1
Q
infections in pregnancy
A
- Development of microbial resistance to antibiotics
- routine antenatal screening is recommended for rubella, Hepatitis B, syphilis, HIV, varicella, and Group B Streptococcus (GBS) and urine culture should be included
2
Q
diagnosis
A
- Antibody screening
- Antibody testing for known or suspected infections
- Antigen detection or assays e.g. direct immunofluorescence or enzyme immunoassay
- Nucleic acid amplification e.g. polymerase chain reaction
- TORCH titres
- Viral cultures
- Wet mount (microscope)
3
Q
4 types of organisms
A
- Viral
- Bacterial
- Fungal
- Protozoan
4
Q
types of infections
A
- UTI (bacteriuria)
- Bacterial vaginosis
- Candidiasis thrush
- GBS
- Hep b and c
- Over 50 STIs are recognised that can affect health of woman and baby
5
Q
7 most common STIs
A
- Chlamydia
- Gonorrhea
- Herpes simplex virus type 2 (genital herpes)
- Human immunodeficiency virus (HIV)
- Human papillomavirus (HPV)
- Syphilis (Treponema pallidum)
- Trichomoniasis
6
Q
UTIs
A
- Bacteria from the GI tract contaminating the perineal area
- most common causative organisms are coliforms especially Escherichia coli, others are Klebsiella pneumoniae and Proteus species. Less frequently are Gram positive organisms such as GBS, enterococci and staphylococci=3-7% UTIs.
- Common when normal coliform organisms of the perineal flora are introduced into the urethra during poor perineal hygiene or during sexual intercourse. Bacteria may migrate from the urethra into the bladder and proliferate before the next urination
- Asymptomatic bacteriuria occurs in 2-10% of pregnant population – if untreated, 20-30% of women will develop symptoms of UTI
- Symptomatic bacteriuria occurs in another 1-1.5%. Women with a UTI history and current bacteriuria are 10 times more likely to develop symptoms during pregnancy than women without either feature
7
Q
signs and symptoms acute cystitis infection
A
frequency, dysuria, urgency
8
Q
kidney infection symptoms
A
- Pyelonephritis is usually present when fever, chills, nausea and vomiting, malaise and flank pain occur (CVAT)
- Incidence 1-2.5% with an increased risk of recurrence.
- Urine may be cloudy and infecting organism often found to be Escherichia.coli
9
Q
treatment and management of UTIs
A
Antibiotics as per organism sensitivity: 7-10 day course for an initial infection.
- Prophylaxis with nitrofurantoin (Macrobid) for women with recurrent UTI.
- Increase clear fluids 1.5-2 litres/day.
- Increase clear fluid intake and void before and after intercourse to decrease the risk of recurrent UTI.
- Education: hygiene measures - perineal hygiene, cotton underwear, avoidance of scented soaps, avoid tight fitting clothes.
- Reduce simple sugars in the diet.
- Eat yoghurt or drink milk containing acidophillus cultures and a probiotic when taking an antibiotic.
- Provide antenatal education to the woman to recognise and promptly report signs and symptoms of an infection
10
Q
bacterial vaginosis
A
- anaerobic bacteria such as Gardnerella vaginilis and Mycoplasma hominis which change the normal vaginal flora to a small amount of lactobacilli which would normally produce lactic acid and maintain an acid pH.
- BV is a vaginal infection and is the most common cause of vaginal discharge in women of childbearing age. It can arise and remit in both sexually active and non-sexually active women.
- Present in up to 20% of women during pregnancy and most are asymptomatic.
- Also contracted by swimming in contaminated water, using contaminated towels or sitting in contaminated hot tubs.
- Main symptom is thin, grey/white vaginal discharge, may have increased vaginal discharge and is characterised by a fishy odour after intercourse due to the release of amines by the alkaline semen. Does not cause vaginal itching or dysuria.
- Treatment: Antibiotics are highly effective. 7 day course of metronidazole (Flagyl) or oral clindamycin.
- Effect on pregnancy: increases the risk of spontaneous abortion, PROM, TPL and LBW infants. May cause intra-amniotic infection, neonatal septicaemia and postpartum endometritis.
11
Q
trichomoniasis
A
- caused by Trichomonas vaginalis, a flagellate protozoan that is most commonly sexually transmitted.
- Constant perineal itching, vaginal discharge may be profuse, frothy, yellow/green or grey and have a foul odour, dyspareunia, mild dysuria and lower abdominal pain.
