MOD5-OB2-T9-Systemic Infections Affecting Pregnancy.pdf

OB2 OBSTETRICS 2 Systemic Infections Affecting Pregnancy TRANS 9...

OB2 OBSTETRICS 2 Systemic Infections Affecting Pregnancy TRANS 9 MODULE 5 Raizza Lezzette Peña-Cruz, M.D., FPOGS, FPIDSOG September 5, 2024 LECTURE OUTLINE Passive immunity transferred across the placenta I Maternal and Fetal Immunology 5 IgG Rapidly increases by 16 weeks AOG and A. Pregnancy-Induced Immunological Changes equals that of the mother by 26 weeks AOG B. Fetal and Newborn Immunology Protective against some infections until 2 II Systemic Viral Infections 6 Breastfeeding months of age A. Varicella Zoster Virus B. Rubella Maternal Primes the fetal cell-mediated immune 7 Vaccination response independent of passive immunity III Sexually Transmitted Illness A. Hepatitis B VERTICAL TRANSMISSION B. Human Immunodeficiency Virus Passage from the mother to her fetus of any infectious agent C. Sexually Transmitted Illnesses through the: 🧠 Must Know 📖 Book 📝 Previous Trans ○ Placenta ○ During labor or delivery ○ By breastfeeding I. MATERNAL AND FETAL IMMUNOLOGY Infections manifesting within 72 hours from birth are acquired in Infections remain to be a major cause of maternal and fetal utero or during delivery. morbidity and mortality worldwide. In maternal serological status, acquisition mode, gestational age at [HANDOUT] SYSTEMIC INFECTION AFFECTING PREGNANCY the time of infection, and immunological status of both mother and (page 1) fetus influence disease outcome. Horizontal Transmission A. PREGNANCY-INDUCED IMMUNOLOGICAL CHANGES ○ Spread of an infectious agent from one individual to another When a woman becomes pregnant there are certain Secondary Attack Rate pregnancy-induced immunological changes that occur: ○ Probability that infection develops in a susceptible individual ○ Increase in CD4 T-cells secreting TH2-type cytokines following known contact with an infectious person including interleukins 4,5,10, and 13. ○ Suppression of TH1-type cytokines including the interferon II. SYSTEMIC VIRAL INFECTIONS gamma and interleukin 2 This results in TH2 bias during pregnancy and affects CASE 23-year-old, G1P0, 10 weeks AOG ability to rapidly eliminate certain intracellular pathogens 1 during pregnancy. This explains why some viral and bacterial infections are Review of History more serious when acquired during pregnancy. Developed fever, colds, and joint pains [HANDOUT] SYSTEMIC INFECTION AFFECTING PREGNANCY Physical Examination (page 1) On her 3rd day of illness, she noted the following pruritic Decidual natural killer (dNK) cells interact with and aid invasion lesions: of fetal extravillous trophoblasts via human leukocyte antigen-G (HLA-G) Cytokines produced during viral infection activate dNK cells to induce protective cytotoxicity Regulatory T cells (Tregs) express forkhead box P3 (FOXP3) ○ An immune-suppressive transcription factor that plays a critical role in inducing maternal immune tolerance to the fetus ○ Also compromises maternal defense against bacterial pathogens Figure 1. Case 1 B. FETAL AND NEWBORN IMMUNOLOGY Video Lecture on Systemic Infections Affecting Pregnancy Part 1 At around 9–15 weeks AOG, fetal innate and adaptive immunity begins to develop. A. VARICELLA ZOSTER VIRUS TYPES OF IMMUNOLOGY PATHOGEN Innate Macrophages and dendritic cells VZV: Double-stranded DNA herpes virus 1 Immunity Adaptive B and T cells 2 Immunity Passive Provided by maternal IgG that is transferred 3 Immunity across placenta 4 IgM Primary fetal response to infection Figure 2. Varicella Zoster Virus Handout on Systemic Infections Affecting Pregnancy Group 6A | Systemic Infections Affecting Pregnancy 1 of 15 EPIDEMIOLOGY Acquired predominantly during childhood 95% of adults are serologically positive for immunity. TRANSMISSION Primary infection (Varicella/Chicken pox) ○ Direct contact with an infected individual ○ Respiratory transmission Herpes Zoster/Shingles ○ Reactivation of primary varicella infection ○ More commonly seen as compared to chicken pox and more common in adults ○ Incubation period: 10–21 days ○ Risk of acquisition: In a person not previously immune to the virus, there is 60–95% risk of infection after exposure. Figure 5. Multiple small round calcified lung lesions in plain radiograph. ○ Infective stage: 1 day before onset of the rash until all lesions Video Lecture on Systemic Infections Affecting Pregnancy Part 1 are crusted over HERPES ZOSTER/SHINGLES Reactivation of chickenpox Unilateral dermatomal vesicular eruption associated with severe pain Not more frequent or severe in pregnant women Occurs in a patient with antibody against VZV, poses no risk to the fetus or neonate Very little evidence that it causes congenital malformations Less contagious than the primary infection but contagious if blisters are broken Figure 3. Typical vesicular lesions seen in VZV infection. Video Lecture on Systemic Infections Affecting Pregnancy Part 1 MATERNAL INFECTION 1–2 days flu-like prodrome → pruritic vesicular lesions that crust over in 3–7 days Figure 6. Unilateral dermatomal vesicular lesions seen in Shingles. Figure 4. Crusted vesicular lesions seen in VZV infection. Video Lecture on Systemic Infections Affecting Pregnancy Part 1 Video Lecture on Systemic Infections Affecting Pregnancy Part 1 DIAGNOSIS [HANDOUT] SYSTEMIC INFECTION AFFECTING PREGNANCY Clinically diagnosed (page 2) Tzanck smear Tissue culture MORTALITY RISKS Direct fluorescent antibody testing rises with advancing age NAAT predominantly due to VZV pneumonia If the patient presents with the typical lesions that started as a papule → vesicle → pustule → dry scab → probably dealing with Varicella Zoster infection VARICELLA PNEUMONIA In most cases, varicella infection is self-limiting. Therefore, even without treatment, patients can recover well. However, in certain situations wherein the patient is immunocompromised or there is early bacterial co-infection, varicella pneumonia may happen. Mortality is common, and it is more severe in adults and in pregnant women. RISK FACTORS Immunosuppression Early bacterial co-infection SYMPTOMS Fever Tachypnea Dry cough Dyspnea Pleuritic pain Figure 7. Findings in the diagnosis of Varicella Zoster. Video Lecture on Systemic Infections Affecting Pregnancy Part 1 Group 6A | Systemic Infections Affecting Pregnancy 2 of 15 [HANDOUT] SYSTEMIC INFECTION AFFECTING PREGNANCY CORNERSTONE MANAGEMENT OF VZV INFECTION (page 3) Isolate any person diagnosed with primary 1 Isolate DIAGNOSIS infection. Clinically diagnosed Perform in patients diagnosed with varicella ○ disseminated, pruritic, vesicular rash infection, especially in pregnant patients. ○ lesions typically occur in crops and evolve in sequential Chest X- 2 Recommended since varicella pneumonia may fashion ray present with few symptoms only. Effects of Papule → vesicle → pustule → dry scab infection on pregnant patients are grave. Supportive Adequate hydration 3 care Antipyretics for fever VZV For pregnant patients who were exposed to 4 serologic patients with varicella infection; tells if pregnant Testing patient has immunity against the virus Hospitalize if needing IV fluids, if with pneumonia, 5 Hospitalize encephalitis, disseminated infection, or is immunocompromised Figure 8. Lesions in shingles [HANDOUT] SYSTEMIC INFECTION AFFECTING PREGNANCY Handout on Systemic Infections Affecting Pregnancy (page 4) Virus may be isolated by scraping the vesicle base during MANAGEMENT primary infection and performing Tzanck smear, tissue culture or direct fluorescent antibody testing Isolate any person diagnosed with primary infection Serologic testing – (+) anti VZV IgM antibody-0 CXR - recommended since varicella pneumonia may present with NAAT/PCR-based testing of amniotic fluid few symptoms only Supportive care VZV serologic testing FETAL AND NEONATAL INFECTION ○ if seronegative and with exposure to an infected individual, give immunoprophylaxis as follows CONGENITAL VARICELLA SYNDROME VariZIG First half of pregnancy 125 units/10 kg body weight up to a maximum dose of 625 units (5 vials) intramuscularly Table 1. Risk for Congenital Varicella Syndrome associated with best given within 96 hours of exposure AOG may be given up to 10 days from exposure to prevent or attenuate varicella infection AGE OF GESTATION RISK Acyclovir 800 mg 5x daily for 7 days orally Before 13 weeks AOG 0.4% Valacyclovir 1000 mg 3x daily for 7 days If pregnant woman develops varicella despite prophylaxis, treat 13–20 weeks AOG: Highest risk, 2% using the same dose of acyclovir or valacyclovir