16- INTRAUTERINE INFECTIONS Quiz

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Questions and Answers

What is the primary microorganism responsible for vulvovaginal candidiasis (VVC)?

Candida glabrata

Aspergillus niger

Candida albicans (correct)

Candida tropicalis

Which of the following factors is NOT associated with an increased risk of vaginal colonization by C. albicans?

Immunosuppression

Chronic hypertension (correct)

Recent use of antibiotics

Pregnancy

What percentage of women will experience at least one episode of vulvovaginal candidiasis during their lifetime?

50%

25%

75% (correct)

90%

Which complication is NOT associated with vulvovaginal candidiasis during pregnancy?

Postpartum hemorrhage Signup and view all the answers

What is the main consequence of untreated early congenital syphilis?

Tertiary syphilis Signup and view all the answers

At what gestational week can T. pallidum begin to cross the placenta and infect the fetus?

Sixth week Signup and view all the answers

Which of the following is a clinical manifestation of vulvovaginal candidiasis (VVC) in pregnancy?

Pruritus Signup and view all the answers

What is one of the classic stigmata of late congenital syphilis?

Hutchinson teeth Signup and view all the answers

The vaginal pH in women with vulvovaginal candidiasis is usually:

Normal and around 4.5-5.0 Signup and view all the answers

Which disorder is primarily concerned with risk to the fetus rather than the mother?

Toxoplasmosis Signup and view all the answers

What is the risk of congenital syphilis associated with maternal primary and secondary syphilis?

50% Signup and view all the answers

Which of the following tests is most definitive for diagnosing early syphilis?

Fluorescent antibody test Signup and view all the answers

What congenital condition occurs in approximately 40% of neonates whose mothers have acute toxoplasmosis?

Toxoplasmosis infection Signup and view all the answers

When is the risk of congenital toxoplasmosis the greatest for the fetus?

First trimester Signup and view all the answers

Which of the following symptoms is NOT associated with congenital toxoplasmosis?

Hypertension Signup and view all the answers

What is the primary means of immunity to Toxoplasma gondii during pregnancy?

T lymphocytes Signup and view all the answers

Why is routine screening for toxoplasmosis in pregnancy not indicated?

Infection is usually asymptomatic Signup and view all the answers

What treatment is preferred for immunocompromised patients with toxoplasmosis?

A combination of sulfadiazine and pyrimethamine Signup and view all the answers

What percentage risk of perinatal death is associated with maternal primary or secondary syphilis?

50% Signup and view all the answers

What significant finding suggests severe fetal injury if confirmed by amniocentesis for toxoplasmosis?

Specific findings on targeted ultrasound examination Signup and view all the answers

What is the primary reason for treating acute toxoplasmosis during pregnancy?

To reduce the risk of congenital infection Signup and view all the answers

Which combination of drugs is used for the aggressive early treatment of infants with congenital toxoplasmosis?

Pyrimethamine, Sulfadiazine, and Leucovorin Signup and view all the answers

What action should pregnant women take regarding cat litter to reduce the risk of toxoplasmosis?

Avoid contact with cat litter if possible Signup and view all the answers

What is the most extensively tested prophylactic treatment for pregnant women exposed to varicella?

Intramuscular varicella-zoster immune globulin (VZIG) Signup and view all the answers

What should be assessed in pregnant women who are uncertain of prior exposure to varicella?

Anti-VZV IgG assay Signup and view all the answers

What is a notable complication associated with acute varicella infection during pregnancy?

Congenital anomalies Signup and view all the answers

When does the risk of fetal anomalies increase with maternal varicella infection?

From weeks 13 through 20 of pregnancy Signup and view all the answers

Which ultrasound finding is NOT associated with congenital varicella damage?

Polyhydramnios Signup and view all the answers

What is the classification of the varicella-zoster virus?

Double-stranded DNA virus Signup and view all the answers

What treatment should be administered if a pregnant patient develops varicella despite prophylaxis?

Oral acyclovir or valacyclovir Signup and view all the answers

Study Notes

Intrauterine Infections

Infectious disease is the most common problem for obstetricians.
Urinary tract infections, endometritis, and mastitis primarily affect the mother.
Group B streptococcal (GBS) infection, herpes simplex virus (HSV) infection, rubella, cytomegalovirus (CMV) infection, and toxoplasmosis pose risks to the fetus and newborn due to potential complications.

