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Systemic Infections in Pregnancy

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Presentation on theme: "Systemic Infections in Pregnancy"— Presentation transcript:

1 Systemic Infections in Pregnancy
Dr. Jasmin Sapanghila-Tamon

2 Varicella Rubella Hepatitis B Syphilis HIV

3 Varicella Infection

4 Varicella Infection DNA Herpesvirus
Primary infection causes varicella (chickenpox) Recurrent infection causes herpes zoster (shingles)

5 Pathogenesis and Clinical Features
Incubation period days Mild prodrome for 1-2 days Maculopapular rash generally appears first on the head; most concentrated on trunk

6 Mode of Transmission Direct Contact – with patient
who sheds the virus from vesicles Indirect Contact – through articles fresh soiled by discharges of infected persons Airborne – or spread by droplet infection

7 Period of Communicability:
The patient is contagious about a day before the eruption of rashes and continuous to be so up to the 5th or 6th day after the last scab formation or until all vesicles have become encrusted.

8 Diagnostic Test: Determination of V-Z virus though Complement Fixation Test Determination of V-Z virus through Electron Microscopic examination of vesicular fluid

9 Complications: Secondary infection of the lesions – furuncles, cellulites, skin abscess, erysipelas Meningoencephalitis Pneumonia Sepsis

10 Groups at Increased Risk of Complications of Varicella
Normal adults Immunocompromised persons Newborns with maternal rash onset within 5 days before to 48 hours after delivery

11 Is risk of severe chickenpox increased in pregnancy?
No definite evidence that varicella is more likely to be fatal in pregnant women than in non pregnant adult Hermmann KL. Clin Obstet Gynecol 1982;25:

12 Fetal Effects of Varicella
No infection Infection Congenital Varicella syndrome Neonatal varicella infection Infant herpes zoster

13 Transmission to the Fetus
<13 weeks AOG: 0.4% 13-20 weeks AOG: 2% >20 weeks AOG: 0 Within 5 days before or after delivery: 10-20% neonatal varicella infection

14 Congenital Varicella syndrome
Damage to sensory nerves Damage to optic nerve and lens vesicles Damage to cervical and lumbosacral cord Damage to brain

15 Diagnosis of Congenital varicella syndrome
Cordocentesis to estimate fetal VZV-specific IgM ab Chorionic villus sampling to detect VZV DNA sequence using PCR Serum AFP UTZ

16 Management of the mother – Post exposure
Check VZV immunity Consider Prevention of chickenpox – VZIG Treatment of chickenpox with antiviral Counseling of mother and close fetal monitoring

17 Exposure Criteria for Use of VZIG:
Continuous household contact Playmate/officemate contact >1hour indoors Hospital contact – adjacent bed or infected staff member Newborn of infected mother – from 5days before to 2days after delivery AND Time lapse from exposure is less than 96 hours 17

18 Varicella zoster Immunoglobulin (VZIG)
Prevent congenital varicella syndrome ? No definite evidence No congenital varicella syndrome among 97 pregnant women who received VZIG, but not sufficient power to reach significance Documented cases of congenital varicella syndrome despite VZIG Enders et al Lancet 1994: 343;

19 If patient is not pregnant but has a significant exposure to varicella
give vaccine within 120 hours of exposure 70-100% effective if given within 72 hours of exposure Not effective if given beyond 5 days of exposure but will produce immunity

20 Treatment Generally, there is no need to treat uncomplicated varicella since this is almost always a self-limiting disease. Only in an immunocompromised host or when complications such as pneumonitis or encephalitis occur should antiviral therapy be considered.

21 Treatment For women infected with varicella
Give acyclovir 800mg 5 times a day for 5-7 days Not recommended for routine use among otherwise healthy infants and children with varicella

22 Summary Chickenpox may be serious for pregnant women and fetus
Increasing numbers of seronegative women could result in increase chickenpox in pregnancy Vaccine strategy should aim to protect all non immune adults especially women of reproductive age Congenital varicella syndrome may be a rare occurrence, but the risk to the fetus is so high that prevention, post exposure prophylaxis and treatment, once infected, should always be an option.

