1. VIRAL INFECTIONS Maternal Child Implications Dai To

2. Hepatitis A virus (HAV) Acquired primarily through a fecal-oral route: ingestion of contaminated food, milk, shellfish or polluted water, and person-person contact. Self-limiting Not a chronic condition Does not usually affect the course of pregnancy

3. Hepatitis A virus (HAV) Manifestation: ◦Flu-like symptoms- anorexia, nausea, vomiting, malaise, and fever, right upper quadrant pain Diagnose  Serologic IgM antibodies  Detectable 5-10 days after exposure  Can remain positive for up to 6 months

4. Hepatitis A virus (HAV)  Vaccination is the most effective means of preventing HAV transmission Therapy:  Supportive  Hospitalized if dehydrated due to N/V  Avoid alcohol and medications affect the liver, such as acetaminophen  If infected: administer gamma globulin Diet: well-balance

5. Hepatitis B virus (HBV) Most threatening to the fetus and neonate Disease of the liver and often a silent infection Transmitted parenterally, perinatally, through intimate contact, and rarely oral (IV, blood, saliva, vaginal secretions, semen, breast milk, and across the placental barrier) Not self-limiting Chronic: approx. 4000-5000 deaths caused annually by liver disease associated with chronic HBV infection Groups at risk: illegal IV drug users, prostitutes, homosexuals, multiple sex partners, or occupational exposure to blood

6. Hepatitis B virus Mother implications Manifestation:  Similar to those of hep A  Can also include arthralgia, arthritis, and skin eruptions or rash  Not usually affect the course of pregnancy Recommendation:  Tested for HBV surface antigen (HBsAg) at first prenatal visit & screened on a regular basis  Vaccination series if negative.

7. HBV Neonatal Implications Perinatal transmission occurs at or near birth Infants have the highest risk of becoming chronically infected, if not treated If mother has HBV infection: risk of prematurity, low birth weight, and neonatal death increase

8. HBV Neonate management Remove maternal blood from the neonate immediately after birth Suction the fluids from the neonate immediately after birth Bath the neonate before any invasive procedure Prevention by routine vaccination soon after birth Hepatis B immune globulin and Hepatitis B vaccine. Discourage the mother from kissing the neonate until he/she has received the vaccine Inform the mother that the hepatitis B vaccine will be given to the neonate and that a second dose should be given at 1 month after birth and a third dose at 6 months after birth Support breast-feeding after neonatal treatment for Hep B. Because feeding is not contraindicated if the neonate has been vaccinated and currently on the immunization schedule

9. HERPES SIMPLEX VIRUS

10. Herpes simplex virus- 1/2 1 in 6 people from 14-49 years old is infected in the US ◦Herpes simplex virus 1 (HSV-1)  Transmitted nonsexually ◦Herpes simplex virus 2 (HSV-2)  Transmitted sexually ◦Initial infection characterized by multiple painful lesions, fever, chills, malaise, and severe dysuria

11. Herpes Simplex

12. Active genital wart lesions

13. Active genital wart lestions

14. HSV-2 Maternal implications Diagnosis: Herpes culture or titer Manifestation:  Painful lesions in the genital area  Lesions may develop on the cervix  Blisters, rash, fever, malaise, nausea, headache.  Can cause miscarriage, preterm labor, stillbirth Therapy:  Acyclovir orally during pregnancy and near term  Weight out the benefit to mom from fetus risk  Cesarean if the woman has active outbreak at birth

15. HSV-2 Neonate & Infants Most severe complication of HSV Most mothers lack history of HSV Manifestation:  Asymptomatic at birth, but symptomatic anytime after birth include small cluster vesicular skin lesions, DIC, pneumonia hepatitis with jaundice, neurologic abnormalities, altered temperature, seizures, and poor feeding. Therapy:  Contact precaution  Throat, conjunctiva, CSF, blood, urine, rectal, and lesion cultures for HSV antibodies.  IV acyclovir (Zovirax)  Follow-up for microcephaly, spasticity, seizures, deafness, blindness  Encourage parental rooming-in and touching the newborn  Show parents hand washing and precaution if mother’s lesions are active

16. Human Immunodeficiency Virus HIV versus AIDS

18. Human immunodeficiency virus (HIV) ◦Half a million Americans were living with HIV/AID by the end of 2007 ◦Heterosexual transmission now the most common means of transmission in women ◦Among American children living with HIV/AID, 91% were exposed perinatally. ◦Fortunately, the number of new pediatric AIDS cases is declining rapidly, associated with new CDC and ACOG guidelines (2008)

19. HIV ◦HIV: Severe depression of the cellular immune system associated with HIV infection. As disease progresses, becomes more severe and is labeled Acquired Immunodeficiency Disease (AIDS). ◦Women’s HIV symptoms: wasting, esophageal candidiasis(yeast infections is common early sign) herpes simplex virus.

20. HIV  Screening and diagnosis  Enzyme-linked immunosorbent assay (ELISA) test & Western blot or immunofluorescence assay (IFA)  Child <18 m: infected if born to a HIV positive mother and has two HIV-positive specimen results  New CDC & ACOG guidelines (2008)  Universal counseling risks of transmission from mother to fetus  Opt-out HIV screening of all pregnant women  Repeat HIV testing 3 rd trimester  Immediate antiretroviral (ART) therapy prophylaxis for HIV positive mother in labor and their infants following birth

21. HIV- Treatment to the infected mother  Screening as part of prenatal routine  Goal ◦ Stabilizing disease ◦ Prevent opportunistic infections ◦ Preventing transmission HIV to the fetus, most effective when the woman receives ARV drugs during pregnancy, labor, and birth ◦ Supporting psychosocial & education

22. HIV Treatment for the infected mother ◦ARV therapy & ZDV (Retrovir or zidovudine) ◦Treating for others STIs & conditions related to AID complications ◦Caution with invasive procedures ◦Cesarean as early as 38 wk related to HIV ◦Postpartum screening ◦Breastfeeding is contraindicated due to potential of passing the virus to neonate

23. HIV Treatment for the fetus ◦Monitor fetal NST ◦Serial ultrasounds ◦Biophysical profiles ◦Avoid invasive procedures (amniocentesis) to prevent the contamination of a noninfected infant

24. HIV Treatment for the neonate 6-week oral zidovudine prophylactically Avoid exposure to persons with infections, esp. chickenpox No live vaccine should be given Teach parents to use gloves when diapering the infant, clean soiled surfaces with 10% bleach solution, identify signs of opportunistic infections. Testing for HIV at 2-3 weeks, 1-2 months, & 4-6 months using the HIV DNA or RNA If positive: ARV (antiretroviral) therapy