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PREGNANCY AND INFECTIOUS DISEASE Presenter : Anil K Malik Moderator : Dr V. Darlong

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Presentation on theme: "PREGNANCY AND INFECTIOUS DISEASE Presenter : Anil K Malik Moderator : Dr V. Darlong"— Presentation transcript:

1 PREGNANCY AND INFECTIOUS DISEASE Presenter : Anil K Malik Moderator : Dr V. Darlong www.anaesthesia.co.inwww.anaesthesia.co.in anaesthesia.co.in@gmail.comanaesthesia.co.in@gmail.com

2 Most infection are no more serious than in non-pregnant woman. 1. Transmitted to fetus in utero or during or immediately after delivery. 2. Serious illness in mother can have nonspecific fetal or obstetric effects.

3 major causes of neonatal death were: 1. Infection (35%) 2. Preterm birth (28%) 3. Asphyxia (23%)

4 Infectious diseases and pregnancy Infections with anesthesia implications: HIV Varicella zoster virus Syphilis Hepatitis Malaria Tuberculosis Borreliosis (Lyme disease)

5 Other infections: Toxoplasma Rubella CMV Herpes simplex virus Parvovirus B19 Group B streptococcus STI UTI Listeria

6 Human immunodeficiency virus (HIV) young women account for 66% of infections among young people leading cause of death and disease among women of reproductive age worldwide One half of people living with HIV globally are women

7 In 2006, CDC published "Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health- Care Settings". -opt-out HIV screening for all pregnant women, -repeat HIV screening in the 3rd trimester for women who are at high risk

8 Women whose HIV status is unknown at the time of labor should be offered opt-out screening with a rapid HIV test. Opt-out HIV testing: women are told that an HIV test will be included in the standard group of prenatal tests but that they may decline HIV testing. Opt-in HIV testing: women are provided pretest counseling and must specifically consent to an HIV test.

9 current recommendations are: HIV screening, included in the routine panel of prenatal screening tests opt-out screening Separate written consent for HIV testing should not be required Repeat screening in the third trimester is recommended

10 SYSTEMIC EFFECTS Nervous system: o Myelopathy o Aseptic meningitis o HIV encephalopathy o Dementia complex o Peripheral neuropathy o Autonomic neuropathy

11 Respiratory system: o Oppertunistic infections -pneumocystis jiroveci -mycobacterium tuberculosis -MAC Cardiovascular system: o Pericardial diseases o DCM

12 GI System: o Oropharyngeal candidiasis o Aphthous ulcer o Leukoplakia o Esophagitis o Hepatobilliary involvement o HIV enteropathy with chronic diarrhoea o vascular kaposi sarcoma of pharynx

13 Musculoskeletal system o AIDS-related wasting syndrome Renal system o FSGS o ESRD Immunological system o Depressed immunity o lymphadenopathy

14 Hematologica sustem o Normocytic normochromic anemia o Thrombocytopenia o Neutropenia o Coagulation abnormality Endocrine system o Adrenal insufficiency o Hypothyroidism o SIADH

15 anesthetic consideration Anesthetic implication of drugs Thrombocytopenia: -zidovudine -isoniazide -rifampin -phenytoin

16 Peripheral neuropathy: -didanosine -stavudine -lamivudin -zalcitabin Neutropenia: -ganciclovir -cotrimoxazole

17 Hepatic dysfunction: Phenytoin Ethambutol Others: Pentamodine: bronchospasm, arrythmias, electrolyte abnormalities

18 Preoperative assesment: -past social/medical history(IV drug abuse) -associated diseases(syphilis, HBV etc.) -carefull physical examination -documentation of any neurological deficits -presence of AIDS-related dementia

19 -oropharyngeal pathology -oppertunistic pulmonary infections -CVS(subclinical cardiomyopathy) -renal system(nephropathy) -hematological studies

20 Anesthesia technique: Necessary safety measures Universal/standard precautions Neuroaxial techniques: -Safe -Tailored to individual obstetric indications No evidence of increased infectious complications with neural anesthesia & analgesia Complication of aneuroaxial anesthesia doesn’t differs

21 GA: Dose adjustment for -h/o drug abuse -compromised liver & kidney function -generalised muscle wasting Higher fraction inspired O2, with lung pathology Increased sensitivity to opioids & BZD

22 VARICELLA-ZOSTER VIRUS Herpes group virus(I & II) spread by respiratory transmission or direct contact severe maternal varicella cause intrauterine death of fetus Infection in 1 st & 2 nd trimester lead to congenital varicella syndrome -its risk is 2% in 1 st half

23 Symptoms: -skin lesion in dermatomal distribution -neurologic defecit -eye disease -skeletal anomaly About 30% of infant born with these lesions die in the 1 st month of life

24 primary varicella: -chiken pox -encephalitis -pneumonia -occaissionally with respiratory failure Secondary varicella: -herpes zoster(shingles)

25 Anesthesia concerns Patient in acute primary varicella at the time of delivery: -current debate about the optimum anesthetic technique GA may exacerbate varicella pneumonia. SAB- theoritical risk of transmitting the virus from skin lesion to the CNS. Epidural may be safer than spinal

26 Neuraxial anesthesia: - A site free of cutaneous lesion should be choosen for needle placement. Maternal risks like bleeding, thrombocytopenia, DIC & hepatitis Pain management is also difficult in these patient Risk of contracting infection

27 Syphilis Caused by Treponema pallidum. Transmission: -sexual -maternal-fetal -rarely by other means. increases the risk of both transmitting and getting infected with HIV Do HIV testing in all patients with syphilis.