23 Rubella

24 Rubella Highly communicable disease
Infected person may shed the virus in the upper respiratory tract from 1 week before to 5-7 days after the onset of rash Incubation Period: 14 days (12-23 days)

25 Rubella Low grade fever and mild upper respiratory tract infection Maculopapular rash on the face and neck, trunk and proximal extremities Development of adenopathy Rash fades within 1-3 days of onset

26 Incubation Period: 12-23 days
20%-50% of infections may be asymptomatic Viremia precedes clinical signs by 1 week, and adults are infectious during viremia until 5-7 days of the rash

27 Rubella Risk of congenital defects: </=12 weeks AOG: 80%

28 Congenital Rubella Syndrome
Eye defects Heart disease – PDA Sensorineural deafness CNS defects Pigmentary retinopathy Purpura Hepatosplenomegaly and jaundice Radiolucent bone disease

29 Rubella in Pregnancy There is no treatment to ameliorate maternal disease or reduce the risk to the fetus when maternal infection is present Prevention of fetal infection requires prevention of maternal infection through widespread vaccination programs

30 WHO Recommendation All countries to assess their rubella status and introduce immunization and surveillance, if appropriate

31 Rubella Do serum rubella IgG on all pregnant patients
If patient is seronegative to rubella, give rubella vaccine postpartum

32 Counseling and Management
Pregnant women with confirmed rubella infection must have proper counseling about the risks and types of congenital anomalies

33 Counseling and Management
Routine use of rubella Ig is not recommended for postexposure prophylaxis since this does not prevent infection nor viremia. Advisory Committee on CDC, Aug, 2006

34 Rubella Vaccine Long term protection (about 15 years) from vaccination is about 98 to 99%; thus about 2% of vaccinated women may be negative when tested. Ideally all vaccinated women should have their serological status determined before becoming pregnant.

35 Rubella Screening MMR should not be given to adolescents who are known to be pregnant or to adolescents who are considering becoming pregnant within 3 months of vaccination.

36 Recommendations Routine screening for rubella susceptibility by history of vaccination or by serology is recommended for all women of childbearing age at their first clinical encounter. Susceptible non pregnant women should be offered rubella vaccination; susceptible pregnant women should be vaccinated immediately after delivery. An equally acceptable alternative for non pregnant women of childbearing age is to offer vaccination against rubella without screening.

37 Hepatitis B

38 Caused by DNA hepadnavirus
Incubation period: 6 weeks to 6 months Highest concentration in the blood, lower concentrations in other body fluids Transmitted by percutaneous or mucous membrane exposure to infectious blood or body fluids that contain blood

39 Risk Factors 1. Persons of Asian, Alaskan, Sub-Saharan African descent
2. History of IV drug use 3. History of STD 4. Multiple sexual partners 5. Worker or patient in a hemodialysis unit 6. Health care or public safety worker

40 Risk Factors 7. Household contact with Hepatitis B carrier 8. Sexual contact with Hepatitis B carrier 9. Worker or residence in an instiution for the developmentally disabled 10. History of blood transfusion 11. Delivery to a carrier mother

41 Hepatitis B Risk for chronic infection is inversely related to age at infection In adults, approximately half of newly acquired HBV infections are symptomatic, 1% result in acute liver failure 90% of infants and 30% of children aged <5 years become chronically infected

42 Diagnosis HBsAg Total anti HBc IgM anti HBc Anti HBs Interpretation -
Never infected + Early acute infection; after vaccination (18 days) Acute infection Acute resolving infection Recovered from previous infection and immune Chronic infection Immune in conc >/= 10mIU/mL

43 Pregnancy and HBV Infection
Transmission of HBV from mother to infant (predominantly intrapartum) is one of the most efficient modes of HBV spread 4 Routes 1. Transplacental 2. Intrapartum 3. Post-partum 4. Breast milk

44 Pregnancy and HBV Infection
Perinatal Transmission Rates of Hepatitis B Virus Clinical Status Transmission Rate HBsAg +, HBeAg - 10-20% HBsAg +, HBeAg + 90% Acute Hepatitis B first trimester 10% Acute Hepatitis B third trimester 80-90%

45 Hepatitis B TREATMENT Acute Hepatitis B
primarily supportive on an ambulatory basis with bed rest High protein diet Avoidance of hepatotoxic drugs

46 Treatment of Hepatitis B
Chronic Hepatitis B Goals of therapy 1. Suppression or complete resolution of chronic active hepatitis 2. Halting progression of liver disease 3. Converting patients to a non-infectious state

47 Prevention Hepatitis B immune globulin (HBIG) Hepatitis B vaccine
0.06mL/kg Hepatitis B vaccine Periodic testing to determine ab levels in immunocompetent persons is not necessary, and booster doses of vaccine are not recommended

48 Hepatitis B CDC National strategy to eliminate transmision of HBV
Prevention of perinatal infection Routine infant vaccination Vaccination of previously unvaccinated children and adolescents through age 18 Vaccination of previously unvaccinated adults at increased risk for infection