Beyond 20 weeks No risk Hospitalize if with pneumonia, encephalitis, disseminated infection or immunocompromised Video Lecture on Systemic Infections Affecting Pregnancy Part 1 If needing hospitalization give acyclovir 10-15 mg/kg IV infused over 1 hour q8 hours for 10 days DIAGNOSIS NAAT analysis of amniotic fluid VACCINATION Detailed anatomical sonographic evaluation (Congenital Anomaly Scan) Prevents pregnant patients from acquiring Varicella Zoster ○ Performed at least 5 weeks after maternal infection; may show infection abnormalities but sensitivity is low Given prior to pregnancy Attenuated Live Virus Vaccine COMMON CLINICAL FEATURES ○ 2 doses and 4–8 weeks apart Chorioretinitis ○ Booster dose after 10 years Microphthalmia ○ 98% seroconversion Cerebral cortical atrophy ○ Not recommended during pregnancy Growth restriction ○ Not recommended for those who may become pregnant within Hydronephrosis 1 month following each vaccine dose Limb hypoplasia ○ Not secreted in breastmilk (we can vaccinate patients Cicatricial skin lesions immediately postpartum) NEONATAL VARICELLA INFECTION If fetus or neonate is exposed to active infection just before or during delivery and before maternal antibody has been formed Attack rate: 25–50% Mortality rate: 30% May develop disseminated visceral and CNS disease which is commonly fatal Treatment: Varicella-zoster Immune globulin (VariZIG) ○ Should be administered to neonates born to mothers who have clinical evidence of varicella 5 days before and up to 2 days after delivery Group 6A | Systemic Infections Affecting Pregnancy 3 of 15 B. RUBELLA (GERMAN MEASLES) [HANDOUT] SYSTEMIC INFECTION AFFECTING PREGNANCY (page 5) CASE 30-year-old G2P1 (1001), 9 weeks AOG MATERNAL INFECTION 2 Mild, febrile illness with a generalized maculopapular rash Review of History beginning on the face and spreading to the trunk and extremities Widely disseminated, non-pruritic, erythematous, maculopapular Developed low grade fever associated with mild conjunctivitis, rash malaise, headache, and the following rash which started on the Postauricular adenopathy face and neck and later on spreading to the extremities and trunk Mild conjunctivitis Physical Examination Constitutional symptoms of malaise, headache, myalgia and arthralgia These symptoms usually resolve within 3-5 days DIAGNOSIS Rubella infection may be diagnosed clinically. The Clinical 1 diagnosis may already be clinched by just looking Examination at the typical rash of the disease. Specific for the IgM antibody which starts to be Figure 9. Case 2 seen 4–5 days after onset of clinical disease; can 2 ELISA Video Lecture on Systemic Infections Affecting Pregnancy Part 1 persist up to 6 weeks after appearance of the rash PATHOGEN Serum IgG Peak 1–2 weeks after rash onset RNA togavirus 3 antibody Commonly affects children and adolescents titers Causes infections of minor importance in the absence of Performed concomitantly with the serological pregnancy IgG Avidity 4 tests; high-avidity IgG antibodies indicate an ○ When acquired during pregnancy, this is where the trouble testing infection at least 2 months in the past. happens. Incubation period: 12–23 days The virus may be isolated from the urine, blood, nasopharynx, and CSF for up to 2 weeks after TRANSMISSION 5 Viral Culture rash onset. However, it takes time for the culture Spread by respiratory droplets and via nasopharyngeal result to come out, so it is not used in the clinical secretions setting. It is seen in the upper respiratory tract and goes to the cervical lymph nodes and is disseminated hematogenously throughout the body. Virus is present in the blood and nasopharyngeal secretions for several days before the appearance of the characteristic rash and continues to be shed from the nasopharynx for several days after the appearance of the rash. Transmission rate: 80% ○ Among susceptible individuals who are not immune to the virus Figure 10. Congenital Rubella Syndrome Characteristic Rash Viremia usually precedes clinical signs by about a week. Handout on Systemic Infections Affecting Pregnancy Adults are infectious during viremia and through 5–7 days of the rash. 50% of maternal infections are subclinical despite viremia that may CONGENITAL RUBELLA SYNDROME (CRS) cause devastating fetal infection. Virus crosses the placenta by hematogenous dissemination. Frequency of congenital infection is critically dependent on time of IMMUNITY exposure to the virus. 