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what are the 3 ways infections can be transmitted from mother to child?
- in utero: transplacentally
- intrapartum: during birth
- neonatal period: post partum - breast feeding
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what are 2 ways of prenatal diagnosis of congenital infection and the risk of fettle death with each?
- amniocentesis: 1%
- percutaneous umbilical cord sampling: 1-2%
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what are the 4 congenital viral infections?
- rubella
- parvovirus B19
- VZV
- CMV
- (remember the first 2 go together and the last 2 are herpesviruses)
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which 7 infections can be acquired during birth? split into 2 categoris
- BBV: HIV, Hep B, Hep C, HTLV
- local infection genital tract: HSV, HPV, VZV
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which 4 tests are done as routine antenatal testing at booking for infections?
- rubella IgG: check immunity (should have IgG)
- HIV Ab/Ag test
- Hep B: look for sAg
- syphilis
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what is the risk to the fetes with maternal rubella infection and when is this a problem?
- first trimester infection
- congenital rubella triad: cardiac, ophthalmic, auditory
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what is the congenital rubella triad?
- cardiac: patent ductus arteriosus
- ophthalmic: cataracts
- auditory: sensorineural deafness
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what are the 2 mechanisms of pathogenesis of fetal damage in rubella infection?
- virus induced tissue damage
- virus induced retardation of cell division
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how do you diagnose maternal rubella infection?
rubella IgM, IgG
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how do you diagnose fettle rubella infection ie pre natal?
- cord blood
- rubella IgM
- nucleic acid test
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how do you diagnose rubella infection in neonate?
IgM
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how does the damage on the fetes differ according to trimester?
- 1st trimester: severely damaged, congenital rubella triad
- 11-20 weeks: deafness only
- after 20 weeks: no documented fettle damage
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how do you manage rubella infection in pregnancy?
no anti viral drug
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how to prevent rubella infection?
universal childhood immunisation: MMR
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which other disease has a similar presentation to rubella?
- parvovirus B19
- so always check blood for both
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what are the other names for parvovirus B19 infection?
- slapped cheek disease
- fifth disease
- erythema infectiouum
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what is the main risk to fetes in parvovirus B19 infection? and when is this risk important?
- 1st 20/40 weeks
- hydrops fetalis: oedema in >2 compartments
- fettle loss/ intrauterine death
- highest in 2nd trimester
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why do you get hydrous fettles in parvovirus B19
- due to severe anaemia due to infection and lysis of erythroid progenitor cells due to B19
- fetal viral myocarditis
- the anaemia causes heart failure and so get oedema
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what are the 2 important causes of anaemia in fetes?
- parvovirus B19
- rhesus disease of the newborn
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how do you make diagnosis of B19 in mother?
B19 IgM and IgG seroconversion
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how do you diagnose B19 in fetes?
- parvovirus DNA detected by dot blot and PCR (B19 NAT)
- check fettle Hb for anaemia
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how do you treat B19 infection?
- no specific antiviral
- serial US scan to detect hydrops (see ascites, pulm oedema..)
- intrauterine fettle blood transfusion if severe anaemia
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what is the most common congenital infection?
CMV
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what are the features of CID? (top to toe all systems)
- cytomegalic inclusion disease
- skin: petechiae (due to thrombocytopenia)
- head: microcephaly
- brain: seizures
- eyes: choroidoretinitis
- lungs: pneumonitis
- abdo: jaundice, hepatosplenomegaly
- overall size: small for gestation
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what 3 things do you find in blood tests for CID?
- 1. low platelets
- 2. high transaminase
- 3. high conjugated biliruin
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what is the prognosis like in CID?
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what are the major sequalae of CID?
- neuro
- mental retardation
- spastic diplegia
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what % of women of childbearing age are CMV seropositive?
60%
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what are signs of primary infection?
- asymptomatic
- glandular fever like
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how is CMV transmitted?
- transplacentally
- during birth
- via breastfeeding
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during which part of pregnancy can CMV infection cause fettle damage? and what is transmission rate? what does this depend on?
- throughout pregnancy
- 40% transmission rate
- if it is mothers PRIMARY INFECTION
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what % of neonates with Congeintal CMV infection get severe symptoms?
- 7% get CID
- 14% are asymptomatic at birth but later get hearing defects and impaired intellectual performance
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how is diagnosis of maternal CMV infection made?
Ab seroconverion and IgM (ie was IgG -ve now IgG+)
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how is CMV diagnosed in fetes?
