ceratin bacterial, viral, fungal, protozoal and parasitic infections prevails in pregnancy. diagnosis and management

2. D E E P T H Y P . T H O M A S
I I Y E A R M S C N U R S I N G
G O V T . C O L L E G E O F N U R S I N G
A L A P P U Z H A
INFECTIONS DURINGPREGNANCY

3. TYPES
 BACTERIAL INFECTION
 VIRAL INFECTIONS
 FUNGAL INFECTIONS
 PARASITIC AND PROTOZOAL INFECTIONS

4. BACTERIAL INFECTIONS
GROUP B STREPTOCOCCAL INFECTION (GBS)
Organism
 Streptococcus agalactiae

5. Risk factors
Risk factors for early onset neonatal GBS include:
 Positive prenatal culture for GBS this pregnancy
 Preterm birth of less than 37 weeks of gestation
 PROM for longer than 18 hours.
 Intrapartum maternal fever greater than 38°C

6. screening

7. Management
The CDC recommends intrapartum antimicrobial
prophylaxis for
 Preterm labour before 37 weeks of gestation
 Duration of ruptured membranes longer than 18
hours.
 Intrapartum temperature greater than 100.4°F

8.  pencillin G
 Ampicillin.
 Cefazolin .

9. TUBERCULOSIS IN PREGNANCY

10. Risk factors for TB
 Positive family history or past history
 Low socioeconomic status
 Area with high prevalence of tuberculosis
 HIV infection
 Alcohol addiction
 Intravenous drug abuse.

11. Clinical features:
 Cough
 Weight loss
 Sleep sweats
 Evening pyrexia
 Malaise and
 Fatigue
 enlarged lymph nodes or pleural rub

12. Diagnosis:
 Tuberculin skin test

13.  X- ray chest
 Early morning sputum (3 samples) for acid- fast
bacilli
 Gastric washings
 Diagnostic bronchoscopy
 Extra pulmonary sites- lymph nodes, bones ( rare in
pregnancy).

14. Effect of pregnancy on pulmonary
TB
 Pregnancy does not worsen the clinical
course of TB.

15. Effect of TB on pregnancy
 The fertility rate is low
 a higher incidence of toxaemia, Preterm labour PPH
and difficult labour in pregnant patients suffering
from TB.
 the maternal and fetal prognosis is good and
therapeutic abortion is not necessary except in a
patient with multidrug resistance.

16. Effect on the mother
 Pregnancy may worsen the maternal outcome in
drug resistant patients. Medical termination of
pregnancy may be considered in selected cases.

17. Effects on the fetus
 Effective chemotherapy has reduced the
incidence of low birth weight.
 Streptomycin use was associated with
congenital deafness.

18. Treatment
 Rifampicin
 isoniazid
 Ethambutol
 Pyrazinamide
 Newer anti-tubercular drugs include clofazimine,
ciprofloxacin, ofloxacin, amikacin, clarithromycin
and azithromycin.

19. Obstetric management:
 In pregnancy
 In labour
 Breast feeding
 Contraception

20. BACTERIAL VAGINOSIS

21. BACTERIAL VAGINOSIS
Organism-
 Gardnerella vaginalis, Mobiluncus, Mycoplasmas
hominis, Prevotella, and Atopobium vaginae.

22. Transmission
 sexual intercourse, hormonal changes, pregnancy,
antibiotic administration, or use of nonoxynol-9
spermicidal products, douching.

23. Signs and symptoms
 Thin, gray or white
homogeneous vaginal
discharge.
 Increased vaginal discharge
odor (fishy) after intercourse.
 Alkaline pH (> 4.5); bacterial
vaginosis does not cause vaginal
itching or dysuria.

24. Treatment
symptomatic
metronidazole (Flagyl), 500 mg orally twice daily for
7 days .
Asymptomatic
 asymptomatic pregnant patients with antibiotics for
bacterial vaginosis to prevent pre term labour.

25. Effect on pregnancy outcome
 spontaneous abortion, premature rupture of
membranes and pre term labour.
 chorioamnionitis and postpartum endometritis.
 May cause neonatal septicemia.

26. CANDIDIASIS

27. CANDIDIASIS
Organism:
 Candida albicans, Candida tropicalis

28. Transmission
 cause vaginal pH to be more alkaline and high
estrogen levels causing increased production of
vaginal glycogen.