90% of infants exposed within 12 weeks after conception will Antibody against rubella does not normally appear in the serum manifest signs of congenital infection. until after the rash has developed. Rate of congenital infection declines sharply with advancing Acquired immunity to rubella usually lasts for life. gestational age. ○ If one acquires rubella, he or she is now immune to the virus ○ Very few fetuses are affected if infection occurs beyond 18 for life. weeks of gestation. Rubella infection in the first trimester poses significant risk for MATERNAL INFECTION abortion and severe congenital malformations. May present with mild febrile illness Neonates born with CRS may shed the virus for many months and Postauricular adenopathy thus be a threat to other infants and to susceptible adults who Mild conjunctivitis contract them. Constitutional symptoms: Malaise, headache, myalgia, and arthralgia ○ Usually resolves within 3–5 days A typical rubella rash appears as a generalized maculopapular, non-pruritic, erythematous rash beginning on the face and spreading to the trunk and extremities. ○ Again, these symptoms usually resolve within 3–5 days. Figure 11. Congenital Rubella Syndrome Video Lecture on Systemic Infections Affecting Pregnancy Part 1 Group 6A | Systemic Infections Affecting Pregnancy 4 of 15  Table 2. Risk for Congenital Rubella Syndrome associated with AOG AGE OF GESTATION RISK 1st 12 weeks 90% 13–14 weeks 54% Late 2nd trimester 25% After 20 weeks Rare Video Lecture on Systemic Infections Affecting Pregnancy Part 1 NOTE: As the age of gestation increases, the risk for congenital Figure 13. Cordocentesis rubella syndrome decreases. The highest risk of congenital rubella Video Lecture on Systemic Infections Affecting Pregnancy Part 1 syndrome is seen if the mother acquires the infection within the first 12 weeks of gestation. Chorionic Villi Sample (10–30%) FETAL EFFECTS OF CONGENITAL RUBELLA SYNDROME (CRS) 1 Sensorineural Most common single defect Deafness (60–75%) 2 Eye Defects (10–30%) Cataracts and congenital glaucoma 3 CNS Defects (10–25%) Microcephaly, developmental delay, mental retardation, meningoencephalitis 4 Congenital heart Patent ductus arteriosus - most defects common Figure 14. Chorionic Villi Sample Supravalvular pulmonic stenosis - Video Lecture on Systemic Infections Affecting Pregnancy Part 1 most pathognomonic Detailed Ultrasound Examination (Congenital Anomaly Scan) 5 Others Pigmentary retinopathy Best used to determine whether serious fetal injury has Neonatal purpura occurred as a result of maternal infection Hepatosplenomegaly and jaundice Possible anomalies detected by ultrasound include growth Radiolucent bone disease restriction, microcephaly, CNS abnormalities, and cardiac Fetal growth restriction malformations. Hemolytic anemia Thrombocytopenia PREVENTION OF RUBELLA INFECTION Women of reproductive age should have a preconception EXTENDED RUBELLA SYNDROME appointment when contemplating pregnancy. Evaluate them for immunity to rubella Progressive panencephalitis and Type 1 Diabetes ○ Request for a rubella IgG May not develop clinically until the second or third decade of life If serologic testing demonstrates susceptibility, they should be DIAGNOSIS OF CRS vaccinated before conception occurs. If preconception counseling is not available, test for rubella Amniocentesis should be done during the 1st prenatal appointment. Procedure of choice because of its lower complication rate Women who are susceptible are counseled to avoid individuals Amniotic fluid sample sent for PCR who may have viral exanthems. Can demonstrate presence of rubella virus but cannot indicate If a susceptible woman is exposed to rubella, serologic testing degree of fetal injury should be done and counseled on the risk of CRS. ○ Possibility of false positive cannot be excluded ○ Susceptible women should be vaccinated immediately after delivery. [HANDOUT] SYSTEMIC INFECTION AFFECTING PREGNANCY (page 8) PREVENTION OF RUBELLA INFECTION Droplet precautions for 7 days after the onset of the rash Women who are susceptible are counseled to avoid