- abnormal fetus
- quantify CMV NA in amniotic fluid as CMV is shed in urine
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how do you make post natal diagnosis of CMV?
CMV in urine of newborn
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how is Congenital CMV managed?
- in pregnancy discuss prognosis (bad)
- no safe antiviral
- however gangiclovir if CNS disease and will stop deafness but TOXIC!
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what is the main worry to mother about getting chickenpox in pregnancy?
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what are consequences to fetes of maternal varicella? and when in preg?
- fetal varicella syndrome in 1st and 2nd trimester
- LENS
- lymb hypoplasia
- eye defects
- neuro abnormalities
- skin scarring in a dermatomal distribution
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what is risk of varicella in 2nd/3rd trimester?
ZOSTER ie shingles in infancy as low immune system
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what is risk of varicella around delivery?
- risk of neonatal varicella which is severe chickenpox
- risk of pneumonitis
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what is the risk of zoster in pregnancy to fetes?
- no risk to fetes
- unless mother is immunosuppressed or shingles is disseminated
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how do you diagnose chickenpox in mothers and post natal babies?
- clinical: typical rash
- culture: EM, VZV NAT (remember no antibodies)
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how do you diagnose chickenpox in fetes?
- ultrasound examintion
- VZV NAT in amniotic fluid?
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if a mother has chickenpox or shingles in pregnancy how to treat?
aciclovir safe in pregnancy
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if mother has contact with someone else with shingles or chickenpox then how to treat, what does it depend on?
- depends if had chickenpox in past
- give VZIg for susceptible within 10 days of contact
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how do you treat maternal chickenpox at birth?
VZIg for neonate
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what must all HCW have had if haven't had chickenpox before?
VZV vaccination
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which 2 bacterial agents are important congenital/neonatal infections?
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what is GBS normal flora of?
- GI tract
- 30% intermittent vaginal colonisation
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what are the 2 forms of neonatal infection with GBS?
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what defines early onset GBS infection?
within 48 hours of birth
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what is the clinical feature of early GBS infection?
septicaemia
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how is early onset GBS acquired?
passage through colonised birth canal
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what are risk factors for early onset GBS?
- prematurity as fragile skin, poor immune system
- prolonged ROM as baby has easy access to bacteria in birth canal
- maternal pyrexia indicated more virulent strain and mum hasn't made Ab so none passed to baby
- previous infected baby
- documented GBS during pregnancy: should give prophylaxis
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what is difference in mortality between early and late onset GBS infection?
- early has high mortality
- 10% overall
- late has only 5% mortality
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what defines late onset GBS infection?
> 1 week after birth
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what is the clinical feature of late GBS infection?
meningitis
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how is late GBS transmitted?
- from genital tract
- transmitted by CARERS post nattily
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what are the 2 risk factors for late onset GBS infection?
- prematurity
- procedures/manipulation
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what are the long term effects of late onset GBS?
- longterm neurological sequalae
- learning difficulties
- hearing loss
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how is GBS diagnosed?
culture of blood urine CSF surface swabs
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what is management of GBS infection?
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if a mother has risk factors for GBS infection, what is done to prevent GBS in neonate?
- intrapartum antibiotics: amoxicillin or if pen allergic clindamycin
- monitor baby for sepsis
- strict infection control on SCBU, NICU
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what is treatment to baby with GBS?
iv penicillin and gentamicin
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what is the name of the GBS organism?
streptococcus agalactiae
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which group of strep is GBS?
B haemolytic group B strep
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which organism causes listeriosis?
listeria monocytogenes
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where is listeria found?
unpasturised animal produce eg pate, soft cheeses
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what temp does listeria multiply at?
refrigeration temperatures
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what are risks to fetes of maternal listeria if transplacental infection?
- fettle death
- prematurity
- septicaemia
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what are risks to fetes if intrapartum infection?
- septicaemia or meningitis
- within 2 weeks
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what is mortality of listeria infection in neonate?
50%!!!
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how is listeria diagnosed in mother?
blood cultures
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how is listeria diagnosed in neonate?
- CSF, meconium, blood, urine
- placenta
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what does placenta of listeria infection look like?
moth eaten due to micro abscesses
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what is treatment of listeria infection?
iv amoxicillin 3 weeks and gentamicin 1 week
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how to prevent listeria infection in mothers?
- dietary regulation
- avoid aborted animal foetuses ie female farmers and farmers wives be careful!