Candidiasis (Monilial Vaginitis)

Vulvovaginal candidiasis (VVC) is primarily caused by Candida albicans.
Approximately 75% of women will experience at least one episode of VVC in their lifetime.
Predisposing factors include diabetes, pregnancy, obesity, recent antibiotic/steroid use, and immunosuppression.
Symptomatic VVC affects 15% of pregnant women.
Congenital candidiasis typically manifests within the first 24 hours after birth, often resulting from intrauterine infection or heavy maternal vaginal colonization during labor and delivery.
VVC is not associated with preterm birth, preterm labor, low birth weight, or premature rupture of membranes (PROM).
Vaginal pH in women with VVC is typically normal (<4.5).
Clinical manifestations during pregnancy include pruritus, burning, dysuria, dyspareunia, and fissures.
Congenital candidiasis can range from superficial skin infection to severe systemic disease with hemorrhage and organ necrosis.

Trichomoniasis

Trichomonas vaginalis is a common cause of vaginitis, often characterized by pruritus, strong odor, and dysuria.
Discharge is typically malodorous, yellow-green, and frothy.
An increased rate of premature rupture of membranes (PROM) at term is associated with positive T. vaginalis genital tract cultures.
T. vaginalis infection at mid-pregnancy is significantly associated with low birth weight, preterm delivery, and PROM.

Bacterial Vaginosis

Gardnerella vaginalis is present in 95% of bacterial vaginosis (BV) cases and in 30-40% of healthy women.
Mycoplasma hominis is also frequently present in vaginal secretions in cases of BV.
BV is the most common type of infectious vaginitis.
10-30% of pregnant women meet the criteria for BV, although half are asymptomatic.
BV is consistently associated with an increased likelihood of preterm delivery, clinical chorioamnionitis, histologic chorioamnionitis, and endometritis.

Gonorrhea

Gonorrhea, caused by Neisseria gonorrhoeae, is a significant concern in pregnancy.
The endocervix is the primary site of infection.
Symptoms typically include vaginal discharge and dysuria.
Maternal gonorrhea is associated with disseminated gonorrheal infection (DGI), amniotic infection syndrome, and perinatal complications such as preterm PROM (pPROM), chorioamnionitis, preterm delivery, intrauterine growth restriction, neonatal sepsis, and postpartum endometritis.
Disseminated gonococcal infection (DGI) is an important presentation of gonorrhea in pregnancy, especially during the second and third trimesters.
Neonatal gonococcal ophthalmia occurs when newborns pass through an infected cervical canal, with a frank purulent conjunctivitis usually affecting both eyes.
Amniotic infection syndrome is an additional manifestation of N. gonorrhoeae infection in pregnancy; this condition is characterized by placental, fetal membrane, and umbilical cord inflammation occurring after premature rupture of membranes (pPROM)

Chlamydial Infection

Chlamydia trachomatis is the most common bacterial STD among pregnant women, with a prevalence ranging from 2% to 3%.
Chlamydia infection during pregnancy is associated with adverse maternal outcomes (preterm delivery, pPROM, low birth weight, and neonatal death), and can cause neonatal conjunctivitis or pneumonia.
Infants of mothers with untreated chlamydial infection have a 60-70% risk of acquiring the infection during delivery.
25-50% of exposed infants show conjunctivitis within 2 weeks.
10-20% of exposed infants develop pneumonia within 3-4 months.
Controversy exists regarding an association between maternal cervical C. trachomatis infection and adverse pregnancy outcomes.

Human Papillomavirus Infection

HPV is a double-stranded DNA virus.
Average incubation period: 2-3 months.
Primary transmission route is sexual.
Urogenital and anorectal infections are common.
Perinatal transmission, especially HPV types 6 and 11, can occur during pregnancy.
Whether maternal cervical C. trachomatis infection is associated with adverse pregnancy outcome is a subject of ongoing debate; some studies show association but with conflicting results.

Transplacental and Intrapartum transmission of HPV

HPV DNA has been detected in 11 neonates born vaginally to HPV-positive women.
All tested infants were negative for HPV by 5 weeks after birth and remained so for 18 months.
It's unknown if cesarean delivery prevents juvenile-onset recurrent respiratory papillomatosis.

Urinary Tract Infection

Women are 14 times more likely to develop UTIs than men.
UTIs in pregnancy place the fetus and mother at risk for substantial morbidity and even mortality.
Asymptomatic bacteriuria (ASB): The presence of 10⁵ or more colonies of bacteria per milliliter of urine on two consecutive clean-catch, midstream-voided specimens in the absence of signs or symptoms of UTI.
Rates of neonatal death and prematurity were two-to three-fold greater in bacteriuric pregnant women receiving a placebo compared to nonbacteriuric women or bacteriuric women who had their infection eliminated with antibiotics.
Prevalence varies between 2% and 11% in pregnant women.
Associated with low birth weight and preterm delivery.

