Obstetrics 14

  1. What is the most likely diagnosis in Newborn sepsis within hours of birth with bilateral diffuse pneumonia?
    GBS(Group B strep) neonatal sepsis

    - Usually fever is absent, hypotension present.
  2. What is the antibiotic of choice for Group B strep sepsis?
    • Penicillin G.
    • Alternatives are clindamycin, erythromycin.
  3. When do we do the vaginal culture for Group B streptococcus?
    At 36 weeks.
  4. What are the criteria for giving prophylaxis against Group B streptococci?
    • Without screening:
    • - Positive urine GBS culture
    • - Previous Neonatal Sepsis

    • Based on culture: 
    • - 36 weeks vaginal culture positive

    • Based on risk factors:
    • - Preterm
    • - ROM (Rupture of membranes) > 18hrs,
    • - Intrapartum fever
    • We give Penicillin G during labor to mother.
  5. What are the diseases with transplacental transmission? [TN 90]
    • Toxoplasmosis
    • Others - AIDS
    • Rubella
    • CMV
    • Herpes virus infection
    • Syphillis 
    • [@ TORCHeS]
  6. Which of the following congenital infections is associated with minimal teratogenic risk to the fetus? [AI 08]

    B) HIV

    No teratogenic effects has been reported with fetal infection with HIV.
  7. Which of the following viruses is least likely to cross placenta? [AI 11]

    A) HBV

    HBV is large virus and does not cross placenta, hence it cannot infect the fetus unless there have been breaks in the maternal fetal barrier.

    The risk of transmission of HBV to fetus ranges from 10% in first trimester to as high as 90% (maximum)  in third trimester. [AI 07]
  8. What is the most common viral infection in pregnancy? [AIIMS 97,UP 00]
  9. What are the modes of transmission of Toxoplasma Gondii?
    • Cat feces. [IOM 08]
    • Cat belong to feline community.

    • 1. Ingestion of undercooked meat, cow's milk and oocysts.
    • Many patients are infected by swallowing oocysts discharged in the feces of infected reservoir cat (feline community) [IOM 08] 

    2. Direct transmission of the parasite by blood or organ products during transplacentation takes place but at a lower incidence. 

    • 3. Transplacental transmission - 
    • Most common - 3rd trimester [AI 99], usually asymptomatic at birth 
    • - Most Lethal – 1st trimester
  10. What are the clinical features of acquired toxoplasmosis?
    • Acute acquired toxoplasmosis is usually asymptomatic. 
    • The most common manifestation of acute toxoplasmosis is cervical lymphadenopathy. [AI 97]
  11. What is the diagnostic triad of early pregnancy Toxoplasma Gondii infection in newborn?
    • 1. Symmetrical IUGR
    • 2. Intracranial calcifications - there may be obstructive hydrocephalus 
    • 3. Chorioretinitis [AIIMS 94,96]
    • [Note:  When you  see chorioretinitis or macular involvement [PGI 97], Toxoplasmosis  is the best answer.

    • But, in HIV  patients, CMV is most common cause of chorioretinits.[AIIMS 92,02, AI 03, CUPGME 03]
    • [@sightomegalovirus damages sight.]]
  12. How do you treat toxoplasmosis in pregnancy?
    • In a pregnant woman with an established recent infection, Spiramycin [KARNATAKA 94]  (3 g daily in divided doses) should be given until term.
    • Once fetal infection is established, treatment with Sulfadiazine and Pyrimethamine [AI 05, AIIMS 95]  plus Calcium folinate is recommended (Spiramycin does not cross the placental barrier).
  13. What is the DOC for ocular toxoplasmosis?
    Sulfadiazine and Pyrimethamine for 4 weeks.
  14. In which infection do you find life long latency?
    Herpes infection, HIV, Cytomegalovirus.
  15. What is the triad of congenital Varicella syndrome?
    • Zig-Zag skin lesions
    • Microopthalmia
    • Extremity hypoplasia
  16. Which viral infection in pregnancy causes maximum congenital malformations? [AIIMS 98, UP 00, AI 04, IOM 2063]

    Rubella infection in first trimester  of pregnancy is an indication  for Medical termination of pregnancy. [SGPGI 03]
  17. What is the risk of fetal infection with Rubella in 1st, 2nd and 3rd trimester?
    • 1st = 90%
    • 2nd = 5%
    • 3rd = <1%
  18. Where do you find ‘Blue berry Muffin’ rash?
    It is seen in rubella because of extramedullary hematopoesis. 

    • It  is a characteristic lesion  of rubella.
    • But  it may be associated with cytomegalovirus  (ToRCHS -  in Rubella  and Cytomegalo) and  metastatic neuroblastoma.
    • [Note: But in exam, when you see Blue berry muffin lesion, always think of rubella]

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  19. What are the  features of congenital rubella syndrome? [AIIMS 99]
    IUGR is the most common manifestation of CRS. 

