnosis:   Tuberculin skin test

12. X- ray chest Early morning sputum (3 samples) for acid- fast bacilli Gastric washings Diagnostic bronchoscopy Extra pulmonary sites- lymph nodes, bones ( rare in pregnancy).

13. Effect of pregnancy on pulmonary TB Pregnancy does not worsen the clinical course of TB.

14. Effect of TB on pregnancy The fertility rate is low a higher incidence of toxaemia, Preterm labour PPH and difficult labour in pregnant patients suffering from TB. the maternal and fetal prognosis is good and therapeutic abortion is not necessary except in a patient with multidrug resistance.

15. Effect on the mother Pregnancy may worsen the maternal outcome in drug resistant patients. Medical termination of pregnancy may be considered in selected cases.

16. Effects on the fetus Effective chemotherapy has reduced the incidence of low birth weight. Streptomycin use was associated with congenital deafness.

17. Treatment Rifampicin isoniazid Ethambutol Pyrazinamide Newer anti-tubercular drugs include clofazimine , ciprofloxacin, ofloxacin , amikacin , clarithromycin and azithromycin .

18. Obstetric management: In pregnancy In labour Breast feeding Contraception

19. BACTERIAL VAGINOSIS

20. BACTERIAL VAGINOSIS Organism - Gardnerella vaginalis , Mobiluncus , Mycoplasmas hominis , Prevotella , and Atopobium vaginae .

21. Transmission sexual intercourse, hormonal changes, pregnancy, antibiotic administration, or use of nonoxynol-9 spermicidal products, douching.

22. Signs and symptoms Thin, gray or white homogeneous vaginal discharge. Increased vaginal discharge odor (fishy) after intercourse. Alkaline pH (> 4.5); bacterial vaginosis does not cause vaginal itching or dysuria .

23. Treatment symptomatic metronidazole ( Flagyl ), 500 mg orally twice daily for 7 days . Asymptomatic asymptomatic pregnant patients with antibiotics for bacterial vaginosis to prevent pre term labour .

24. Effect on pregnancy outcome spontaneous abortion, premature rupture of membranes and pre term labour . chorioamnionitis and postpartum endometritis . May cause neonatal septicemia.

25. CANDIDIASIS

26. CANDIDIASIS Organism : Candida albicans , Candida tropicalis

27. Transmission cause vaginal pH to be more alkaline and high estrogen levels causing increased production of vaginal glycogen.

28. Signs and symptoms Vaginal and vulvar irritation ( erythematous and edematous) Pruritic , white, curd like vaginal discharge Yeasty odor Dysuria Dyspareunia

29. Screening Saline or KOH wet mount microscopically examined: shows hyphae , pseudohyphae and budding yeast Usually pH lower than 4.7 Whiff test absent amine (fishy) odor

30. Treatment in pregnancy Use an antifungal, intravaginal agent such as butoconazole , clotrimazole , miconazole or terconazole Sitz baths

31. LEPROSY (HENSEN DISEASE) IN PREGNANCY

32. mycobacterium leprae With established leprosy, there is chance of exacerbation of the lesions during pregnancy. However, the baby should be separated from the infected mother, immediately after delivery. When the disease becomes quiescent and non-infectious, the baby may be given to the mother. Dapsone and Clofazimine appear safe in pregnancy..

33. GONORRHOEA

34. GONORRHOEA Organism : Neisseria gonorrhoeae Transmission : Gonorrhea is transmitted by close sexual contact. The incubation period is 3 to 5 days.

35. Signs and symptoms Vaginal discharge: may be profuse purulent and yellow green Itching or swelling of vulva Dysuria Dyspareunia Joint and tendon pain Anal discharge, discomfort and pain with rectal infection.

36. Screening Molecular diagnostics . Endocervical culture

37. Treatment in Pregnancy cefixime , 400 mg orally, or one dose of Ceftriaxone , 125 mg intramuscularly. Sexual partners within the preceding 60 days should be identified, examined, cultured and treated.

38. Effect on pregnancy outcome It can affect pregnancy outcome in any trimester, causing chorioamnionitis , pre term delivery, PROM, IUGR or postpartum sepsis. If the organism is present at the time of delivery, the greatest neonatal risk is gonococcal ophthalmia , which can cause blindness.

39. SYPHILIS

40. SYPHILIS Syphilis is a sexually transmitted disease caused by Treponema pallidum .

41. Signs and symptoms Incubation- 10 to 90 days Primary syphilis Stage one is evident by a chancre, which is highly infectious, painless, round ulcerated sore that does not get better fast. It may last 3 to 6 weeks.

42. Secondary syphilis: evident by a maculopapular rash This rash usually exhibited between 1 week and 3 months after primary chancre. It typically clears in 2-6 weeks but can last upto one year. Other manifestations include wart like genital growth, lymphadenopathy , fever, sore throat, patchy hair loss, head ache weight loss, muscle aches and tiredness.