- Treatment is for 5-7 days daily or in a large single dose of oral metrondiazole (Flagyl) and treat the partner(s) too.
- Implicated in PROM, LBW and preterm delivery.
- May be asymptomatic in 10-50% of women. May be acquired perinatally and occurs in 5% of babies born to infected mothers.
12
Q
candidiasis
A
- Candida albicans is a common fungal infection in pregnancy, causing vulvitis, vaginitis and vaginal discharge. Is a commensal and is found in the flora of the mouth, GIT and vagina.
- The vagina may be colonised from the lower intestinal tract or through sexual intercourse.
- Thrush results from a disturbance in normal vaginal flora and conditions that cause vaginal pH to be more alkaline e.g. using antibiotics, eating large amounts of simple sugars.
- May be found in the vagina, mouth or skin around the nipple.
- Clotrimazole most commonly in a vaginal suppository or cream is used for the full 7 days at night to relieve the maternal symptoms and avoid occurrence of neonatal thrush. Also treat the partner
13
Q
bacterial infections (chlamydia)
A
- Chlamydia is the most common, treatable and notifiable infectious disease in many countries and the most common STD especially among young people
- Is a leading cause of PID and is asymptomatic in 80% of cases. Called the “silent STI”.
- Chlamydia trachomatis is now classified as a Gramnegative intracellular bacterium based on its sensitivity to antibiotics and its reproductive cycle.
- Infection rates in pregnancy range from 2-30%
- The rate of chlamydia infection in the past ten years has tripled.
- Aboriginal and Torres Strait Islander people have about an eight-fold higher rate of diagnosis (per 100,000 population) than non-Aboriginal people
- easily diagnosed by self collected specimens including first pass urine and can be easily treated by erythromycin, clindamycin or single dose azithromycin.
- Can cause amnionitis and postpartum endometritis and 70% babies born to mothers with chlamydia become infected.
- Convincing evidence of the association between chlamydia infection and infertility. Long term consequences of infection experienced predominantly by women: chronic pelvic pain, ectopic pregnancy and infertility
14
Q
syphilis
A
- Caused by a motile spirochete bacterium Treponema pallidum.
- Most women who have syphilis have no symptoms and fortunately it is also now relatively uncommon in most of Australia except in the NT and QLD where rates are rising.
- Syphilis can present as a primary genital ulcer, a rash of secondary syphilis or as a large number of serious conditions as part of tertiary syphilis, if left untreated.
- It is particularly important in pregnancy because it may infect the fetus and can cause spontaneous abortion, preterm birth, death and can have serious life-long consequences. It also increases HIV transmission, particularly when a genital ulcer is present.
- Antenatal screening: VDRL at booking–in, repeated at 28 weeks and after birth if mum is high risk.
- Note: Testing is highly sensitive and non-specific and pregnancy may cause false positive results.
- Women who have a positive VDRL or RPR but no symptoms also need to be screened for lupus.
- Primary and secondary syphilis in pregnancy is effectively treated and most commonly by a single dose of 2.4 million units IMI benzyl penicillin. It crosses the placenta.
- If diagnosed after 20 weeks gestation, U/S performed to evaluate for fetal syphilis. Treatment failure is much higher in the presence of fetal hepatomegaly, ascites, hydrops polyhydramnios and placental thickening.
15
Q
GBS
A
- Streptococcus agalactiae is a naturally occurring Gram positive bacteria found in the rectovaginal flora of up to 25% of healthy women. Has the potential to cause infection and ongoing complications for the pregnant woman, the fetus and the neonate.
- NB: Screening issues and prophylaxis are very controversial. Know what happens in your own unit.
- Early onset neonatal GBS infection has high morbidity and mortality if not recognised and treated with antibiotics.
- 90% of neonates have onset of symptoms within 12 hours of birth and most cases occur in the first 72 hours. Late onset disease occurs on days 7-90.
- Incidence of early onset disease varies between 0.2- 1/1000 live births.
16
Q
possible effects of bacterial infections
A
- Asymptomatic bacteriuria
- Intra-amniotic infection
- Endometritis
- Stillbirth
- PROM
- Cultured in a urine sample and UTI
- Wound infections
- Preterm labour/birth
- Spontaneous miscarriage
- Sepsis across the perinatal period
17
Q
viral infections - HPV
A
- Responsible organisms are human wart viruses.