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what is the infectious eye problem worry about in neonates?
- ophthalmia neonatorum
- infectious neonatal conjunctivitis
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what are organisms that cause ophthalmia neonatorum?
- N gonorrhoea: G-ve diplococci
- C trachomatis
- S aureus
- S pneumo
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when and how does gonococcal ophthalmia neonatorum present?
- within 5 days of birth
- purulent discharge
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how do you diagnose GC ophthalmia neonatorum?
microscopy and culture of eye swab
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what is treatment of GC ophthalmia neonatorum?
systemic benzylpenicillin OR cefotaxime
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when does chlamydial ophthalmia neonatorum present and how?
- 6-21 days after birth
- mucopurulent discharge, watery bloody discharge
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how is chlamydial ophthalmia neonatorum diagnosed?
NAAT on eye swab
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what is treatment for chlamydial ophthalmia neonatorum?
systemic erythromycin and topical tetracycline
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who else must be treated in ophthalmia neonatorum?
parents (STD)
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what 2 diseases can chlamydia trachoma's cause in neonates?
- conjunctivitis
- pneumonitis
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why is chlamydial pneumonitis underdiagnosed? what are symptoms and treatment?
- mild symptoms
- dyspnoea and staccato cough
- Rx: erythromycin
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what is long term risk of pneumonitis?
30% develop asthma
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what is name of organism for congenital toxoplasmosis?
toxoplasma gondii
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which animal is toxoplasma assoc with?
cats
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what kind of organism is toxoplamsa?
protozoan parasite
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what is mode of transmission for toxoplasma to fetes? and how does that affect fettle infection and damage?
- transplacentally
- 1st T: low infection, high damage
- 2nd T: 50:50
- 3rd T: high infection as large placenta but little damage
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what are main consequences to fetes in congenital toxoplasmosis?
- abortion or still birth
- if live birth: classical triad of: intracranial calcification, hydrocephalus, choroidoretinitis
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what are the more common signs of congenital toxopl?
- encephalitis
- epilepsy
- mental and growth retardation
- jaundice
- hepatoplenomegaly
- thrombocytopenia
- rash
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which organ is most affected by congen toxopl?
EYES - choroidoretinitis can even be picked up later in life
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how is toxoplasma infection diagnosed in mother?
- infection often asymptomatic
- serology but IgM can stay positive for 3 years!
- rely on combo of IgG, IgM, IgA and AVIDITY
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which special serological test do you do in toxoplasmosis?
- avidity ie how avid is the Ab being that brings to toxoplasma
- high avidity means infection was >6/12 ago
- low avidity: RECENT infection
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how is fettle infection with toxoplasma diagnosed?
- imaging see damage
- PCR on amniotic fluid
- post natal serology until 12 months
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what are 2 options of treatment for congenital toxoplasmosis?
- termination
- treatment during pregnancy: sulphadiazine/pyrimethamine/folinic acid alternating with spiramycin
- neonate: sulphadiazine/pyrimethamine/folinic acid for 1 year
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what is important to FU in toxoplasmos infection?
eyes
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what advice do you give to prevent toxoplasmosis?
- avoid undercooked meats and uncooked vegetables
- avoid cat litter!
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what is the transmission rate if a mother has early untreated syphilis?
70%
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how is transmission of syphilis during pregnancy reduced?
treat syphilis!
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what are signs of early congenital syphilis?
- signs of secondary syphilis
- skin: condylomata lata, rashes
- skeletal: osteochondritis, periostitis
- organs: hepatosplenomeg, GN, CNS, eye
- blood: haemolysis, low plt
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what are late manifestations of congenital syphilis?
- interstitial keratitis: cloudy cornea
- hutchinson's teeth: notched incisors
- clutters joints: large malformed as inflamed
- gummatous involvement
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what is the ANC screening test for syphilis?
- EIA (specific for treponema)
- if EIA positive then do TPPA, RPR, IgM
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what is antenatal management of penicillin?
- im procaine penicillin for 10 das
- or 1 dose benzathine penicillin im stat
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what tests are done to neonates to screen for syphilis?
- serology IgM
- darkfield microscopy of skin lesions
- repeat serology up to 1 year
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how is infected neonate managed?
iv or im penicillin for 10 days
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2 day old neonate born after premature ROM is febrile and has convulsions, what is differential for organism?
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which 2 Ix do for febrile convulsions
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what Rx start?
- ben pen and gent
- add amox if suspect listeria
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