43. Latent syphilis: Stage three is usually asymptomatic. The spirochete goes to hiding for 5 to 20 years. The patient is seroactive during this stage. During the first year of this stage, the patient is infectious.

44. Tertiary syphilis: The fourth stage is remanifestation of the disease. It slowly destroys the heart eyes, brain, CNS, and occasionally the liver, bones and skin.

45. Investigations : Serological test- VDRL fluorescent treponemal antibody absorption test (FTA- ABS) Treponema pallidum micro – haemagglutination (MHA- TP) test which are specific.

46. Treatment For Mother : For primary and secondary syphilis(<I year duration): Benzathine penicillin 2.4 million units intramuscularly single dose. When the duration is more than 1 year- Benzathine penicillin 2.4 million units intramuscularly weekly for 3 doses is given.

47. For Baby : Positive serological reaction with a single intramuscular dose of penicillin G 50,000 units per kg body weight. Infected baby with positive serological reaction- (1) isolation with mother (2) IM administration of aqueous procaine penicillin G 50,000 units per kg body weight each day for 10 days.

48. URINARY TRACT INFECTIONS

49. URINARY TRACT INFECTIONS Asymptomatic bacteriuria Cystitis Pyelonephritis

50. Organism: E.coli , klebsiella pneumonia, proteus species in recurrent UTI. Less frequent gram positive causative organism includes group B streptococci, enterococci and staphylococci.

51. Transmission: sexual intercourse and improper wiping after defecation.

52. Signs and symptoms Urinary frequency Urinary urgency Dysuria Hesitancy and dribbling Suprapubic tenderness Gross hematuria Accompanying symptoms with pyelonephritis usually are chills, fever, and backpain with costovertebral angle tenderness.

53. Screening Microscopic examination shows WBC, bacteria may or may not be present. Dip urine may be positive for nitrates and leukocyte esterase Clean catch midstream specimen for culture and sensitivity.

54. Treatment in pregnancy for asymptomatic bacteriuria and acute cystitis: antibiotic therapy for asymptomatic bacteruria is effective in lowering the risk of pyelonephritis and preterm labour . Usually 7-10 day course is preferred

55. Treatment in pregnancy for pyelonephritis : The usual treatment is amoxicillin clavulanate ( augmentin ) 875 mg bd for 7-10 days Cephalosporin

56. Effect on pregnancy outcome The endotoxins released from gram negative bacteria may stimulate the production of prostaglandins and thus cause preterm labour .

57. VIRAL INFECTIONS IN PREGNANCY

58. AIDS

59. Organism : the HIV organism is a retrovirus of the lentivirus family that has an affinity for the T- lymphocytes, macrophages and monocytes .

60. Transmission infected blood or body secretions of semen or vaginal fluid. unprotected sexual activity sharing of contaminated needles. Pediatric HIV primarily results from perinatal or breast feeding transmission

61. Immunopathogenesis leads to slow but progressive destruction of T cells The incubation period is about 1 to 3 weeks. After a peak viral load there is gradual fall more destruction of host cells  progressive immunosupression  opportunistic infections and cancers

62. Clinical presentation : fever, malaise, headache, sore throat, lymphadenopathy and maculopapular rash. constitutional symptoms like weight loss, lymphadenopathy or protracted diarrhea. multiple opportunistic infections with candida , tuberculosis, pnemocystitis , and others

63. Diagnosis: enzyme immunoassay Western blot test or immunofluroscence assay

64. Management : Prenatal care Voluntary serological testing for HIV Counseling assessed by – CD 4 + T lymphocyte counts and HIV RNA at every 3 to 4 months interval

65. Highly active antiretroviral therapy(HAART) (1) Nucleoside reverse transcriptase inhibitors ( Zidovudine , Zalcitabine , Lamivudine , Stavudine ) (2) Nonnucleoside reverse transcriptase inhibitors ( Nevirapine , Delavirdine ) (3) Protease inhibitors ( Indinavir , Saquinavir , Ritonavir ) (4) Entry inhibitors ( Efavirenz ).

66. Intrapartum care Zidovudine is given IV infusion starting at the onset of labour or 4 hours before caesaren section. Loading dose 2 mg/kg/hr until cord clamping is done. Amniotomy and oxytocin augmentation for vaginal delivery should be avoided whenever possible. Elective caesarean delivery is recommended at 38 weeks of women receiving HAART

67. Postpartum care Breast feeding Zidovudine syrup- 2mg/kg, is given to the neonate 4 times daily for first 6 weeks of life .

68. TORCH INFECTIONS Toxoplasmosis This is a systemic infection caused by the protozoan Toxoplasma gondii

69. Consequences of fetal infection The classic triad of hydrocephalus, intracranial calcification and chorioretinitis . The common manifestations are mental retardation, seizure disorder, hepatosplenomegaly and central nervous system (CNS) involvement.

