Got it from your Mama
(Maternal findings)
(Maternal findings)
The most common perinatal viral infection leading to neonatal/congenital disease?
What is CMV?
Cytomegalovirus affects 1% of live births.
Primary maternal infection associated with 30-50% transmission rate. Reactivation/secondary infection 0.15-1% transmission.
A pregnant patient's 2y/o son comes home from daycare with a fever, rhinorrhea, & red cheeks. 2 months later, the fetus is found to have hydrops fetalis most likely caused by _____ one of the TORCH “Other” infections (Hint: aka fifth disease).
Parvovirus B19 is the most frequent infectious cause of fetal non immune hydrops fetalis
Next steps: Serologic testing for IgM + IgG
What is the best way to prevent the transmission of cytomegalovirus?
Hand-washing
These 2 TORCH infections are vaccine preventable. (Hint: both are live vaccines)
What are: Rubella and Varicella?
Both are LIVE vaccines and cannot be given in pregnancy.
A pregnant mother has 1-2 days of flulike symptoms. These resolve, but she then develops a pruritic vesicular rash at 15 weeks, which then resolves.... What congenital TORCH infection is her infant at high risk of?
Congenital Varicella: can result in fetal limb atrophy, FGR, skin lesions, hydrocephaly, hydronephrosis, microcephaly, eye abnormalities (chorioretinitis/microphalmia). High risk of transmission 13-20 weeks gestation.
Maternal sx 5 days before birth to 2 days PP = 25%-50% chance newborn will catch varicella, & high neonatal mortality rate (30%)
Reactivation infection (ie shingles) alone in pregnancy is NOT associated with causing congenital infection.
Name 2 modes of transmission for congenital infections?
Modes of Vertical Transmission:
Intrauterine: Trans-placental (cross via placenta), Ascending infections
Intra-partum: birth canal exposure during vaginal delivery, external contamination (after ROM), blood-borne infections
Postpartum/Neonatal: Blood-borne infections, Breastmilk, Human transmission
When should you screen a pregnant patient for varicella zoster virus?
No prior history of chickenpox, or has not gotten both doses of their varicella vaccine (live vaccine- cannot be given in pregnancy). Note: transmission highest risk with a primary maternal varicella infection between 13-20 wks gestational age.
True or False: A *low* maternal anti-CMV IgG avidity level in someone in their third trimester would indicate transmission occurred during pregnancy
TRUE! Infection likely occurred within the last 6 mo
Diagnosis : IgG seroconversion (previously negative, now positive) OR CMV IgM +'ve, IgG +'ve, and low IgG avidity.
Gold standard dx: Amniocentesis for CMV NAAT at least 6-8wks after maternal infection and >21wks
True or false: It is safe to receive MMR (for Rubella) or Varivax (for VZV) are both safe to give in patients who are breastfeeding?
TRUE! Do not delay vaccination because of breastfeeding.
Name any one of the TORCH infections most often associated with congenital/neonatal hearing loss.
What are CMV and Rubella? (and syphilis)
True or False: Pregnant patients will always demonstrate clinical symptoms of congenital TORCH infections.
FALSE! Many patients can be asymptomatic, and findings suggestive of fetal congenital TORCH infection first appear on prenatal screening or US findings.
A 36 year old G3P2 presents to triage 3 days prior to her scheduled induction because of a vesicular unilateral rash on her mid-back that is incredibly painful. She has a history of childhood chicken pox. Is the fetus at risk of developing congenital varicella?
No - symptoms consistent with reactivation VZV or herpes zoster / shingles which causes a unilateral dermatomal vesicular eruption.
No evidence that herpes zoster infection causes congenital infection. Can treat with oral acyclovir therapy and management of symptoms.
What is the neonatal mortality rate for infants who contract congenital herpes simplex virus (HSV)?
A) 50% B) 25% C) 10% D) 89%
A) 50%
A G1P0 pt is seen at 34 weeks. Pregnancy has been uncomplicated, besides a PMHx of HSV-2, with one genital outbreak earlier in pregnancy. What would you recommend if she is planning for a vaginal delivery?
Antiviral suppression starting at 36 weeks (min. 2 weeks prior to, up until delivery)
Acyclovir 400mg TID OR Valacyclovir 500mg BID
Vaginal delivery is contraindicated if there is an active genital outbreak/lesions.
Congenital _____ can result in saber shins, saddle-shaped nose, Hutchinson's teeth, and deafness.
What is Syphilis
True or false: Only HSV-2 is associated with genital lesions.
False: BOTH HSV-1 and HSV-2 can cause genital lesions, although the HSV-2 strain is more associated with genital lesions.
A pregnant patient runs a daycare was told one of the children tested positive for Parvo-B19. She asks to be tested. Her initial serologies come back and show: IgG negative, IgM negative. Next step is A) no further follow up needed B) Repeat test in 2-4 weeks C) US with MCA dopplers
B) Repeat test in 2-4 weeks. High risk : Patients with children <3 or daycare workers. IgG indicates long term immunity/prior inf., IgM indicates immediate immune response
Both negative = no immunity, but not positive for infection (at this time) --> If IgG- &IgM+ OR if IgG+ and IgM+ then US+MCA Doppler Q2wks for 10 weeks post infection
What trimester is associated with worse outcomes for primary maternal rubella infection?
1st trimester = high risk of SA & severe congenital malformations (organogeneisis)
If rash/maternal sx at
12 wks = 90% transmission rate
13-14wks = 54%
>20wks = rare to get severe neonatal deficits
What is a treatment for Toxoplasmosis in pregnancy? (Hint: can be dependent on gestational age)
<18wks Spiramycin
>18wks Pyrimethamine + sulfadiazine + folinic acid
Intrauterine death from Parvovirus is mostly due to this complication (the underlying cause of hydrops fetalis).
What is fetal anemia?
What are some maternal symptoms associated with maternal syphilis infection?
Primary : Chancre (2-8 weeks)
Secondary : sx appear 4-10 weeks after primary infection
- palmar/planta rash, mucous patches, alopecia, condylomata, constitutional sx (fever/malaise/HA/myalgias)
- More severe = hepatitis, nephropathy, aseptic meningitis
Latent syphilis: reactive serological testing but no sx
Tertiary/Late syphilis: progressive, neurosyphilis
Me-OW! Sorry cat lovers: unsporulated oocytes of this protazoa within (mostly outdoor) cat feces/litter, if ingested by a pregnant person increases risk of preterm birth <37wks +/- congenital infection
What is: Toxoplasma gondii / Toxoplasmosis (can also be caused by undercooked meat)
Risk of transmission increases w gestational age: 13wks = 15%; 26wks=44%; 36wks 71%
Severity of fetal congenital infection is associated with earlier GA at the time of seroconversion/ primary maternal infection.
The likely diagnosis in a SGA baby found to have seizures, microcephaly, thrombocytopenia, hepatosplenomegaly and jaundice.
What is CMV? (same symptoms can be seen with congenital Toxo, but thrombocytopenia is not associated with Toxo)
Penicillin G is used for treatment of syphilis in pregnant women. What is the alternative treatments for syphilis are there for pregnant women who are allergic to penicillins?
TRICK QUESTION! No proven alternatives to penicillin G are available for treatment of syphilis during pregnancy. Steps: 1) confirm true penicillin allergy, 2) Penicillin desensitization treatment and subsequent treatment with penicillin G.
Name one of the 2 congenital TORCH infections that may be related to intracranial calcifications seen on fetal ultrasound.
What are: Toxoplasmosis (generally located cerebral) and CMV (periventricular calcifications)