Care Lecture 13: Reproduction and Infection - Preconception

developmentally reproductive years BEFORE pregnancy

when should you start providing preconception care?

-medical history

-infection disease control

-genetic screening

-health promotion

-partner violence

what is included in preconception counseling?

optimized control

**obtain optimal control of their history, including diabetes, HTN, mood disorders

what should be characteristic of a medical history for preconception counseling?

-family history for both partners

-prior screenings with the patient

what should be included in the genetic screening for preconception counseling?

the 5 P's

what tool is used to assess risk behaviors associated with sexually transmitted infections?

-partners

-prevention of pregnancy

-protection from STIs

-practices

-part history of STIs

what are the 5 P's?

-are you sexually active?

-how many partners do you currently have, or have you had?

-how many partners does your partner have?

regarding the "Partners" for the 5 P's, what question(s) should you ask the patient?

-are you preventing pregnancy if you are sexually active and not wanting to start a family?

-what preventative measures are you using?

regarding the "Prevention of Pregnancy" for the 5 P's, what question(s) should you ask the patient?

used for infections:

-T: toxoplasmosis

-O: other infection

-R: rubella

-C: cytomegalovirus

-H: herpes simplex

what does TORCH stand for and what is it used for?

-TRC = antenatally

-herpes and hepatitis = perinatally

regarding TORCH infections, which are acquired antenatally, and which are perinatally?

cognitive malformation

most fetuses, if infected with a TORCH infection during the first trimester, will suffer from a syndrome of what?

**usually asymptomatic

-fever

-rash

-eosinophilia

what are the maternal symptoms of toxoplasmosis?

immune after 1st episode of toxoplasmosis

**unless immunocompromised

what is true of maternal immunity and toxoplasmosis?

risk of fetal infection = incidence ↑ w/ gestational age

risk of fetal infection of toxoplasmosis has what relationship with gestational age?

-hydrocephalus

-nervous system problems

-cerebral palsy

-epilepsy

-enlarged liver/spleen

if a fetus is infected with toxoplasmosis in the 1st trimester, what symptoms might be present?

-vision loss

-hearing loss

-learning difficulties

if a fetus is infected with toxoplasmosis in the 3rd trimester, what symptoms might be present?

newborns are born without clinical signs of disease --> may develop later in life

what is true of newborn symptoms of toxoplasmosis when the mother is infected during the 3rd trimester?

toxoplasmosis titers (toxoplasma IgG, & IgM)

if a mother is at risk of toxoplasmosis, what should be done?

every 10 weeks throughout pregnancy

how often should toxoplasmosis titers be completed for a mother at risk of contracting toxoplasmosis?

-Sulfadine

-combination of Sulfadiazine & pyrimethamine

what is used as fetal infection treatment for toxoplasmosis?

in 1st trimester to protect the fetus

**these meds have an effect on the fetus during this time

fetal infection treatment for toxoplasmosis should be avoided when?

-women who are cat owners (parasite is in cat feces)

-women who garden

which populations of women are at increased risk of toxoplasmosis?

-wash hands before eating

-wash hands after handling raw meat

-wash hands after contact with cat feces & soil

-have someone else change cat litter

-cook meat adequately

what are some things we should educate women on regarding the prevention of toxoplasmosis?

syphilis (bacterium treponema pallidum)

AKA “kissing disease”; enters through subcutaneous tissue during intercourse, biting, or oral sex

non-painful lesions on palms and soles

what are the maternal symptoms of syphilis?

routine blood test (RPR or VDRL)

what can be used for maternal screening of syphilis?

-first prenatal visit

-in third trimester

for a pregnant woman at risk of having syphilis, when should the routine blood test be conducted?

penicillin

what is the treatment for syphilis?

follow up is mandatory --> retest them to make sure they’re negative

what MUST be done after a woman is treated for syphilis?

transplacental transmission may occur at any time

what is true of fetal infection of syphilis during pregnancy?

-preterm births

-IUGR

-blindness

-deafness

-nervous system problems

fetal infection of syphilis puts the fetus at risk of what?

birth defects --> congenital varicella syndrome

if a woman is infected with varicella during the first 20 weeks of pregnancy, what effect does this have on the fetus?

-underdeveloped arms and legs

-incomplete brain development

what characterizes congenital varicella syndrome?

life-threatening infection – neonatal varicella

if varicella develops during delivery and immediately during postpartum, what does this mean for the neonate?

oral antivirals

what can be used to reduce severity and complications associated with maternal varicella during delivery?

hepatitis A

RNA virus that is the most common form of hepatitis infection

fecal-oral contact

how is hepatitis A transmitted?

-malaise

-jaundice

-light color stools

-liver failure (extremely rare)

what are the symptoms of hepatitis A?

-screening: HAV

-prevention: hep A vaccine 2 doses (inactive)

what is the screening/preventative methods for hepatitis A?

given vaccine at 12 and 24 months

when can infants get the hepatitis A vaccine?

hepatitis B

type of hepatitis that is considered a DNA virus

-hepatitis

-cirrhosis

-liver cancer

what are some complications of hepatitis B?

10-20% will pass to fetus

for those that are chronic carriers of hepatitis B, what percentage shows how many fetuses will become infected?

