OB Prenatal Care and Infections

How do you calcuate the due date?

• Naegele’s Rule

• Month of period - 3 months (month), Last period + 7 days (day), + 1 year (year)

What is “G’s and P’s”?

• G: Gravida- # of pregnancies

• P: Para- # of deliveries after 20 weeks

• Multiples are counted as one pregnancy (G) and one birth (P)

What is GTPAL?

• G: Gravida- # of pregnancies, including this one

• T: # of term births 37 or more weeks

• P: # of preterm births between 20 weeks and 36 weeks 6 days

• A: # of pregnancies ending in “abortion” before 20 weeks (elective or miscarriage)

• L: # of currently living children

When is routine prenatal screening w/ lab work done?

• Done on initial visit unless otherwise stated

• Additional STI/TORCH screening done/repeated w/ high-risk behaviors

What is tested with routine prenatal screening lab work?

• Blood type & Rh (ABO Rh)

• Rubella IgG

• HBsAg

• HIV

• H&H

• RPR (Syphilis)

• UA

• Glucose Tolerance Test (GTT)

• Group Beta Strep (GBS)

Blood type & RH (ABO RH) test: What results are you watching for and what do you need to do for mom/baby?

• O negative- need to check baby’s ABO/RH at delivery

Rubella IgG: What results are you watching for and what do you need to do for mom/baby?

• Non-immune- need to offer MMR after delivery for mom (baby later on)

Hepatitis B Surface Antigen (HBsAg): What results are you watching for and what do you need to do for mom/baby?

• Positive- offer Hep B vaccine AND HBIG (Hep B immunoglobulin) @ delivery (given to baby)

HIV: What results are you watching for and what do you need to do for mom/baby?

• Positive- baby and mom need ART, no breastfeeding

RPR (Syphilis): What results are you watching for and what do you need to do for mom/baby?

• Positive- mom and baby need TX w/PCN

Hemoglobin: What results are you watching for?

• 9.8 g/dL

Hematocrit: What results are you watching for?

• 29.4%

UA: What results are you watching for?

• Neg protein, neg glucose, POS WBC/bacteria

Glucose Tolerance Test (GTT): What results are you watching for and what do you need to do for mom/baby?

• Defer until 28 weeks- if positive- Gestational diabetes

Group Beta Strep (GBS): What results are you watching for and what do you need to do for mom/baby?

• Defer until 36 weeks- if positive- ABX given in labor (for baby)

Blood type A

• Antibodes in plasma = Anti-B

• Antigens in red blood cell = A antigen

Blood type B

• Antibodies in plasma = Anti-A

• Antigens in red blood cell = B antigen

Blood type AB

• Antibodies in plasma = none

• Antigens in red blood cell = A and B antigens

Blood type O

• Antibodies in plasma = Anti-A and Anti-B

• Antigens in red blood cell = none

What is ABO incompatibility?

• If mom is O and baby is not O → Baby is more likely to become jaundiced

  • No prevention- not usually too serious for baby (increased risk of jaundice)

  • Bilirubin is by-product of RBC’s being broken down and w/this RBC’s break down way faster than normal

  • The Anti-A and Anti-B antibodies move from mom to baby, cross the placenta, get more ramped up, and look for invaders

How does RH isoimmunization occur?

• Only happens if mom is negative (does not have the D antigen on RBC) and baby is positive (has D antigen on RBC)

• Each pregnancy is affected more seriously- potentially fatal for baby

What happens with RH isoimmunization?

• The exposure: If blood from an Rh-positive baby crosses into the mother's circulation, her immune system sees the D antigen as a foreign invader.

• The reaction (Sensitization): The mother's body creates its own anti-D antibodies to fight it off (immune response creates more antibodies)

• The risk: While it may not hurt the first baby, these IgG anti-D antibodies can cross the placenta in a later pregnancy and attack an Rh-positive baby's red blood cells.

What is the prevention for an RH negative pregnancy?

• Anti-D immune globulin (RhoGAM) in 3rd trimester

• RhoGAM is also given within 72hrs of delivery if baby has + blood type

• RhoGAM prevents moms body from having an immune response

What is the most frequently reported STI?