    • Classical triad of CRS includes: 
    • - Congenital deafness - most common among  triads. 
    • - Congenital cataracts
    • - Congenital heart disease
  20. What are the cardiac features of congenital rubella syndrome? [AIIMS 91]
    • PDA - most common [AIIMS 92,AI 93,96]
    • Pulmonary stenosis
    • Atrial septal defect
  21. Which of the following is not seen in congenital rubella syndrome [AI 02]

    D) Aortic stenosis
  22. What is the finding in fundus in congenital rubella?
    • Rubella retinopathy is more common finding than cataract in congenital rubella syndrome.
    • The retina has a characteristic salt and pepper appearence. [AIIMS 93,91,UP 00]
  23. Antibodies seen in neonate after an intrauterine infection are [KERELA 99]
    a) IgD
    b) IgA
    c) IgM
    d) IgG
    • IgM is the earliest immunoglobulin to be synthesized by the fetus, beginning by about 20 weeks of intrauterine life.
    • Because it is not transported across the placenta, the presence of IgM in the fetus or newborn indicates intrauterine infection and its detection is useful in diagnosis of congenital syphillis, rubella, and toxoplasmosis.
    • Many techniques have been developed for selective detection of IgM antibodies and these include modifications of FTA-ABS, [AI 01] TPHA, EIA and VDRL tests using whole sera or separated IgM fractions.
  24. How do you diagnose congenital rubella syndrome? [AI 05]
    • If an infant has IgM rubella antibodies [AIIMS 02] shortly after birth (as IgM antibodies donot cross the placenta, their presence indicates that they must have been synthesized by the infant in uterus)
    • If IgG antibodies persist for more than 6 months by which time maternally derived antibodies would have disappeared.
  25. What is the immunization strategy to prevent congenital rubella syndrome?
    • First priority is to protect women of child bearing age (15-34 or 39 years). [AI 07] 
    • Next priority is to vaccinate all children currently 1-14 years of age (to intercept transmission)
    • Next priority is to vaccinate all children at one year of age (to intercept transmission).
  26. What is the most common cause of congenital deafness?
  27. What is the difference in head size in Toxoplasma and Cytomegalovirus?
    • Toxoplasma -- hydrocephalus causing macrocephaly. 
    • Cytomegalovirus -- microcephaly.

    [@ though it has name megalo, it causes small head]
  28. What is the difference in calcification in Toxoplasma and CMV?
    • Toxoplasma, intracranial calcifications scattered anywhere. 
    • CMV, periventricular calcifications. 

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  29. Newborn, SGA(Small for Gestational Age), IUGR with petechiea rashes in newborn. What is the most probable diagnosis?

    If you see newborn  with petechiae, the most probable diagnosis is CMV.
  30. What is the DOC for CMV? [DEHLI 96]
    Drug of choice for CMV is Gancyclovir  [@ C -G]
  31. What is the mode of transmission of Herpes?
    Mucocutaneous contact
  32. Which of the following is true regarding neonatal herpes [PGI 00]

    D) Caused by HSV II
  33. If there is genital ulcer at the time of labor, management?
    Emergency C/S.

    If the lesion is Herpes and if the baby gets it, mortality is 50%.
  34. What is the management of Genital herpes in pregnancy?
    • Valaciclovir, famciclovir (FDA B) - can be given less frequently so these drugs are the DOC.
    • Acyclovir (FDA A) - should be given more frequently so not preferred these days.

    On exam however, choose Acyclovir. Valaciclovir is used for prophylaxis that decreases herpes transmission.
  35. Congenital transmission is seen in all of the following except [BHU 02]

    C) Cryptococcus
  36. When does Treponema pallidum  cross placenta in pregnancy? [UP 97, AIIMS 92]
    • At any stage of pregnancy, but the lesions of congenital syphillis generally develop after the 4th month of gestation.
    • At this time, the fetal immunologic competence begins to develop.
    • This timing indicates that the pathogenesis
    • of congenital syphillis depends on the immune response of host rather than a direct toxic effect of T. pallidum.
  37. What are the features of early congenital syphilis?
    • Non Immune hydrops probably due to anemia
    • Macerated skin
    • Thrombocytopenia
    • Characteristic snuffles (persistent runny nose that has spirochetes on it)
  38. What are the features of late congenital syphilis?
    • Hutchinson teeth
    • Moon's molar  or Mulberry molars
    • Saber shins/tibia [AI 93,UP 97,AIIMS 91] 
    • Saddle nose
    • Clutton joints
    • Olympian brow [JIPMER 91] -  recurrent periostitis leads to thickening of the bones causing frontal bossing, bony prominence of the forehead 
    • Rhagades [AP 96] - linear fissures appearing in the skin, especially at the  corner of the mouth or anus, causing pain
  39. What is Clutton's joint?  [AI 95,BHU 02,UP 94]
    Clutton's joint is a late manifestation of congenital syphillis that typically develops between ages of 8-15 years. It is caused by chronic painless synovitis  with effusion of large joints, particularly the knees and elbows.

    (In Charcot's osteodystrophy and Clutton's joint, there is no pain)
  40. Which perinatal infections are delivered vaginally, which need CS?
    • Vaginal delivery:
    • - GBBS,
    • - Toxoplasmosis,
    • - Rubella,
    • - CMV 

    • C/S:
    • - Varicella/HSV,
    • - HIV
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Obstetrics 14