Chorioamnionitis

Bacterial infection of the amniotic cavity is a major cause of perinatal mortality and maternal morbidity.
Significant associations are found between chorioamnionitis and long-term neurologic development in newborns (eg., cerebral palsy).
Clinical chorioamnionitis occurs in 0.5–10% of pregnancies (fever, uterine tenderness).
Histologic chorioamnionitis is more frequent than clinically evident infection.
Infection is observed more often in preterm than term births, ranging up to 20% of term births and over half of preterm births.
With the onset of labor or rupture of membranes, bacteria from the lower genital tract can reach the amniotic cavity.

Listeriosis

Listeriosis is an infection by Listeria monocytogenes (motile, non-spore-forming, gram-positive bacillus).
Concerns for obstetricians include association of maternal listerial infection with stillbirth, preterm labor, fetal infection, high perinatal mortality.
Neurologic sequelae, like hydrocephalus and mental retardation, are common in late-onset disease.
Ascending infection from cervical colonization by L. monocytogenes may play a role in neonatal infection.
Affected patients exhibit a flu-like syndrome (fever, chills, malaise, myalgias, back pain, upper respiratory symptoms).
A Gram stain revealing gram-positive, pleomorphic rods with rounded ends in febrile pregnant women is highly suggestive of L. monocytogenes.
Penicillin G and ampicillin are effective against L. monocytogenes.

Mumps

Mumps is an acute, generalized, non-exanthomatous infection affecting the parotid and salivary glands.
Mumps in pregnant women is generally benign and no more severe than in nonpregnant women
First trimester mumps is associated with a twofold increase in spontaneous abortion.
No association with preterm delivery, fetal growth restriction, or perinatal mortality
Whether mumps infection results in congenital disease is controversial.

Parvovirus Infection

Parvovirus B19 is the causative agent.
Maternal parvovirus infection during pregnancy can cross the placenta, infecting fetal bone marrow red blood cell progenitors.
Suppresses erythropoiesis, leading to severe anemia and high-output congestive heart failure.
Fetal myocarditis can result, further contributing to heart failure.
The most obvious manifestation of congenital infection is hydrops fetalis.
Peak systolic blood flow measurement in the fetal middle cerebral artery (MCA).
If velocimetry indicates fetal anemia, cordocentesis for fetal hematocrit determination and potential intrauterine blood transfusion are warranted.

Rubella

Rubella is an RNA virus.
Common clinical manifestation: widely disseminated, nonpruritic, erythematous, maculopapular rash.
Serum IgM antibody levels peak 7–10 days after onset and decline over 4 weeks.
Congenital rubella syndrome (CRS) incidence has dramatically decreased due to successful vaccination campaigns.
Approximately 10–20% of women remain susceptible, and their fetuses are at risk for serious injury if infection occurs during pregnancy.
50% of fetuses exposed in the first trimester or less will manifest signs of congenital infection.
Infection risk is substantially lower if infection occurs after the 18th week of gestation.
CRS is associated with specific anomalies (deafness, eye defects, CNS defects, cardiac malformations).

Treatment for Congenital CMV Infection

Currently, there's no consistently effective therapy for congenital CMV infection.
Hyperimmune globulin (Cytogam, CSL Behring) was shown effective, in a 2005 study, as treatment and prophylaxis.

Herpes Simplex Virus (HSV) Infection

HSV can infect the mother, newborn, or fetus in rare cases.
Newborns, with their underdeveloped immune systems, are susceptible to systemic and frequently lethal disease.
In adults, HSV commonly causes infection of the oral cavity, skin, and genital tract.
Genital herpes is transmitted through sexual contact.
Transplacental infection leading to congenital infection is rare, with documented incidences limited.
Maternal HSV infection and the avoidance of fetal exposure through cesarean delivery are key concerns.
PCR to detect HSV DNA is often the most helpful diagnostic test.
Acyclovir (400 mg orally three times daily) is highly effective for primary and recurrent HSV infection.

Human Immunodeficiency Virus (HIV) Infection

HIV is a single-stranded, enveloped RNA retrovirus.
The Centers for Disease Control and Prevention (CDC) recommends universal HIV screening in pregnant women.
In the absence of intervention, perinatal HIV transmission is approximately 25% and primarily occurs during delivery.
Postnatal transmission from breastfeeding is possible.
Preterm delivery, severe maternal illness, and intrapartum blood exposure are among the key risk factors.
Prophylactic zidovudine is highly effective in reducing perinatal HIV transmission (from 26% to 8%).
If viral load is <1000 copies/mL, vaginal delivery is acceptable.