exposure to individuals who may have viral exanthems RUBELLA VACCINATION Best way to prevent congenital rubella syndrome is to be vaccinated prior to being pregnant. ○ Available: Monovalent, Bivalent (MR), and Trivalent (MMR) ○ Attenuated live virus Figure 12. Amniocentesis No evidence that the vaccine induces malformation when Video Lecture on Systemic Infections Affecting Pregnancy Part 1 inadvertently given during pregnancy. Cordocentesis 95% of the population will actually seroconvert when given the Can be used to determine total and viral-specific IgM vaccine. concentrations Antibody levels persist for 18 years in more than 90% of Technically difficult before 20 weeks gestation vaccines/vaccinated people. Fetal immunoglobulins usually cannot be detected before 22–24 Vaccinated patients may breastfeed their infants. weeks. ○ However, they should practice secure contraception for at least 1 month after vaccination. Contraindications for vaccination include: ○ Acute febrile illness ○ Immunosuppression Group 6A | Systemic Infections Affecting Pregnancy 5 of 15  ○ Pregnancy 90% born to (+) HBsAg and (+) HbeAg mothers will be Women who are non-immune should be offered MMR vaccine infected. immediately after postpartum. Other possible transmission: ○ Premastication - Very rare form [HANDOUT] SYSTEMIC INFECTION AFFECTING PREGNANCY ○ Nosocomial infection - Rare; lapses in healthcare infection (page 8) control procedures RUBELLA VACCINATION [HANDOUT] SYSTEMIC INFECTION AFFECTING PREGNANCY Small overall theoretical risk of up to 2.6%, there is no evidence (page 9) that the vaccine induces malformations Adverse effects: TRANSMISSION ○ Low-grade fever Highest concentrations of HBV are located in blood. ○ Malaise Present in lower concentrations in wound exudates, semen, ○ Arthralgias vaginal secretions and saliva ○ Arthritis RISK FACTORS ○ Pain and paresthesia on injection site Unprotected sex with an infected partner Vaccinate all children 12-15 months or older and all susceptible Multiple partners adolescents and adults Men having sex with men All obstetric patients should be screened as early as possible in History of other STIs their pregnancy Injecting drug use Precaution in patients with neomycin allergy III. SEXUALLY TRANSMITTED ILLNESSES DIAGNOSIS Systemic infections that are sexually-transmitted includes: Confirmed through serologic testing ○ Hepatitis B Table 3. Serologic tests for Acute and Chronic Hepatitis B ○ HIV/AIDS Active Viral Replication/ CASE A 34-year old G3P2 (2002), 28 weeks AOG consulted at Acute Hepatitis B Chronic Hepatitis B High Level of Infectivity 3 the clinic for prenatal check-up. Initial laboratory tests (+) HBsAg (+) HBsAg were requested and all were normal except for her (+) HBeAg hepatitis B screening which turned out to be reactive. (+) HBc IgM (+) HBc IgG Below is the result of her hepatitis B profile. Source: Video Lecture on Systemic Infections Affecting Pregnancy Part 2 Hepatitis B Profile 1 HBsAg: Reactive PREVENTION OF PERINATAL TRANSMISSION Anti-HBs: Non-reactive Routine screening of all pregnant women for Hepatitis B Antigen Anti-HBc: Reactive should be done at the first prenatal visit. Anti-HBc IgM: Reactive Infants delivered to serum-positive mothers should receive Anti-HBc IgG: Non-reactive hepatitis B immunoglobulin (HBIG) within 12 hours after birth. HBeAg: Reactive Begin Hepatitis B vaccination series before hospital discharge. Anti-HBe: Non-reactive CDC recommends universal vaccination of all infants for Diagnosis: Acute Hepatitis B infection, High infectivity Hepatitis B. Hepatitis B Profile 2 Vaccine should be offered to all women of reproductive age. In women with high HBV DNA levels (>103 colonies/mL), treatment HBsAg: Reactive should be initiated as follows: Anti-HBs: Non-reactive ○ Tenofovir 300 mg OD Anti-HBc: Reactive ○ Lamivudine 100 mg daily from 28 weeks gestation until 1 Anti-HBc IgM: Reactive month after delivery Anti-HBc IgG: Reactive ○ HBIG 100–200 IU IM at 28, 32 and 36 weeks’ gestation HBeAg: Non-reactive Diagnosis: Chronic Hepatitis B infection, Low infectivity [HANDOUT] SYSTEMIC INFECTION AFFECTING PREGNANCY (page 10) A. HEPATITIS B HBV INFECTION 90% of patients mount an effective immunologic response to the Can be either self-limited or chronic virus and completely clear the infection. 