- Sexual contact is the most common form of transmission especially in adolescents, hence current vaccination target. Recent controversy about also treating boys.
- 25% of cervical cancer cases are associated with HPV. Most women with HPV are asymptomatic
- Visible warty growths are single or multiple growths called condylomata acuminata (genital warts)
- most are asymptomatic and can be transmitted before lesions appear. Visible warty are fleshy coloured, pale pink or red, raised or flat and small or large
- during delivery can cause pelvic outlet obstruction and severe haemorrhage related to lacerations of the friable condylomatous tissue
18
Q
genital herpes (HSV-2)
A
- double stranded DNA virus.
- HSV genital infection has been rising in prevalence in the developed world.
- Transmission through direct, intimate, oral-genital or genital-genital contact.
- Is a chronic infection characterised by periods of remissions and exacerbations.
- Lesions appear 2-14 days after exposure.
- S/S may be local or systemic: Intense pain, dysuria, occasional itching vaginal discharge and lymphadenopathy. Viraemia: fever, headache, nausea, malaise and myalgia
- Screening at booking-in for STD history.
- Transmission of virus to the fetus causes neonatal herpes, a potentially fatal but rare condition.
- Can experience a safe pregnancy and normal vaginal birth if no primary episodes of HSV-2 in third trimester.
- If the woman already has a history of genital herpes, the woman’s antibodies will protect the fetus from an infection during pregnancy and the neonatal period.
- Aciclovir* (Zovirax) therapy continues to be the recommended treatment for HSV during pregnancy, as well as analgesia and topical anaesthetic gels.
- primary genital herpes in the third trimester have a high risk of transmitting HSV to the neonate and should be counselled and offered LSCS to decrease this risk
19
Q
hep B virus
A
- Hep B is a partially double stranded DNA virus consisting of a core antigen (HBcAg) carried in a lipoprotein envelope that contains the surface antigen (HBsAg). It carries a third antigen, the e antigen (HBeAg) that is highly infectious.
- Transmitted by blood and body fluids.
- The organism is extremely hardy and can live outside the body in dried blood or body secretions for up to one week or more.
- Pregnant women with acute hepatitis may be asymptomatic or may have S/S of chronic low grade fever, anorexia, N&V, fatigue, skin rashes, arthralgia.
- transmission to the fetus. If the mother is HBsAg and HBeAg positive the child has a 90% risk of becoming infected.
- To prevent HBV infection later in life all newborns are recommended to have routine HBV vaccination.
- In addition, those babies born to HBsAg positive mums also receive Hepatitis B immunoglobulin at birth. This prophylaxis is 85-95% effective in preventing exposed infants from becoming chronic carriers
20
Q
hep c virus
A
- Affects between 1-8% of pregnant women.
- Hepatitis C is an RNA virus and is currently the most common bloodborne infection.
- Most common route of transmission is parenteral including illicit IV drug use, accidental needle sticks and blood transfusions. Sexual transmission is rare.
- HCV becomes chronic in 60-85% of infected people and is the most frequent indication for liver transplantation in the U.S
- Majority of people are asymptomatic until significant liver damage results.
- Risk of vertical transmission to the fetus is low at 5% or less, but higher if the woman is also HIV positive.
- In pregnancy - routine antenatal care with baseline liver function studies. Avoid ARM and FSE in labour.
- Available evidence suggests that B/F does not transmit HCV although avoid B/F if cracked or bleeding nipples, or if the mother is symptomatic with a high viral load.
21
Q
HIV issues
A
- Vertically acquired HIV infection has been virtually eliminated in developed countries through the appropriate use of antiretroviral therapy, the use and timing of ELSCS, and support for the avoidance of breastfeeding.
- Is a cytoplasmic retrovirus of the human T-cell leukemia and lymphoma virus family.
- Transmission occurs from exposure to infected blood or body secretions of semen or vaginal fluid. Most common means is unprotected sex or the sharing of contaminated needles.
- In pregnancy transmission occurs across the placenta, during delivery through exposure to birth canal secretions and blood, and through breast milk.
- The risk of transmission to the fetus or neonate is approximately 20-25% without the use of antiretroviral therapy
- Elective LSCS at 38 weeks if viral load >50 copies/ml, if the viral load is unknown, if the mother has only been receiving ZDV monotherapy, or requests LSCS after discussing the known and potential benefits and risk to her and the baby.