49 Hepatitis B Post-Exposure Prophylaxis
Percutaneous or mucosal exposure to HbsAg (+) blood or body fluids that contain blood Administer Hepatitis B vaccine and Hepatitis B Ig Sexual or needle sharing contact of an HbsAg (+) person Victim of sexual assault/abuse of a perpetrator who is HbsAg (+)

50 Hepatitis B Post-Exposure Prophylaxis
Victim of sexual assault/abuse of a perpetrator with unknown HbsAg status Administer Hepatitis B vaccine Percutaneous or mucosal exposure to HbsAg (+) blood or body fluids that contain blood from a source with unknown HbsAg status

51 Management of HbsAg (+) Persons
Persons with chronic HBV infection should be referred for evaluation of CLD Household, sexual and needle-stick sharing contacts of chronically infected persons should be identified Sexual partners should be counseled to use methods to protect themselves from sexual exposure to infectious body fluids Protect liver from further harm

52 Syphilis

53 Syphilis Caused by the spirochete Treponema pallidum
Acquired by sexual contact 3-10% contract the disease from a single sexual encounter with an infected partner

54 Stages Primary – genital &extragenital
Secondary – bacteremia involving all major organs Latent – lack of clinically apparent disease Tertiary – 1-20 years after the disease has become latent, progressive damage involving CV, muskuloskeletal and CNS

55 Syphilis Primary Syphilis Chancre – hallmark lesion
Typically single, painless ulcer with raised rounded borders and a “clean” indurated base arise at the site of entry of T.pallidun into the body, inapparent breaks in the host’s skin during intercourse

56 Secondary syphilis

57 Diagnosis Dark field microscopy of secretions from chancre demonstrate the spirochetes

58 Diagnosis Non Treponemal Tests: VDRL, RPR - screening tests
- correlates with disease activity - use to assess treatment response

59 Diagnosis Treponemal Tests: FTA-ABS, TPHA - confirmatory test
- remains positive for the remainder of the patients’ lives regardless of treatment or disease activity

60 Fetal and Neonatal Infections
Spirochetes readily cross the placenta causing congenital infection Hepatomegaly, anemia, thrombocytopenia, ascites and hydrops High serologic titers and unknown duration of infection are major predictors of congenital syphilis

61 Treatment Penicillin G is the treatment of choice for all stages of syphilis No proven alternatives to penicillin therapy during pregnancy Jarisch-Herxheimer reaction - acute febrile reaction frequently accompanied by headache, myalgia, and fetal heart deceleration - usually occur within the first 24 hours after treatment

62 Management of Sex Partners
Persons exposed within 90 days before the diagnosis of primary, secondary or early latent syphilis must be treated presumptively If exposed >90 days before the diagnosis, treat presumptively if the serologic test result is not immediately available and follow up is uncertain Long term partners of patients with late latent syphilis should be evaluated clinically and serologically and treat on the basis of the findings

63 Follow up Patients should be reexamined clinically and serologically using non treponemal test titers 3,6,12, and 24 months after treatment Failure of nontreponemal test titers to decline 4-fold within 6 months after treatment might be indicative of probable treatment failure For retreatment, give Penicillin G x 3doses

64 HIV

65 Introduction Human Immunodeficiency Viruses DNA retroviruses
HIV-1 and HIV-2 most cases are caused by HIV-1 infection mode of transmission sexual intercourse: major mode of transmission blood or blood-contaminated products mothers may infect their fetuses

66 Pathogenesis thymus-derived lymphocytes, T lymphocytes, defined phenotypically by the CD4 surface antigen, are the principal target CD4 site serves as a receptor for the virus co-receptors are necessary for infection chemokine receptors – CCR5 and CXCR4

67 Pathogenesis after initial infection, the level of viremia usually decreases to a set point patients with the highest viral burden at this time progress more rapidly to AIDS and death over time, the number of T cells drop insidiously and progressively --- results in profound immunosuppression

68 Clinical Manifestations
Incubation period: days to weeks acute illness similar to many viral syndromes lasts less than 10 days common symptoms: fever, night sweats, fatigue, rash, headache, lymphadenopathy, pharyngitis, myalgias, arthralgias, nausea, vomiting and diarrhea

69 Clinical Manifestations
AIDS HIV-positive assay results associated with any number of clinical findings CD4+ count of less than 200/mm3 generalized lymphadenopathy, oral hairy leukoplakia, aphthous ulcers, and thrombocytopenia neurologic disease is common

