Infections in pregnancy

When would you start a patent on HIV medications in pregnancy?

1st trimester

• if viral load > 100,000 and CD4 count <200

2nd trimester

• if viral load > 30,000

3rd trimester

• if viral load is unknown or >10,000

When would you start HIV prophylaxis for the infant and for how long?

if Very low risk (maternal load <50 and cART > 10 weeks)

• zidovudine for 2 weeks

if LOW risk ((maternal load <50 and baby born prematurely)

• zidovudine for 4 weeks

HIGH risk (viral load >50)

• combination PEP

Management of SROM at term in HIV patient

VL <50 - immediate induction

VL 50-399 - CS

VL >400 - CAT 2 CS

IV Zidovudine in labour/prior to CS

What is the management of PPROM in HIV?

if VL <50 and on ART > 10 weeks consider conservative management

MDT if not

What is the COVID maternal mortality rate?

2.4 per 100,000

COVID complications in pregnancy and risks

• stillbirth x2 risk

• preterm x2-3

Patient on aspirin who gets COVID

ensure to hold aspirin due to risk of thrombocytopenia

Steroids doses in COVID management

If steroid for lung maturity are NOT required

• PO 40mg OD or IV hydrocortisone 80mg BD for 10 days

If steroid for lung maturity IS required

• IM dexamaethasone every 12 hours x4 then PO?IV for 10 days

Which antiviral medication is used in COVID?

tocilizumab if in ICU

remdesevir if not improving

TB prophylactic for the newborn

Isoniazid for 3 months and a vaccine

Management of TB

for 2 month

• rifampicin, isoniazid (pyridoxine B6)

• pyrazinamide + ethambutanol

for 4 months

• rifampicin, isoniazid (pyridoxine B6)

Risk of neonatal herpes with SVD in primary vs secondary herpes?

primary - 41%

secondary 0.3%

Dose of acyclovir for herpes in pregnancy

acyclovir 400mg TDS for 5 days and then from 32/40

Levels of IgG varicella zoster to confirm immunity

> 100 confirms immunity or 150 in immunosuppressed

Management of varicella zoster if the patient is exposed

from day 7-14 acyclovir 800 mg QDS for 5 days

or immunoglobulin if <10 days ago

Dose of acyclovir in management of symptomptomatic varicella zoster

acyclovir 800mg x5/day for 7 days

What is the commonest cause of infectious neurodevelopmental impairment?

CMV

including most common viral cause of sensorineural deafness

Transmission and risk of severity of CMV

transmission lowers in first trimester 25% however most severe if present in first trimester

(same as toxoplasmosis)

CMV result meaning ◦ IgM positive, IgG avidity low <30%

IgM positive, IgG avidity high >30%

means that infection is recent in the last 3 months

means infection in the last 12 weeks

Management of CMV infection after 24 weeks

• refer to fetal medicine

• ultrasound every 2 weeks

• if any abnormal features eg cerebellar abnormalities, hyper echoic bowel then do amnioscentesis

• if positive MRI brain

• if positive valacyclovir intrauterine

Negative amnioscentesis for CMV - how many newborns will have CMV?

3%

Which blood results would prompt amnioscentesis for CMV

<24 weeks

IgG and IgM + now but negative at booking

IgM positive, IgG avidity low <30%

give valacyclovir while waiting for amniocentesis

Pathophysiology of COVID 19, which receptors does it affect?

ACE 2 - which converts angiotensin 2 into angiotensin 1

• so can lead to vasoconstriction and thrombosis

Hep B, Hep C and with HIV - which ones should be delivered by CS

Hep B - no indication. give immunoglobulin and vaccine to newborn

Hep C - no indication

Hep C + HIV - ELCS as reduces transmission risk