50% of newly-acquired HBV are symptomatic Less than 1% of infected patients develop fulminant hepatitis and 1% result in acute liver failure and death die. Risk for chronic infection is inversely related to age at acquisition Only 10% of the patients who acquire hepatitis B develop into a 90% of infected infants and 30% of infected children 1000 copies/mL OR Non-Reactive ○ The bag of membrane has ruptured for ≥4 hours B. HBsAg: Reactive | HBeAg: Non-reactive | Anti-HBc IgG: If the patient has been on HAART already, then just continue Reactive whatever regimen she is taking C. HBsAg: Non-Reactive | HBeAg: Non-Reactive | Anti-HBs: ○ Most antivirals are not contraindicated during pregnancy Reactive ○ The baby will also be given antiviral prophylaxis for 6 weeks D. HBsAg: Reactive | HBeAg: Non-reactive | Anti-HBc IgM: from birth. Reactive 🧠 IMPORTANT TO REMEMBER IN HIV INFECTION UNIVERSAL SCREENING DURING PREGNANCY ○ Using the Opt-out approach. ○ Inform the patient that this IS part from the standard test that she needs to accomplish. Group 6A | Systemic Infections Affecting Pregnancy 11 of 15  3 What is the percentage risk of congenital varicella 8 29 years old multigravida, 25 weeks age of gestation syndrome if the infection is acquired beyond 20 weeks age consulted at the emergency room for dysphagia. of gestation? Inspection of the oral cavity showed multiple whitish A. 50% plaques. The patient was suspected to have AIDS and thus B. No risk needs a screening test to be facilitated. How should this be C. 2% carried out at the emergency room? D. 0.4% A. Ask patient to sign consent then extract blood for testing B. Immediately extract blood and send to the laboratory for 4 40 years old multigravida at 10 weeks age of gestation testing consulted due to severe body pain associated with C. Refer to an HIV counselor prior to blood extraction and generalized malaise. Physical examination revealed the testing following painful skin lesions: D. Ask relative to sign consent prior to blood extraction and testing 9 35 years old, multigravida, 15 weeks AOG, consulted for routine prenatal check-up with the following laboratory results: HBsAg: Non-Reactive HBeAg: Non-Reactive Which among the following statements is TRUE regarding Anti-HBs: 5 mIU/ml its effect on the fetus? What is the next best step in the management of this A. The fetus will most likely develop congenital varicella patient? syndrome B. There is very little evidence that it causes congenital A. Give hepatitis B immunoglobulin malformations B. Repeat serological testing after 1 month C. The fetus will most likely develop neonatal varicella C. Give hepatitis B vaccine infection D. Reassure the patient that she has immunity from hepatitis D. Incidence of neonatal mortality is very high 10 35 years old multigravida, 37 weeks age of gestation, 5 25 years old primigravida consulted due to high grade diagnosed with HIV infection 10 years ago and has been on fever associated with body malaise, conjunctivitis, and the HAART for 5 years has the following laboratory results: following skin rashes: HIV RNA: undetectable CD4+ count: 500 cells What is the best route of delivery for this patient? A. Spontaneous vaginal delivery B. Cesarean section C. Assisted vaginal delivery D. Cesarean-Hysterectomy When is the best time to do serological testing for IgM to VIII. RATIONALIZATION confirm diagnosis? A. Within 24 hours after onset of clinical disease No. RATIONALIZATION B. Beyond 6 weeks after the appearance of skin rash C. 4 days after onset of clinical disease 1 CORRECT ANSWER: D. IgG D. May be done at any stage of the disease IgG is a type of immunity that is passively transferred across 6 A 20-year old primigravida at 9 weeks AOG presented with the placenta which rapidly increases by 16 weeks AOG and fever, non-pruritic maculopapular rashes which initially equal that of the mother’s by 26 weeks AOG. appeared on the face then spread to the trunk and A is incorrect because IgM is the primary fetal response to extremities, joint pains, conjunctivitis, and head and neck infection. lymphadenopathies. What is the MOST common congenital heart defect associated with this condition?. B is incorrect because IgE is an antibody that plays a key role in