Download Varicella Infection

Systemic
Infections in
Pregnancy
Dr. Jasmin Sapanghila-Tamon
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Varicella
Rubella
Hepatitis B
Syphilis
HIV
Varicella Infection
Varicella Infection
• DNA Herpesvirus
• Primary infection causes
varicella (chickenpox)
• Recurrent infection causes
herpes zoster (shingles)
Pathogenesis and Clinical Features
• Incubation period 14-16 days
• Mild prodrome for 1-2 days
• Maculopapular rash
generally appears first
on the head;
most concentrated on trunk
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
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.
Diagnostic Test:
• Determination of V-Z virus
though Complement Fixation
Test
• Determination of V-Z virus
through Electron Microscopic
examination of vesicular fluid
Complications:
• Secondary infection of the
lesions – furuncles, cellulites,
skin abscess, erysipelas
• Meningoencephalitis
• Pneumonia
• Sepsis
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
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;25:605-609.
Fetal Effects of Varicella
• No infection
• Infection
– Congenital Varicella syndrome
– Neonatal varicella infection
– Infant herpes zoster
Transmission to the Fetus
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<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
Congenital Varicella syndrome
• Damage to sensory nerves
• Damage to optic nerve and lens
vesicles
• Damage to cervical
and lumbosacral
cord
• Damage to brain
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
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
Exposure Criteria for Use of
VZIG:
1. Continuous household contact
2. Playmate/officemate contact >1hour
indoors
3. Hospital contact – adjacent bed or
infected staff member
4. Newborn of infected mother – from
5days before to 2days after delivery
AND
5. Time lapse from exposure is less than
96 hours
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; 1548-1551.
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
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.
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
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.
Rubella
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)
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
• 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 57 days of the rash
Rubella
• Risk of congenital defects:
– </=12 weeks AOG: 80%
– 13-14 weeks AOG: 54%
– 15-28 weeks AOG: 25%
Congenital Rubella Syndrome
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Eye defects
Heart disease – PDA
Sensorineural deafness
CNS defects
Pigmentary retinopathy
Purpura
Hepatosplenomegaly and
jaundice
• Radiolucent bone disease
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
WHO Recommendation
• All countries to assess their
rubella status and introduce
immunization and surveillance,
if appropriate
Rubella
• Do serum rubella IgG on all
pregnant patients
• If patient is seronegative to
rubella, give rubella vaccine
postpartum
Counseling and Management
• Pregnant women with confirmed
rubella infection must have
proper counseling about the
risks and types of congenital
anomalies
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
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.
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.
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.
Hepatitis B
• 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
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
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
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
Diagnosis
HBs
Ag
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
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
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%
Hepatitis B
TREATMENT
Acute Hepatitis B
• primarily supportive on an
ambulatory basis with bed rest
• High protein diet
• Avoidance of hepatotoxic drugs
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 noninfectious state
Prevention
• Hepatitis B immune globulin
(HBIG)
– 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
Hepatitis B
CDC National strategy to eliminate
transmision of HBV
1. Prevention of perinatal infection
2. Routine infant vaccination
3. Vaccination of previously
unvaccinated children and
adolescents through age 18
4. Vaccination of previously
unvaccinated adults at increased
risk for infection
Hepatitis B Post-Exposure
Prophylaxis
Percutaneous or
mucosal exposure to
HbsAg (+) blood or
body fluids that contain
blood
Sexual or needle sharing
contact of an HbsAg (+)
person
Administer Hepatitis B
vaccine and Hepatitis B
Ig
Victim of sexual
assault/abuse of a
perpetrator who is
HbsAg (+)
Administer Hepatitis B
vaccine and Hepatitis B
Ig
Administer Hepatitis B
vaccine and Hepatitis B
Ig
Hepatitis B Post-Exposure
Prophylaxis
Victim of sexual assault/abuse
of a perpetrator with unknown
HbsAg status
Administer Hepatitis
B vaccine
Percutaneous or mucosal
Administer Hepatitis
exposure to HbsAg (+) blood or B vaccine
body fluids that contain blood
from a source with unknown
HbsAg status
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
Syphilis
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
Stages
1. Primary – genital &extragenital
2. Secondary – bacteremia
involving all major organs
3. Latent – lack of clinically
apparent disease
4. Tertiary – 1-20 years after the
disease has become latent,
progressive damage involving
CV, muskuloskeletal and CNS
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
Secondary syphilis
Diagnosis
• Dark field microscopy of
secretions from chancre
demonstrate the spirochetes
Diagnosis
• Non Treponemal Tests:
– VDRL, RPR
- screening tests
- correlates with disease activity
- use to assess treatment
response
Diagnosis
• Treponemal Tests:
– FTA-ABS, TPHA
- confirmatory test
- remains positive for the
remainder of the patients’ lives
regardless of treatment or
disease activity
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
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
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
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
HIV
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
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
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
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
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
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
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)
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
Maternal and Fetal-Neonatal Infection
• transmission rates
20%
before 36 weeks
50%
days before delivery
30%
intrapartum
30-40%
during breastfeeding
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
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%
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 HIVinfected pregnant women regardless
of CD4+ T cell count or HIV RNA level
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
Management during Pregnancy
Antiretroviral agents:
1. nucleoside reverse transcriptase
inhibitors
2. non-nucleoside reverse
transcriptase inhibitors
3. protease inhibitors
4. fusion inhibitors – block HIV-1 cell
membrane binding and cell entry
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
Management during Pregnancy
• treatment failures
– nonadherence
– inadequate drug potency
– suboptimal levels of antiretrovirals
– viral resistance
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)
Prevention of Vertical
Transmission
• 2 principal approaches:
1. antiretroviral therapy
2. cesarean delivery
Prevention of Vertical
Transmission
TIME OF
ADMINISTRATION
Antepartum
Intrapartum
Neonate
ZIDOVUDINE REGIMEN
100 mg orally five times daily,
initiated at 14 to 34 weeks and continued
throughout pregnancy
intravenous zidovidine in a 1-hr initial dose
of 2 mg/kg, followed by a continuous infusion
of 1 mg/kg/hr until delivery
give syrup at 2 mg/kg every 6 hours for 6
weeks, begin at 8 to 12 hours after birth
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%
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
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
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
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