70 Clinical Manifestations
opportunistic infections: esophangeal or pulmonary candidiasis persistent herpes simplex, zoster lesions condyloma acuminata tuberculosis cytomegalovirus pneumonia, retinitis or gastrointestinal disease molluscum contagiosum Pneumocystis pneumonia toxoplasmosis

71 Serological Testing Standard Testing Protocol
Enzyme Immunoassay (EIA) – used as a screening test for HIV antibodies repeatedly positive screening test has a sensitivity of more than 99.5% positive test is confirmed with either Western blot or immunoflourescence assay (IFA)

72 Maternal and Fetal-Neonatal Infection
mother-to-child transmission accounts for most pediatric HIV infections pregnancy rates among women with HIV infection increased significantly in the current era

73 Maternal and Fetal-Neonatal Infection
transmission rates 20% before 36 weeks 50% days before delivery 30% intrapartum 30-40% during breastfeeding

74 Maternal and Fetal-Neonatal Infection
Vertical transmission is more common in preterm births, especially if with prolonged membrane rupture 3.7 relative risk for intrapartum viral transmission

75 Maternal and Fetal-Neonatal Infection
transmission at birth was increased from 15 to 25% in women whose membranes were ruptured for more than 4 hours placental inflammation and chorioamnionitis may increase HIV -1 transmission by 3%

76 Management during Pregnancy
counseling is mandatory should be started early in pregnancy antiviral therapy therapeutic goal: maximal and enduring suppression of viral load and restoration and preservation of immunologic function therapy should be offered to all HIV-infected pregnant women regardless of CD4+ T cell count or HIV RNA level

77 Management during Pregnancy
antiviral therapy (generally) Symptomatic severe symptoms of HIV AIDS CD4 count 200cells/mm3 or less Viral load 1,000 copies/ml or greater

78 Management during Pregnancy
Antiretroviral agents: nucleoside reverse transcriptase inhibitors non-nucleoside reverse transcriptase inhibitors protease inhibitors fusion inhibitors – block HIV-1 cell membrane binding and cell entry

79 Management during Pregnancy
measurement of CD4+ T-cell count approximately every trimester, or about every 3-4 months HIV RNA levels should be monitored 4 weeks after initiation of treatment, then monthly until undetectable, then every 3 months, and finally near term monitor for antiretroviral toxicities during the initial 1-2 months of treatment surveillance for hepatic toxicity and lactic acidosis

80 Management during Pregnancy
treatment failures nonadherence inadequate drug potency suboptimal levels of antiretrovirals viral resistance

81 Management during Pregnancy
additional medical care hepatitis B, influenza, and pneumococcal vaccines are given after viral suppression therapies for opportunistic infection and tuberculosis if CD4+ T-cell count is below 200/mm3, primary prophylaxis for P. carinii pneumonia is recommended (sulfamethoxazole-trimethoprim, dapsone)

82 Prevention of Vertical Transmission
2 principal approaches: 1. antiretroviral therapy 2. cesarean delivery

83 Prevention of Vertical Transmission
TIME OF ADMINISTRATION ZIDOVUDINE REGIMEN Antepartum 100 mg orally five times daily, initiated at 14 to 34 weeks and continued throughout pregnancy Intrapartum intravenous zidovidine in a 1-hr initial dose of 2 mg/kg, followed by a continuous infusion of 1 mg/kg/hr until delivery Neonate give syrup at 2 mg/kg every 6 hours for 6 weeks, begin at 8 to 12 hours after birth

84 Prevention of Vertical Transmission
Cesarean Delivery vertical transmission was reduced by one half when cesarean section was compared with vaginal delivery when antiretroviral therapy was given along with cesarean delivery, the likelihood of transmission was reduced by 87%

85 Prevention of Vertical Transmission
Cesarean Delivery scheduled cesarean delivery should be discussed and recommended for HIV-infected women whose HIV-1 RNA load exceeds 1000 copies/ml recommended at 38 weeks

86 Breastfeeding not recommended
the probability of transmission per liter of breast milk ingested is estimated to be similar in magnitude to heterosexual transmission with unsafe sex in adults risk is related to maternal HIV RNA level, HIV disease status, breast health, duration of breastfeeding most transmission occur in the first 6 months

87 Post partum otherwise healthy women with normal CD4+ T cell counts and low HIV RNA levels may discontinue treatment after delivery close monitoring pyschologic support is important

88 Postpartum Contraception
All HIV infected individuals should be counseled to use condoms consistently OCP – significantly interact with amprenavir/ fosamprenavir, efavirenz, lopinavir, nelfinavir, nevirapine, and ritonavir IUD

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