A. Atrial septal defect the immune system’s response to allergens and parasitic B. Patent ductus arteriosus infections. IgE production generally begins after birth when the C. Supravalvular pulmonic stenosis infant is exposed to various environmental factors, including D. Ventricular septal defect potential allergens. The immune system develops overtime, and the production of IgE can increase as a response to allergens 7 Which of the following is INCORRECT regarding Hepatitis and other foreign substances. B vaccination? C is incorrect because IgA is an antibody that is crucial in A. HBIG contains HBsAg produced in yeast by recombinant protecting mucous membranes, such as those in the respiratory technology and digestive tracts. This antibody is primarily passed to the B. Hepatitis B vaccine may be given at a dosing interval of newborn postnatally, through breastfeeding. either 0,1,6 or 0,2,4 Source: Batch 2025 Ratio C. HBIG provides temporary protection D. Hepatitis B vaccine can be used for both pre-exposure vaccination and post-exposure prophylaxis Group 6A | Systemic Infections Affecting Pregnancy 12 of 15  2 CORRECT ANSWER: A. HBsAg: Reactive | HBeAg: 5 CORRECT ANSWER: C. 4 days after the onset of clinical Reactive | Anti-Hbs: Non-Reactive disease Vertical transmission is the passage of an infectious agent from This is a case of rubella (german measles) since the patient the mother to her fetus through the placenta, during labor or presented with the symptoms typical of rubella: delivery, or by breastfeeding. 20% of infants born to (+) HBsAg Mild, febrile illness mothers will be infected and 90% of infants born to (+) HBsAg Postauricular adenopathy and (+) HBeAg mothers will be infected. The fact that there is Mild conjunctivitis Hepatitis B infection and high level of infectivity (active viral Malaise, headache, myalgia, and arthralgia replication) as evidenced by positive serologic test findings for Generalized maculopapular rash, non-pruritic, erythematous HBsAg and HBeAg, respectively, best explains the answer. rash beginning on the face and spreading to the trunk and Negative or non-reactive results were found for anti-HBs, extremities meaning that no Hepatitis B surface antigen was found. The incubation period for this RNA togavirus is 12-23 days. B is wrong because although HBsAg is reactive, HBeAg is Antibodies against rubella do not normally appear in the serum non-reactive. Two possible interpretations are (1) there is late until after the rash has developed. However, acquired immunity acute or chronic HBV infection with low infectivity or (2) it is an to rubella usually lasts for life. To diagnose rubella, we can do HBeAg-negative (“precore-mutant”) Hepatitis B infection. clinical examination, ELISA, serum IgG antibody titers, IgG C is wrong because it could either be immunization with HBsAg avidity testing, and viral culture. after vaccination, remote past HBV infection, or false-positive A is incorrect since, as stated above, the virus has an result for Hepatitis B antibodies, hence, infectivity is less likely incubation period of 12-23 days, and that antibodies against to happen. rubella do not normally appear in the serum until after the rash D is wrong because it tells that the patient has an ongoing has developed. Doing a serological test for IgM within 24 hours active infection as evidenced by (+) HBsAg and Anti-HBc IgM, after the onset of clinical disease will not yield any significant but not highly infectious due to non-reactivity of HBeAg. result. Source: Batch 2025 Ratio B is incorrect since IgM antibodies can only be detected within 4-5 days after the onset of clinical disease up to 6 weeks after 3 CORRECT ANSWER: B. No risk the appearance of the rash, not beyond 6 weeks after the appearance of skin rash. D is incorrect since detection of IgM antibodies can only be done within 4-5 days after the onset of clinical disease up to 6 weeks after the appearance of the rash, not at any stage of the disease. Source: Batch 2025 Ratio 6 CORRECT ANSWER: B. Patent ductus arteriosus 4 CORRECT ANSWER: B. There is very little evidence that it The patient presents with congenital rubella syndrome, as the causes congenital malformations patient presented with fever, non-pruritic maculopapular rashes which