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Infectious Diseases in Pregnancy
Infectious Diseases in Pregnancy
Infectious Diseases in Pregnancy
Pregnancy
Natasha Kumar
Warren S. Alpert Medical School
August 28, 2015
Objectives
Recognize ID complications in pregnancy
HIV
HPV
HSV
Hepatitis
GBS
Rubella
Toxoplasmosis
Cytomegalovirus
Varicella
Parvovirus
Other STIs
HIV in Pregnancy
Dx: +HIV at first PNV or in third trimester (>28)
rapid HIV test for women in labor (unknown status)
Sequelae: perinatal transmission of HIV, infections
and chronic diarrhea in neonate
Management
ARVs during pregnancy + labor
On HAART before pregnancy: continue regimen minus teratogenic
ARVs (e.g. efavirenz); zidovudine infusion in labor / 3 hours before CS
Hepatitis B in Pregnancy
+HbSAg at first PNV visit
HbSAg
+
Anti HBc +
HbSAg
+
Anti HBc +
Anti HBs -
Chronic infection
(HbSAg+ >20 wks)
Sequelae
Mom: chronic infection liver disease
Baby: perinatal transmission
85-95% risk of chronicity vs. 10-20% in adult-acquired HBV
Management
Mom: refer to specialist for chronic HBV (tenofovir if high risk)
Fetus: HBIG / HBV within 12 HOL + 2 more HBV by 6 months
CS is not indicated, breastfeeding is safe
Rubella in Pregnancy
Screen: Rubella antibodies at first PNV visit
Dx: maternal serology if suspected (+IgM, 4-fold
increase in IgG)
Mom: Rash,
lymphadenopathy, arthritis
Baby: PDA (or pulmonary
artery hypoplasia),
cataracts, and deafness,
blueberry muffin rash
Management
MMR vaccine preconception or postpartum (live vaccine)
HPV in Pregnancy
Dx: HPV+ on Pap smear (at 1st PNV or <5 years when >30
yo)
Sequelae
Minimal risk of perinatal transmission
Respiratory papillomatosis
Management
HPV 6 and 11 (warts)
If possible, delay treatment due to risk of PTL
If warts obstruct vagina, treat with surgery, cryotherapy or electrotherapy
REVIEW!
HIV
Hepatitis B
Rubella
HPV
WHAT HISTORY/PHYSICAL
EXAM/LABS DO YOU NEED?
Patient B: 36 Visit
PE: examine patient for possible herpetic outbreak
Third trimester PNV (>28)
Repeat HIV / RPR + TDAP vaccine
Repeat GC/chlamydia swabs
Risk factors: Hx of chlamydia in pregnancy, multiple
sexual partners
>35-37 PNV
GBS swab
HSV in Pregnancy
Dx: no routine screening
Ask about HSV symptoms early in pregnancy
PE for herpetic lesions if known history of HSV
Culture new lesions if no history of HSV
Neonatal Sequelae
Disseminated (25%), CNS (30%), skin/eyes/mouth (45%)
High mortality rates (30% disseminated, 4% CNS)
Neurologic impairment (20% of survivors)
GBS in Pregnancy
Dx: routine screen at 35-37 rectovaginal swab!
Treat if GBS in urine, prior infant with GBS sepsis
(no screen)
Management
Mom: IV penicillin 5 million units when admitted in labor,
repeat 2.5 million units q4 hrs
If <37 weeks, empiric Rx
PCN allergy: clindamycin (if sensitive) or vancomycin
(unknown sensitivity / resistant)
Chlamydia
Dx: swab at 1st PNV (routine) / 36 PNV for (high risk)
Sequelae: PROM, PTB, LBW, neonate conjunctivitis/pneumonia
Mgmt: azithromycin+ceftriaxone, TOC; neonate eye ointment
Gonorrhea
Dx: swab at 1st PNV (high risk) / 36 PNV (high risk)
Sequelae: SAB, PROM, PTB, LBW, neonatal conjunctivitis
Mgmt: chlamydia Rx + neonate eye ointment
Hepatitis C in Pregnancy
Dx: no routine screening, Ab screen for high risk
patients
History of IV drug use
Transfusion recipient before 1987, organ transplant before
1992
Seeking evaluation or treatment for STDs e.g. HIV
Management
Mom: Refer to specialist for follow-up, no Rx in pregnancy
No preventive measures for vertical transmission to
neonate
REVIEW!
HSV
GBS
Hepatitis C
Syphilis
Gonorrhea/Chlamydia
Sequelae:
Mom: reticular rash on trunk, peripheral arthropathy,
transient aplastic crisis, asymptomatic (20%)
Baby: spontaneous resolution, spontaneous abortion,
hydrops fetalis (2/2 to aplastic anemia), stillbirth
Hydrops unlikely if >8 weeks after maternal infection
Varicella in Pregnancy
Dx: US abnormalities after maternal infection
Hydrops, hyperechogenic foci in liver and bowel, cardiac malformations, limb
deformities, microcephaly, IUGR
Sequelae:
Mom: pneumonia (10-20%)
Baby: congenital varicella syndrome (1st trimester 0.4%, 2nd
trimester 2%, 3rd trimester 0%)
skin scarring, limb hypoplasia, chorioretinitis, microcephaly
Management
Mom: VZIG <10 days (ideally 96 hours), oral acyclovir <24
hours after rash
Infants: VZIG if mom develops varicella around delivery, IV
acyclovir if infected
VZV vaccine preconception or postpartum if nonimmune
Toxoplasmosis in Pregnancy
Dx: maternal serology, fetal US abnormalities,
amniocentesis (PCR) after 18
US; ventriculomegaly, intracranial calcifications, microcephaly,
ascites, HSM, IUGR
Sequelae:
Mom: asymptomatic cervical LAD (80%), fever,
malaise, night sweats, myalgias, HSM
Baby: chorioretinitis, hydrocephalus, periventricular
calcifications, seizures
Management
Maternal infection: Spiramycin
Does not prevent fetal infection but may reduce severity
Cytomegalovirus in Pregnancy
Most common congenital infection
(0.2-2.2% neonates)
Sequelae:
Mom: usually asymptomatic, may have mono-like syndrome (fever,
chills, abnormal liver function, LAD)
Baby: death, neurologic morbidities, congenital hearing loss
REVIEW!
Parvo
Varicella
Toxoplasmosis
CMV
References
ACOG Practice Bulletin No 82. Management of herpes in
pregnancy. 2007.
ACOG Practice Bulletin No 86. Viral hepatitis in pregnancy. 2007.
ACOG Practice Bullent No 151. Cytomegalovirus, Parvovirus B19,
Varicella Zoster, and Toxoplasmosis in Pregnancy. 2015.
Hollier LM, Wendel GD. Third trimester antiviral prophylaxis for
preventing maternal genital HSV recurrences and neonatal
infection. Cochrane Database Syst Rev 2008; (1): CD004946.
Jamieson DJ et al. Cesarean delivery for HIV infected women:
recommendations and controversies. Am J Obstet Gynecol 2007;
197 (3 Suppl): S96-100.
Jamieson DJ et al. Recommendations for HIV screening,
prophylaxis and treatment for pregnant women in the US. Am J
Obstet Gynecol 2007: 197 (3 Suppl): S26-32.
Winn HN. GBS infection in Pregnancy. Clin Perinatol 2007; 34:
387-92.