• Chlamydia

What are the signs/symptoms for Chlamydia?

• Often asymptomatic

What are the maternal complications for Chlamydia?

• Untreated can lead to ectopic pregnancy/infertility

• Untreated can lead to Pelvic Inflammatory Disease (PID)- very painful

What are the Fetal/Newborn complications for Chlamydia?

• Most common cause of opthalmia neonatorum (can cause blindness if not treated)

What is the screening/treatment/prevention for Chlamydia?

• Routine screening of asymptomatic and pregant women (especially w/high-risk behaviors)

• May rescreen at end of pregnancy with high-risk behaviors

• ABX

• Erythromycin for newborns (routine NB medication)

What is the oldest communicable disease?

• Gonorrhea- may spread from vagina to rectum

What are signs/symptoms of gonorrhea?

• Often asymptomatic

• Pelvic pain, longer menses

• May have purulent discharge (vagina/rectum- possibly throat)

What are maternal complications for gonorrhea?

• Untreated can lead to ectopic pregnancy/infertility

• Untreated can lead to Pelvic Inflammatory Disease (PID)

• Preterm labor, PROM, chorioamnionitis, sepsis

What are Fetal/Newborn complications of gonorrhea?

• IUGR (Intrauterine Growth Restriction)

• Sepsis

What is the screening/treatment/prevention for gonorrhea?

• Routine screening of asymptomatic and pregnant women (especially with high-risk behaviors)

  • Swab vagina, rectum, throat?

• ABX

How is Syphilis transmitted?

• Transmission by entry in subcutaneous tissue through microscopic abrasions (kissing, biting, oral-genital sex)

• VERTICAL transmission during any gestation of pregnancy

What are signs/symptoms and maternal complications of Syphilis?

• Stage 1/Primary Syphilis: lesion/chancre (contagious)

• Stage 2/Secondary Syphilis: maculopapular rash on the palms and soles and generalized lymphadenopathy. Wart-like lesions on outer Genito-rectal area. (contagious)

• Latent phase if no treatment- no symptoms

• Stage 3/tertiary Syphilis: 1/3 will develop if no treatment, NOT CONTAGIOUS! Neurological/Cardiovascular involvement.

What are fetal/newborn complications of Syphilis?

• Transmission through placenta

• Congenital Syphilis

• Still birth, preterm delivery

What is the screening/treatment/prevention for Syphilis?

• RPR- looks for Syphilis antibodies, but can detect other disease antibodies (can be false positive)

• If RPR is positive → Treponema- sensitive for ONLY Syphilis antibodies

• TX: PCN only when pregnant!

What are signs/symptoms of Human Papillomavirus (HPV)- genital warts?

• Lesions to Genito-rectal area (cauliflower-like mass)

• More common in pregnancy/grow more

What are maternal complications of HPV?

• Large lesions may inhibit vaginal delivery

• May lead to cancer of cervix, anus, penis, mouth

What are fetal/newborn complications of HPV?

• Neonatal infection is rare

What is the screening/treatment/prevention for HPV?

• Tx for warts- cryotherapy (freezing)

• Diagnosis through Papanicolaou (Pap smear)

• HPV is not curable

• Gardasil vaccine for prevention of some types of HPV

What are the two types of Herpes Simplex Virus?

• HSV-1: more typically oral presentation but can cause genital outbreak

• HSV-2: more typically genital presentation but can cause oral outbreak

What are the signs/symptoms for Herpes Simplex Virus?

• Inital infection- multiple painful lesions, fever, chills, malaise

• “fever blisters” that crust over

• Subsequent outbreak- Tingling/burning- can feel them coming on

What are the maternal complications of HSV?

• Cannot deliver vaginally if genital lesions present

• Primary infection during 1st trimester associated with increased miscarriage rates

What are the fetal/newborn complications of HSV?

• Viral culture if concerns- if positive → IV acyclovir

• Liver and lungs often affected

• HIGH MORTALITY RATE!

What is the screening/treatment/prevention for HSV?

• Diagnosis through physical inspection and viral culture

• Medications for discomfort not cure (Acyclovir)

• Acyclovir at 36 weeks to prevent vaginal outbreaks

Is Group Beta Streptococcus (GBS) an STI?