28 STAGES OF SYPHILIS 1. Primary 2. Secondary 3. Latent Early latent Late latent 4. Late or tertiary May involve any organ, but main parts are: Neurosyphilis Cardiovascular syphilis Late benign (gumma)

29 Primary syphilis Incubation period 9-90 days, usually ~21 days. Develops at site of contact/inoculation. Classically: single, painless, clean-based, indurated ulcer, with firm, raised borders. - Atypical presentations may occur.

30 Mostly anogenital, but may occur at any site (tongue, pharynx, lips, fingers, nipples) Non-tender regional adenopathy Very infectious. May be darkfield positive but serologically negative. Untreated, heals in several weeks, leaving a faint scar.

31 Secondary syphilis Seen 6 wks to 6 mos after primary chancre Usually w diffuse non-pruritic, indurated rash, including palms & soles. May also cause: ◦ Fever, malaise, headache, sore throat, myalgia, arthralgia, generalized lymphadenopathy ◦ Hepatitis (10%) ◦ Renal: an immune complex type of nephropathy with transient nephrotic syndrome ◦ Iritis or an anterior uveitis ◦ Bone: periostitis ◦ CSF pleocytosis in 10 - 30% (but, symptomatic meningitis is seen in <1%)

32 Latent syphilis Positive syphilis serology without clinical signs of syphilis (& has normal CSF). ◦ It begins with the end of secondary syphilis and may last for a lifetime. ◦ Pt may or may not have a h/o primary or secondary syphilis. Is divided into early and late latency.

33 LATE SYPHILIS ‘Tertiary Syphilis’ Is the destructive stage of the disease. Lesions develop in skin, bone, & visceral organs (any organ). The main types are: ◦ Late benign (gummatous) ◦ Cardiovascular & ◦ Neurosyphilis

34 Can be crippling and life threatening Blindness, deafness, deformity, lack of coordination, paralysis, dementia may occur It is usually very slowly progressive Late syphilis is noninfectious

35 neurosyphilis Divided into 5 groups, which may overlap: ◦ Asymptomatic neurosyphilis ◦ Syphilitic meningitis ◦ Meningovascular syphilis ◦ General paresis ◦ Tabes dorsalis

36 diagnosis Dark field Microscopy VDRL, RPR FTA-ABS, MHA-TP Direct Fluorescent Antibody (DFA)

37 Pregnancy and syphilis pregnancy usually does not affect the course of syphilis But syphilis may affect pregnancy and can cause: -IUGR -pre term birth -still birth -neonatal death -congenital malformations

38 Anesthesia concerns Mainly related to late stage syphilis affecting aorta, dorsal column, nerve roots. For aortic involvement: -special care must be taken to minimize aortic wall stress(with beta blocker) For CNS involvement: -neuroaxial analgesia may not be ideal -sensory testing compromised

39 Hepatitis Acute hepatitis: -one of the most serious infection durig pregnancy -HEV associated with 20% mortaliy -cause: hepatitis virus group EBV HSV CMV rubella

40 Chronic hepatitis: - may be associated with: -cirrhosis -hepatic failure -HCC All pregnant woman should undergo screening for hepatitis B, as recommended by CDC

41 Anesthesia concerns Preoperative assesment: - severity of hepatitis -Coagulation abnormality Neuraxial anesthesia: - no coagulopathy, if present prior replacement of clotting factors -metabolism of local anesthetics is also of concern(amide LA) -decreased hepatic pseudocholinesterase

42 Theoritical risk of LA toxicity with large dosage in epidural spinal is prefered over epidural GA : indications: -coagulopathy -severe haemorrhage -umbilical cord prolapse Intravascular volume, evaluated with consideration for invasive monitoring when ascitis or CVS compromise are present

43 Avoid hepatotoxic drugs Judicious use of opioids Avoid hypoxia & reduction in hepatic blood flow RSI can be done with succinylcholine

44 MALARIA The disease is almost always symptomatic Potentially lethal in non immune, particularly gravid females Possible pregnancy complications: -IUGR -preterm -spontaneous abortion -eclampsia -PPH -puerperal fever

45 Anesthesia concern P atient may be present with complications of malaria like -pulmonary edema -ARDS -seizure -severe anaemia -ARF

46 Tuberculosis Pregnancy doesn’t change its course Serious risk to mother, neonate & health care provider Active disease treated with firstline therapy Isoniazide causes hepatitis & risk increased in pregnancy

47 Anesthesia concern LFT monitored very closely Precautions: - placing the patient in negetive pressure room -wearing particulate filter mask Anesthesia technique as per indication