initially appeared on the face then spread to the trunk The patient in the case most likely has herpes zoster/shingles, it and extremities, joint pains, conjunctivitis, and head and neck is a reactivation of chickenpox (varicella) which presents as a lymphadenopathies. unilateral, dermatomal vesicular eruption associated with severe pain. As seen in the photo the physical examination reveals a unilateral and dermatomal lesion, it was also described as painful. Herpes zoster/shingles poses no risk to the fetus or neonate and it has very little evidence that it causes congenital malformations. A is wrong because there is only 0.4% risk present since shingles occurred before 13 weeks AOG. Highest risk (2%) of developing congenital varicella syndrome between 13 to 20 weeks AOG. While there is no risk if it occurred beyond 20 weeks AOG. Thus, making the statement “the fetus will most likely develop congenital varicella syndrome” false. C is incorrect because neonatal varicella infection occurs if the fetus or neonate was exposed to active infection just before or during delivery and before maternal antibody has been formed. Source: Batch 2025 Ratio The statement “The fetus will most likely develop neonatal 7 CORRECT ANSWER: A. HBIG contains HBsAg produced in varicella infection” is unlikely because it is still far from delivery yeast by recombinant technology and is currently at 10 weeks AOG. D is also incorrect since there is little to no risk of getting congenital malformations or being affected by the infection the mother has. Making the statement “Incidence of neonatal mortality is very high” false. Source: Batch 2025 Ratio Source: MOD5-OB2-T9-Systemic Infections Affecting Pregnancy Group 6A | Systemic Infections Affecting Pregnancy 13 of 15  8 CORRECT ANSWER: C. Refer to an HIV counselor prior to blood extraction and testing The patient should be referred to an HIV counselor before any testing is conducted. The counselor can explain the testing process, provide information about HIV, and obtain informed consent from the patient. Informed consent is a crucial step in medical testing, especially for HIV, as it is a sensitive issue. The patient's rights and privacy should be respected throughout the process. The counselor can also offer support and answer any questions the patient may have. A is incorrect since it assumes that the patient can provide informed consent immediately, but it doesn't account for the need to ensure the patient fully understands the nature of the testing and the implications of an HIV diagnosis. It's important to offer pre-test counseling to address any concerns or questions the patient may have before obtaining consent. B is incorrect since conducting HIV testing without prior counseling and obtaining informed consent is not ethical or legally sound. Patients have the right to be informed about the testing process, potential outcomes, and the confidentiality of their results before undergoing such tests. D is incorrect since testing for HIV requires the informed consent of the individual being tested. Asking a relative to sign consent on behalf of the patient is not appropriate, as it does not respect the patient's autonomy and right to make decisions about their own healthcare. Additionally, HIV testing is a sensitive issue, and the patient should be directly involved in the decision-making process. Source: Batch 2025 Ratio 9 CORRECT ANSWER: C. Give hepatitis B vaccine Non-reactive HBsAg and HBeAg means there is no active infection, and an anti-HBs less than 5mIU/ml indicates negative/low immune response for hepatitis B. For immunity to be present, there must be at least 10 mlU/mL. Since pregnancy is not a contraindication, there is no active infection and the patient has low immunity, Hepatitis B vaccination is the best management for this patient. A is INCORRECT because immunoglobulin is best given during the last trimester to those with current hepatitis infection. B is INCORRECT because HBV serological testing is done to see level of infectivity and differentiate between acute and chronic. For pregnant patients, this should be done at the 1st prenatal checkup and again at delivery. D is INCORRECT because >12 mIU/ml anti-HBs is considered protective, between 5-12 mIU is indeterminate, and