• NO

• Considered normal vaginal flora that is in approx. 25% of healthy women

What are the signs/symptoms for GBS?

• Usually none maternally

• If cause of UTI, will treat during labor even if negative swab

What are the maternal complications for GBS?

• UTI

• Chorioamnionitis

• Maybe preterm labor (rare)

What are the fetal/newborn complications for GBS?

• Early onset GBS sepsis (1st week)

  • Hypothermia, respiratory distress, poor feeds, lethargy, cyanosis

• Late onset GBS sepsis (usually more serious)

  • Additionally- meningitis

What is the screening/treatment/prevention for GBS?

• Screening at 35-37 weeks of gestation decreases risk of neonatal transmission

• IV ABX- ideally PCN Q4 hrs during labor/after SROM until delivery (prophylactic)

• ABX are for BABY!

What STI is most threatening to a neonate?

• Hepatitis B

What are the signs/symptoms of Hepatitis B?

• Disease of liver, often a silent infection

• May be “fulminating”- sudden and severe to point of fatality (joint pain, malaise, anorexia, N/V, HA, fever, abdominal pain)

Are there maternal complications known for Hepatitis B?

• No

What are the fetal/newborn complications for Hepatitis B?

• Transmission through placenta

• Liver problems, jaundice

• Can still breastfeed if baby is treated

What is the screening/treatment/prevention for Hepatitis B?

• HBsAG (current or past infection) testing early in pregnancy

• Hepatitis B Vaccine (if mom “reactive”)

• HBIG (Hepatitis B Immunoglobulin) for baby within 7 days (different site than Hep B vaccine) if mom is HBsAG+.

  • 94% chance of not contracting if both medications given!

What is the most common blood born pathogen?

• Hepatitis C

What are the signs/symptoms for Hepatitis C?

• Jaundice, fever, anorexia, light stool, dark urine

What are the maternal complications for Hepatitis C?

• None known

What are the fetal/newborn complications for Hepatitis C?

• ~6% transmission during birth process

• No documented cases of Hep C transmission with breastfeeding

What is the screening/treatment/prevention for Hepatitis C?

• Screen with high-risk behaviors: history of IV drug use

• Tx after pregnancy/done breastfeeding

What are the signs/symptoms for Human Immunodeficiency Virus (HIV)?

• Usually none maternally

• If cause of UTI will treat during labor even if negative swab

What are the maternal complications of HIV?

• If high viral load (higher risk of transmission) C/S @ 38 weeks recommended

What are the fetal/newborn complications for HIV?

• Transplacental transmission (1-2% with proper treatment)

• Medication after delivery

• Breastfeeding NOT recommended

What is the screening/treatment/prevention for HIV?

• Screen with high-risk behaviors: IV drug use, high-risk sex partners, multiple sex partners

• Antiretroviral therapy (ART)

• Highly active antiretroviral therapy (HAART)

What are some fun facts about Trichomoniasis?

• up to 50% of all cases of vaginitis

• PROTOZOAL Parasite- has flagella- hairs like structure for movement

• Males usually asymptomatic

What are signs/symptoms for Trichomoniasis?

• yellowish-to-greenish, frothy, mucopurulent, copious, malodorous discharge

Are there any maternal or fetal/newborn complications for Trichomoniasis?

• None known

What is the screening/treatment/prevention for Trichomoniasis?

• Speculum exam

• Tx: ABX/antiparasitic: metronidazole

What is special about TORCH infections?

• ALL cross the placenta!!

What infections fall under TORCH?

• Toxoplasmosis

• Other (Zike/Varicella/etc.)

• Rubella

• Cytomegalovirus

• Herpes Simplex Virus (HSV)

What is Toxoplasmosis/what does it affect with the mom/fetus?

• Parasite found in cat feces- don’t change litterbox if pregnant

• Fetal brain/nervous system damage, increased risk of miscarriage

What does Rubella caused with mom/fetus?

• Risk of miscarriage if contracted in 1st trimester

• Congenital Rubella Syndrome:

  • microcephaly, PDA, eye problems, deafness

• Blueberry Muffin Rash

What is Cytomegalovirus?

• Most common cause of birth defects in US

• Deafness