90% will pass to fetus

for those that are positive HBsAg (acute episode/infection), what percentage shows how many fetuses will become infected?

transplacentally to fetus at birth

how is hepatitis B transmitted to the fetus?

-screening: routine HBsAg in moms

-prevention: HBIG (hepatitis B immune globulin), HBV vaccine at birth

what is the screening/preventative methods for hepatitis B?

HBIG and HBV vaccine = build up immunity

a non-immune mother exposed to hepatitis B in pregnancy is given what, and for what reason?

-hepatitis

-cirrhosis

-liver cancer (as an adult)

**same as hepatitis B

what are some complications of hepatitis C?

with HCV viral titer

the risk of transmission of hepatitis C correlates with what?

-high-risk pregnant patients

-intravenous drug users

-those who had a blood transfusion before 1995

screening for hepatitis C is recommended in which patient populations?

mother's antibodies will not be out of the infant until around this age

why will an infant not be tested for hepatitis C until 18 months of age?

avoid high risk behavior

what is the best education you can give someone regarding hepatitis C?

Rubella virus (togaviruses RNA)

what is the causative organism of rubella (german measles)?

via respiration

what is the route of infection for rubella?

in the nasopharyngeal secretions

where is the rubella virus concentrated in the body?

provide respiratory isolation

if someone is rubella positive, what should be done regarding transmission precautions?

-mild pyrexia

-arthralgia

-rash = persists for > week and always affecting the face

-lymphadenopathy

what are some of the symptoms of rubella?

first 16 weeks gestation

the risk of fetal transmission of rubella is at the highest risk at what point in pregnancy?

50-60%

what percentage of fetuses are affected by rubella if maternal primary infection is in the first month of gestation?

22%

what percentage of fetuses are affected by rubella if maternal primary infection is in the second month of gestation?

6-10%

what percentage of fetuses are affected by rubella if maternal primary infection is in the third-fourth month of gestation?

-rubella IgG titer

-in the 1st trimester

what is used for routine antenatal maternal screening for rubella? when is this done?

> 1.1 = immune

what level of a rubella IgG titer indicates maternal immunity?

vaccination before or after pregnancy

what are the best preventative methods for rubella?

it is a live virus- avoid pregnancy for 1 month after vaccination d/t negative effects on fetus

why can't a mother receive the rubella vaccine while she is pregnant?

cytomegalovirus (CMV)

a DNA virus in the herpes virus family (not the same as genital herpes)

50-60% (CMV)

what percentage of women of childbearing age have evidence of prior CMV infections with antibodies present?

positive viral titers

how is CMV diagnosed?

**usually mild or asymptomatic

-fever w/ or w/o lymphadenopathy

-sore throat

what are some maternal symptoms of CMV?

direct person to person contact

how is CMV transmitted?

-saliva

-breastmilk

-urine

-semen

-tears

-stools

-blood

-cervical and vaginal secretions

what bodily fluids can be used to transmit CMV from person to person?

-delayed speech

-learning difficulties

-sensorineural hearing loss

-chorioretinitis (visual problems)

if a fetus is infected with CMV, what manifestations can result?

no current licensed treatment for CMV

what is the treatment for CMV?

-hand washing

-contact precautions

-sexual protection

how can CMV be prevented?

primary vs recurrent

what are the 2 different types of herpes simplex?

primary herpes simplex

type of herpes simplex that is:

-very painful

-lasts for a couple weeks

-first time being infected

fetal loss - associated with ↑ miscarriages when affected in 1st trimester

regarding fetal status, what happens frequently with a maternal case of primary herpes simplex?

recurrent herpes simplex

type of herpes simplex that is:

-milder/not as painful

-unilateral

at time of delivery in 90-95% of cases (vaginal delivery)

**baby passes through lesions and obtains it themselves

when does transmission of herpes simplex usually occur?

-SEM complications (skin, eyes, and mucous membranes)

-CNS disease = seizures, poor feeding, lethargy

if an infant is infected with herpes simplex during delivery, what manifestations can result?

-fetal death d/t severe coagulation, liver and respiratory issues

-can be caused by herpes simplex

what is fetal dissemination? what can it be caused by?

any lesion should be suspected of being an active case and cultured

what is true of the assessment for herpes simplex?

recommend c-section

if herpes simplex lesions are present at time of delivery, what should be done?

daily oral acyclovir

what medication can be considered in late third trimester for those with herpes simplex?

-integrate partners into plan of care

-prenatal testing on partners for STD’s

what is important regarding TORCH infections and sexual partners?

stress can cause outbreaks - encourage relaxation

what is true of stress and herpes simplex?

infertility

the inability to conceive or carry a pregnancy to term after 12 months of trying to conceive

-ovulation disorders

-uterus abnormalities

-damage to fallopian tubes

-endometriosis

what are causes of infertility for women?

-hormonal or sexual disorders

-abnormal production of sperm

-genetic conditions

what are causes of infertility for men?

-having regular intercourse

-maintaining healthy personal habits/body weight

-exercising regularly

-avoiding exposure to toxins

-avoid smoking and alcoholic drinks

-limiting the intake of caffeine

how can infertility be prevented?