Evelyn M. Hickson, RN, MSN, CNS, WCC Maternal Infections Evelyn M. Hickson, RN, MSN, CNS, WCC

Group B Streptococci (GBS) The proportion of pregnant women colonized with GBS ranges from 10 – 30% Isolation of the organism can be intermittent. Antepartum rectal or genital colonization is typically asymptomatic GBS accounts for significant peripartum infection, such as endometritis, amnionitis, and UTI.

Indications for Prophylaxis CDC, ACOG, and AAP recommend intrapartum antibiotic prophylaxis if: Previous birth of a child with GBS infection GBS bacteriuria during current pregnancy Positive GBS screening during current pregnancy (unless planned c-section) Unknown GBS status and any of the following Delivery at < 37 week gestation Membrane rupture > 18 hours Intrapartum fever > 100.4 F (38 C) Gold standard for prophylaxis: PCN Ampicillin, 2 gm loading dose followed by 1 gm every 4 hours For PCN allergies, clindamycin 3

GBS (cont.) Intrapartum Antibiotic Prophylaxis Not Indicated Previous pregnancy with a positive GBS screening culture and negative current culture Planned C-section delivery performed without labor or membrane rupture Negative vaginal and rectal GBS screening culture                                                                                                                                                                                                                                                            

GBS Prophylaxis Regimens PCN G, 5 million units load, then 2.5 million units IV q 4h until delivery Alternate: Ampicillin, 2 grams IV load, the 1 gram q 4h until delivery If allergic to penicillins Clindamycin, 900 mg IV q 8h until delivery Alternate: Erythromycin 500mg IV q 6h until delivery

GBS: CDC Recommendations Unless a GBS-specific UTI is present, antimicrobial agents should not be used before the intrapartum period to treat asymptomatic GBS colonization. If patient comes in with frequent UTIs that respond briefly to antibiotics, consider that you may have a patient with GBS UTI 6

GBS and the Neonate Prophylactic intrapartum antibiotics typically provide effective prevention of early-onset GBS infection in the neonate Clinical onset of early-onset GBS infection typically occurs within the first 24 hours of life, up to the first 7 days of life A healthy-appearing infant who is > 38 weeks' gestation at delivery and whose mother received > 4 hours of intrapartum antibiotic prophylaxis before delivery may be discharged home as early as 24 hours after delivery. Late-onset GBS infection occurs after the first 7 days of life

Hepatitis Hepatitis A: Little effect on pregnancy and is rarely transmitted Hepatitis B: Serologic testing for HBsAg part of routine prenatal care. Pt may have vaccine during pregnancy if HBsAg negative, but have risk factors for Hepatitis B. Universal HBV immunization is recommended for all neonates who weigh more than 2 kg at birth. Hepatitis C: Pt requires regular monitoring of liver function tests. Breastfeeding not contraindicated.

Hepatitis B Both term and preterm neonates born to women known to be HBsAg positive should be vaccinated and receive one dose of HBIG within 12 hours of birth. No special care of neonate is indicated other than removal of maternal blood to avoid inoculation of the virus contaminating the skin. Breastfeeding of newborns by HBsAg-positive women poses no additional risk

HSV Cesarean is indicated for women with active genital HSV lesions at the time of delivery. If pt has ROM and is at or near-term, cesarean delivery should be performed ASAP Some women with active lesions are now opting to cover the lesion and delivery vaginally – must have appropriate information regarding risks and benefits Treatment with acyclovir of women near term reduces the rate of occurrences and the cesarean rate.

HSV New information shows that patients with HSV lesions are much more susceptible to other STDs and HIV. HSV lesions can shed HIV virus Remember Type I and II can be found in any area of the body – there is no line at the umbilicus that separates the two.

HSV Neonatal transmission rate from birth through an active outbreak is 30-50%, particularly if HSV is acquired late in pregnancy. After birth, obtain cultures. Close observation of Signs and Symptoms: vesicular lesions of the skin, respiratory distress, seizures, or signs of sepsis. Neonates are treated with acyclovir.

Hospital Preparation Checklist for HIV-Positive Women 2008 Washington State routinely puts out updated guidelines – most recent update was 2008: http://www.doh.wa.gov/cfh/hiv_aids/prev_edu/provider.htm Hospital Preparation Checklist for HIV-Positive Women 2008 Prenatal Checklist for HIV-Positive Pregnant Women 2008 Screening and Management of Maternal HIV Infection 2008

HIV CDC recommends routine HIV testing for all pregnant women. Without any intervention, the risk of neonatal infection from an HIV positive mother is about 25%. Prenatal and intrapartum administration of ZDV to HIV pregnant women has reduced the rate of transmission to the newborns by 68%.