70. Management Prenatal counselling Prevention Medications: Pyrimethamine and sulphadiazine plus folinic acid.

71. Rubella RNA toga virus spread by nasopharyngeal droplets, with an incubation period of 14- 21 days. A disease prodrome of malaise, fever, headache, conjunctivitis and pharyngitis , lasting 1-5 days, precedes the classic manifestations of widespread pink/red maculopapular rash and generalized lymphadenopathy .

72. Effect of maternal infection on the fetus and newborn Spontaneous abortion Congenital rubella syndrome causing symmetric IUGR, congenital heart disease, hepato-splenomegaly and thrombocytopenic purpura . CNS manifestations include deafness, eye lesions such as congenital cataract, retinopathy, microphthalmia , microcephaly , pan-encephalitis, brain calcification and psychomotor disorders.

73. Management Immunization of all adult women. Education of parents about the dangers of rubella infection. All pregnant women should be screened for rubella antibodies at the first prenatal visit.

74. Cyto megalo virus It is a double stranded DNA virus that belongs to the herpes virus family. Humans are the only known hosts of this virus.

75. Transmission CMV is transmitted through blood via transfusion or transplacental route commonly and droplet infection. Body fluids: semen, vaginal secretions, saliva, urine, breast milk (rare), organ transplant and rarely through direct contact.

76. Effect of maternal infection on the fetus and the newborn About 15% of the infants are symptomatic non-immune hydrops , symmetric IUGR, hepatosplenomegaly , CNS sequeale like chorioretinitis , microcephaly , hydrocephaly and calcifications. Almost 85% of infants are asymptomatic

77. Management Prenatal counselling is highly recommended. Drugs such as ganciclovir , forcarnet and cidoforvir .

78. Herpes simplex virus simplex virus is a member of the herpes virus family. It is a DNA virus

79. Transmission Transmission is through intimate mucocutaneous contact. It is one of the most contagious sexually transmitted diseases (STDs).

80. Significance: Spontaneous abortion Intra uterine growth retardation Fetal death Preterm labour Neonatal infection Neonatal herpes

81. Management Acyclovir administered 200mg, four times daily for 14 days. Topical application of acyclovir cream Severe infections : IV administration of Acyclovir 5 mg/kg body weight/ 8 hourly for 5 days.

82. HEPATITIS B The virus is transmitted by parenteral route, sexual contact, and vertical transmission and also through breast milk.

83. Maternal infection The acute infection is manifested by flu like illness as malaise, anorexia, nausea and vomiting. There may be arthralgia and skin rash.

84. Diagnosis Diagnosis is confirmed by serological detection of HBsAg (denote high infectivity) and antibody to hepatitis B core antigen ( HBcAg ).

85. Management Rest Isolation Nutrition Drugs Prevention of complications

86. HUMAN PAPILLOMA VIRUS ( HPV) Condylomata acuminate

87. Effect in pregnancy can grow more rapidly during pregnancy and are located over the genital tract and the perineal regions . They can grow so large as to cause dystocia and severe hemorrhage when disruption occurs during vaginal delivery.

88. Management Excisions of the lesions by cautery or use of cryosurgery

89. PARASITIC AND PROTOZOAL INFESTATIONS MALARIA

90. Effects of malaria on the mother Anaemia Hypoglycemia Metabolic acidosis Jaundice due to hepatic dysfunction Renal failure- due to block of renal micro circulation Pulmonary edema and respiratory distress Convulsions and coma- cerebral malaria

91. Effects on the fetus Abortion Preterm labor Pre maturity IUGR IUFD

92. Management Prevention from mosquito bites using mosquito nets and repellents. Prophylaxis with chloroquine ( 300mg base) orally once a week

93. INTESTINAL WORMS

94. CHLAMYDIA Organism : Chlamydia trachomatis

95. NURSING MANAGEMENT

96. Primary prevention of STI Secondary prevention Tertiary prevention

97. Nursing diagnosis Acute pain related to excoriation from scratching pruritic areas, ulcerations etc. Impaired skin integrity related to presence of skin infections. Risk for complications, IUGR; spontaneous abortion; PROM; preterm labour and fetal death related to presence of STDs or other infections. Risk for fetal or neonatal infections, fetal malformations and anomalies related to complications of maternal TORCH or STDs.

98. Sexual dysfunction or ineffective sexuality patterns related to perineal discomfort and prescribed abstinence during treatment. Self esteem disturbance related to the diagnosis of sexually transmitted disease. Ineffective coping related to diagnosis of STDs. Knowledge deficit related to disease condition, mode of transmission, fetal outcome, possible treatment opportunities etc. Fear and anxiety related to the possible fetal outcome secondary to the infections.

99. THANK YOU……