48 Borreliosis caused by Borrelio burgoderferi Spread by ticks A spirochetal diease Affect cardiovascular & neurological syste

49 Anesthesia concern: - If there is neurological involvement then avoid neuroaxial anesthesia - Thorough cardiac evaluation

50 STI in pregnancy Syphilis - 2.4-17% Chlamydia - 5.3-21.5% Gonorrhea - 2.0-20% Bacterial vaginosis - 9-48.5% Trichomoniasis - 9.9-27.5% HSV - 6.7-53.4% HIV - 15- 42.5%

51 TORCH Infections T=toxoplasmosis O=other (syphilis) R=rubella C=cytomegalovirus (CMV) H=herpes simplex (HSV)

52 TOXOPLASMOSIS Caused by protozoan – Toxoplasma gondii Domestic cat is the definitive host with infections via: ◦ Ingestion of cysts (meats, garden products) ◦ Contact with oocysts in feces Much higher prevalence of infection in European countries

53 Acute infection usually asymptomatic 1/3 risk of fetal infection with primary maternal infection in pregnancy ◦ Infection rate higher with infxn in 3 rd trimester ◦ Fetal death higher with infxn in 1 st trimester

54 Clinical Manifestations Most (70-90%) are asymptomatic at birth Classic triad of symptoms: ◦ Chorioretinitis ◦ Hydrocephalus ◦ Intracranial calcifications Other suggestive symptoms: - fever, -rash, -HSM, -microcephaly,

55 -seizures, -jaundice, -thrombocytopenia, -lymphadenopathy Initially asymptomatic infants are still at high risk of developing abnormalities, especially chorioretinitis

56 Diagnosis Toxoplasma serology Maternal IgG indicates past infection Can be isolated in culture from placenta, umbilical cord, infant serum PCR testing on WBC, CSF, placenta ◦ Not standardized Newborn serologies with IgM/IgA

57 Prevention and Treatment Treatment for pregnant mothers diagnosed with acute toxo ◦ Spiramycin daily Macrolide antibiotic ◦ Small studies have shown this reduces likelihood of congenital transmission (up to 50%) If infant diagnosed prenatally, treat mother with ◦ Spiramycin, ◦ pyrimethamine and sulfadiazine ◦ Leucovorin rescue with pyrimethamine

58 Rubella Single-stranded RNA virus Vaccine-preventable disease Mild, self-limiting illness Infection earlier in pregnancy has a higher probability of affected infants

59 Clinical menifestations Sensorineural hearing loss (50-75%) Cataracts and glaucoma (20-50%) Cardiac malformations (20-50%) Neurologic (10-20%) Others to include growth retardation, bone disease, HSM, thrombocytopenia, “blueberry muffin” lesions

60 Diagnosis: -serology -PCR Treatment: -immunization -supportive care

61 Cytomegalovirus (CMV) Most common congenital viral infection Mild, self limiting illness Transmission can occur with primary infection or reactivation of virus ◦ 40% risk of transmission in primary infection Studies suggest increased risk of transmission later in pregnancy ◦ However, more severe sequalae associated with earlier acquisition

62 Typical clinical symptoms: -IUGR -microcephally -hepatosplenomegally -petechiae -jaundice -thrombocytopenia -anemia -chorioretinitis

63 long-term neurodevelopmental sequelae include: -mental retardation -motor impairment -SNHL -visual impairment Primary maternal CMV infection during gestation poses a 40% risk of intra uterine transmission

64 Diagnosis and treatment Diagnosis: -serology -PCR Treatment: -Once the diagnosis of congenital CMV infection is confirmed, (i)one option is pregnancy termination. (ii) second proposed antiviral agents such as ganciclovir, foscarnet, and cidofovir

65 - These drugs are of moderate effectiveness in treating CMV infection in the adult, particularly the immunocompromised patient -they are not of proven value in preventing or treating congenital CMV infection (iii) hyperimmune globulin (iv)A live attenuated vaccine using the Towne 125 strain has been developed, and appears to be safe

66 Anesthesia concerns No specific consideration Patients with chronic CMV infection, AIDS related may have polyradiculopathy - it improves with antiCMV therapy

67 Herpes Simplex (HSV) HSV1 or HSV2 Primarily transmitted through infected maternal genital tract ◦ Rationale for C-section delivery prior to membrane rupture Primary infection with greater transmission risk than reactivation

68 diagnosis Culture of maternal lesions if present at delivery Cultures in infant: ◦ Skin lesions, oro/nasopharynx, eyes, urine, blood, rectum/stool, CSF CSF PCR Serologies again not helpful given high prevalence of HSV antibodies in population

69 treatment High dose acyclovir 60mg/kg/day divided q8hrs ◦ X21days for disseminated, CNS disease ◦ X14days for SEM Ocular involvement requires topical therapy as well

70 Thank you Thank you www.anaesthesia.co.inwww.anaesthesia.co.in anaesthesia.co.in@gmail.comanaesthesia.co.in@gmail.com


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