HIV (cont.) After delivery, HIV-infected women can receive care in the postpartum care unit, with the use of standard care precautions. Few neonates with HIV infection show clinical evidence of infection in the first weeks after delivery. Gloves should be used until all amniotic fluid and blood is removed from skin. Skin where IM injections are given should be washed with soap and water prior to prepping and giving Vit K or vaccines If baby had FSE in place, area of presenting part where the electrode was placed must also be washed with soap and water Gloves are not required for changing diapers. Routine standard precautions should be used.

HPV May be exacerbated during pregnancy. Cryotherapy, laser therapy, and trichloroacetic acid may be used safely in pregnancy – remember that this may impact cervical dilatation since the cervix will be scarred Vaginal delivery may not be recommended if likelihood of extensive vulvovaginal lacerations. Neonates do not need to be managed with special precautions.

Gonorrhea Cephalosporins are the recommended treatment. Chlamydia is commonly concurrent. Gonorrhea infection in the newborn usually involves the eyes. Antimicrobial prophylaxis recommended for all neonates immediately after delivery. This may include: 0.5% erythromycin ointment 1% tetracycline ointment 1% silver nitrate (difficult to find – not widely manufactured)

Chlamydia Most common STD in the U.S. Often asymptomatic and unrecognized Treating woman and her sexual partner(s) is important If untreated, neonates born to untreated women generally develop purulent conjunctivitis (50%) a few days to several weeks after delivery and neonatal pneumonia occurs (5-20%). Neonates should be treated with oral erythromycin for 14 days Standard precautions and good hand hygiene by parents should be used in baby care

Syphilis Rates of infection are highest in urban areas and the rural South. All patients should be tested. On the rise again in the U.S. Treatment: Penicillin regimen Tetracycline and doxycycline contraindicated during pregnancy. Erythromycin is suboptimal because poor transplacental passage. Neonate: may not appear infected at birth and serologic tests may be difficult to interpret. Pen G is preferred treatment.

TB Positive PPD in past 2 years without active disease. Rx isoniazid 300mg daily starting after the 1st trimester and continuing for 9 months or if HIV + for 12 months. For active disease, prompt multi-drug therapy with isoniazid and rifampin, supplemented by ethambutol if isoniazid drug resistance is suspected. Continued therapy for at least 6 months.

TB Neonatal Management Neonate: Usually transmitted after birth by inhalation of droplets. Transmission before birth possible by blood in the placenta or infected amniotic fluid, or aspiration of infected amniotic fluid. The mother and other household members should be screened with PPD and evaluated. If mother (or household contact) has negative x-ray and is asymptomatic, no separation or special care required. If active TB, separation and treatment of both mother and baby from rest of patients in the unit. Public Health notification and involvement.

References Centers for Disease Control and Prevention. (2006). “Genital Herpes in Pregnancy.” Sexually Transmitted Diseases Treatment Guidelines 2006. Retrieved from http://www.cdc.gov/std/treatment/2006/genital-ulcers.htm Centers for Disease Control and Prevention. (2009). HIV/AIDS: Pregnancy and childbirth -- What women can do. Retrieved from http://www.cdc.gov/hiv/topics/perinatal/protection.htm. Centers for Disease Control and Prevention. (2009). Tuberculosis and Pregnancy. Retrieved from http://www.cdc.gov/tb/publications/factsheets/specpop/pregnancy.htm Guidelines for Perinatal Care, (5th ed.)/AAP and ACOG, 2002 Lowdermilk, D. and Perry, S. (2007). Maternity and Women’s Health Care (9th ed.). St. Louis, MI: Mosby Elsevier. Mattson, S. and Smith, J. (2004). Core Curriculum for Maternal-Newborn Nursing (3rd ed.). St. Louis, MI: Mosby Elsevier. Schrag, S. et al. (2002). Prevention of Perinatal Group B Streptococcal Disease: Revised Guidelines from CDC. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5111a1.htm. ACOG Patient Education. (2009). Group B Streptococcus and Pregnancy. Retrieved from http://www.acog.org/publications/patient_education/bp105.cfm. Simpson, K. and Creehan, P. (2001). Perinatal Nursing (2nd ed.). Philadelphia, PA: Lippincott. Baker, C. (2002). CDC revises Group B Strep prevention guidelines. Retrieved from http://aapnews.aappublications.org/cgi/content/full/21/3/118