- Breastfeeding is contraindicated due to significant transmission rates. Contraception should be emphasised.
- If women take ART medication and their babies receive treatment at birth, the transmission rate can be down to 1% or less.
22
Q
pregnancy issues HIV
A
- Routinely screened for STIs
- Sensitive handling of formula
- Cervical cytology
- Triponema serology
- Genotypic resistance
- Refer paeds
23
Q
midwifery management - HIV
A
- Provide sensitive advice around risk of HIV transmission through BF
- Refer to available services for assistance with formula
24
Q
varicella
A
- Illness caused by infection with varicella zoster virus – DNA virus from herpes family
- Via respiratory droplets or by direct contact
- Mild febrile illness, malaise, vesicular rash – lasts 7-10 days
- Shingles – eruption of painful vesicles covering an area of skin corresponding to one or two sensory nerves
25
complications varicella
- Pneumonia
- Fetal risks – fetal varicella syndrome (skin loss, eye defects, hypoplasia) and varicella infection of newborn – increased risk of miscarriage
26
medical management varicella
- USS arranged 5 weeks after infection to detect FVS
27
midwifery management varicella
- Arrange for bloods to be tested
- Notify if rash
- Consider admission
- If >20 weeks, arrange oral acyclovir
- Inform of other symptoms – chest etc
- Topical soothing agents
28
rubella
- When maternal infection/exposure occurs in the first trimester, fetal infection rates are nearly 80% and the risk of miscarriage. The risk of congenital defects after maternal infection is essentially limited to the first 16 weeks of gestation.
- Maternal infection early in pregnancy can lead to fetal death, LBW, deafness, cataracts, jaundice, congenital heart disease, microcephaly and intellectual disability
- A woman cannot be vaccinated against rubella whilst she is pregnant, so all girls and women should be encouraged to have the vaccination prior to having a baby
29
listeriosis
- Contracted from contaminated food such as meat and dairy products, unpasteurised raw milks, pâté.
- Caused by the bacterium Listeria monocytogenes a gram positive bacillus. Found in soil and water
- Pregnant women are about 20 times more likely than other healthy adults to get listeriosis.
- May lead to preterm birth, neonatal sepsis or stillbirth. In neonates the mortality rate is approx 50%.
- Prevention: freshly prepared food is safe, Listeria is destroyed during normal cooking. Avoid refrigerated, ready to eat foods, including cold meats, stored salads, soft cheeses, pâté, raw meats, raw seafood and unpasteurised dairy products.
30
midwifery management listeriosis
- Summon medical aid if any concerns of fetal compromise
- After delivery examine placenta and note any signs of chorioamnionitis (yellow or green tinge of membranes or chorion)
- Send samples for culture
- Observe signs of infection
31
toxoplasmosis
- Caused by the parasite Toxoplasma gondii.
- Primary infection is usually asymptomatic and provides lifelong antibody response and provides immunity from further infection.
- Acquired by 4 routes in humans: ingestion of viable tissue cysts in undercooked meat, ingestion of oocytes excreted by cats and contaminating soil or water, mother to child transmission when primary infection occurs during pregnancy, or by transplanted organs or blood products from other humans infected with toxoplasmosis.
- Primary prevention methods: wash hands thoroughly before handling food, thoroughly wash all fruit and vegetables, thoroughly cook raw meats and ready prepared chilled meals, wear gloves and thoroughly wash hands after handling soil and gardening and avoid cat faeces in cat litter or soil.
- The greatest risk of transmission to the fetus occurs in the third trimester, however primary maternal infection in the first 10-24 weeks can result in visual and hearing loss, mental and psychomotor retardation, seizures, haematological abnormalities, hepatosplenamegaly, or stillbirth.
32
cytomegalovirus
- Member of the herpes virus family. Primary infections can occur in all trimesters. Is the most common intrauterine infection affecting 0.6%-0.7% of all live births.
- Causes a mild, flu-like illness in the mother but may result in severe fetal abnormalities such as IUGR, hepatitis, thrombocytopenia, and meningoencephalitis. Survivors have severe neurological morbidity.
- Diagnosis: viral cultures. Infected babies remain infectious for many months excreting the virus in their urine.
- CMV poses a risk to pregnant women, therefore universal precautions to be maintained in areas of risk e.g. baby nurseries, child care centres.
- Fatal case of CMV at RHW
- postnatally acquired in a preterm infant, EBM was the most probable mode of infection
Complex care 2
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