Group B Streptococcal (GBS) Infection

Streptococcus agalactiae (GBS) is a bacterium, commonly implicated in obstetric infections.
Streptococcus pyogenes (Group A) has been recognized as a pathogen in perinatal infections.
GBS is responsible for 1–5% of UTIs in pregnant women, and plays a role in chorioamnionitis and puerperal endometritis.
Neonatal sepsis develops in only 1% of infants of colonized mothers.
Key risk factors for GBS neonatal sepsis include prematurity, maternal intrapartum fever (possibly due to chorioamnionitis), prolonged rupture of membranes (>18 hours), and a prior infant with GBS disease, plus GBS bacteriuria.

Treatment of GBS Infection (in pregnancy)

Recommended drug: Penicillin G (5 million units initially, then 2.5-3.0 million units every 4 hours IV until delivery).
Alternative: Ampicillin (2 g IV initially, followed by 1 g every 4 hours).
Intravenous antibiotics are given during labor or rupture of membranes if exposure is present or if the result of a GBS culture is unknown.
No prophylaxis is indicated before labor/rupture of membranes (ROM) in a cesarean delivery.

Toxoplasmosis

Toxoplasma gondii is a protozoan parasite with three developmental stages (tropozoite, cyst, oocyst).
Transmission occurs mainly through ingestion of infected meat or oocysts in cat feces.
Clinically significant Toxoplasmosis during pregnancy is rare (1 in 8000 pregnancies).
Primarily transmitted through T-lymphocytes.
Routine screening for toxoplasmosis in pregnancy is not recommended.
Serologic tests for acute infection include IgM detection, extremely high IgG titer documentation, and IgG seroconversion.
Congenital infection is most likely following maternal infection during the third trimester, with a higher fetal injury risk in the first trimester.
Clinical manifestations of congenital toxoplasmosis include disseminated purpuric rash, splenomegaly, hepatomegaly, ascites, chorioretinitis, uveitis, periventricular calcification, ventriculomegaly, seizures, and mental retardation.

Varicella-Zoster Virus (VZV) Infection (chickenpox)

Varicella zoster virus (VZV) is a DNA organism belonging to the herpesvirus family.
Varicella (chickenpox) is a concern in pregnancy due to its risk to mother, fetus, and newborn.
Varicella typically occurs in approximately 1–5 cases per 10,000 pregnancies.
Lesions typically progress in crops from papules, vesicles, to pustules, then crusting over into dry scabs.
Pregnant women should be screened for prior varicella exposure during their first prenatal appointment.
Exposure in susceptible women should receive treatment within 72-96 hours with either intramuscular Varicella-zoster immune globulin (VZIG) or oral acyclovir (800 mg 5 times daily) or valacyclovir (1000 mg 3 times daily) for 7 days in order to prevent active infection.
Pregnant women who develop varicella despite prophylaxis should be treated with the same doses indicated above.
Acute varicella infection during pregnancy can lead to spontaneous abortion, intrauterine fetal death, and congenital anomalies.
Fetal anomalies are rare but have been diagnosed in the first 12 weeks of pregnancy, and 2% or less after the 13th week.
Ultrasound can evaluate for intrauterine growth restriction, microcephaly, ventriculomegaly, echogenic foci in the fetal liver, and limb anomalies.

Viral Influenza

Influenza is caused by an RNA virus in the myxovirus family.
Maternal influenza is a significant concern in pregnancy primarily because of the associated increased risk of life-threatening pneumonia in the pregnant woman.
The influenza virus is not associated with increased risk of spontaneous abortion, stillbirth, or congenital anomalies.
Infection and fetal outcome frequency is less than 1% in weeks one through 12 and 2% or less after week 13 through 20.

Viral Hepatitis A

Hepatitis A is an RNA virus transmitted via the fecal-oral route.
Diagnosis is confirmed by detection of IgM antibodies specific to Hepatitis A virus.
Perinatal transmission is rare.

Viral Hepatitis B

Hepatitis B is a DNA virus transmitted through parenteral and sexual contact.
Approximately 20% of seropositive mothers transmit the virus to their neonates in the absence of intervention.
Neonates should receive Hepatitis B immune globulin (HBIG) and the hepatitis B vaccination series within 12 hours of birth and before discharge from the hospital.

Other infections

Other mentioned infections (mumps, rubella, syphilis).

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