29. Signs and symptoms
 Vaginal and vulvar irritation (erythematous and
edematous)
 Pruritic, white, curd like vaginal discharge
 Yeasty odor
 Dysuria
 Dyspareunia

30. Screening
 Saline or KOH wet mount microscopically examined:
shows hyphae, pseudohyphae and budding yeast
 Usually pH lower than 4.7
 Whiff test absent amine (fishy) odor

31. Treatment in pregnancy
 Use an antifungal, intravaginal agent such as
butoconazole, clotrimazole, miconazole or
terconazole
 Sitz baths

32. LEPROSY (HENSEN DISEASE) IN
PREGNANCY

33.  mycobacterium leprae
 With established leprosy, there is chance of
exacerbation of the lesions during pregnancy.
 However, the baby should be separated from the
infected mother, immediately after delivery.
 When the disease becomes quiescent and non-
infectious, the baby may be given to the mother.
 Dapsone and Clofazimine appear safe in pregnancy..

34. GONORRHOEA

35. GONORRHOEA
Organism:
 Neisseria gonorrhoeae
Transmission:
 Gonorrhea is transmitted by close sexual
contact. The incubation period is 3 to 5 days.

36. Signs and symptoms
 Vaginal discharge: may be profuse purulent and
yellow green
 Itching or swelling of vulva
 Dysuria
 Dyspareunia
 Joint and tendon pain
 Anal discharge, discomfort and pain with rectal
infection.

37. Screening
 Molecular diagnostics .
 Endocervical culture

38. Treatment in Pregnancy
 cefixime, 400 mg orally, or one dose of Ceftriaxone,
125 mg intramuscularly.
 Sexual partners within the preceding 60 days should
be identified, examined, cultured and treated.

39. Effect on pregnancy outcome
 It can affect pregnancy outcome in any trimester,
causing chorioamnionitis, pre term delivery, PROM,
IUGR or postpartum sepsis.
 If the organism is present at the time of delivery, the
greatest neonatal risk is gonococcal ophthalmia,
which can cause blindness.

40. SYPHILIS

41. SYPHILIS
 Syphilis is a sexually transmitted disease caused by
Treponema pallidum.

42. Signs and symptoms
 Incubation- 10 to 90 days
 Primary syphilis
Stage one is evident by a chancre, which is highly
infectious, painless, round ulcerated sore that does
not get better fast. It may last 3 to 6 weeks.

43. Secondary syphilis:
 evident by a maculopapular rash
 This rash usually exhibited between 1 week and 3
months after primary chancre. It typically clears in
2-6 weeks but can last upto one year.
 Other manifestations include wart like genital
growth, lymphadenopathy, fever, sore throat, patchy
hair loss, head ache weight loss, muscle aches and
tiredness.

44. Latent syphilis:
 Stage three is usually asymptomatic. The spirochete
goes to hiding for 5 to 20 years. The patient is
seroactive during this stage.
 During the first year of this stage, the patient is
infectious.

45.  Tertiary syphilis:
 The fourth stage is remanifestation of the disease. It
slowly destroys the heart eyes, brain, CNS, and
occasionally the liver, bones and skin.

46. Investigations:
 Serological test- VDRL
 fluorescent treponemal antibody absorption test
(FTA- ABS)
 Treponema pallidum micro –haemagglutination
(MHA- TP) test which are specific.

47. Treatment
For Mother:
 For primary and secondary syphilis(<I year
duration): Benzathine penicillin 2.4 million units
intramuscularly single dose.
 When the duration is more than 1 year- Benzathine
penicillin 2.4 million units intramuscularly weekly
for 3 doses is given.

48.  For Baby:
 Positive serological reaction with a single
intramuscular dose of penicillin G 50,000 units per
kg body weight.
 Infected baby with positive serological reaction- (1)
isolation with mother (2) IM administration of
aqueous procaine penicillin G 50,000 units per kg
body weight each day for 10 days.

49. URINARY TRACT INFECTIONS

50. URINARY TRACT INFECTIONS
 Asymptomatic bacteriuria
 Cystitis
 Pyelonephritis

51.  Organism:
 E.coli, klebsiella pneumonia, proteus species in
recurrent UTI. Less frequent gram positive causative
organism includes group B streptococci, enterococci
and staphylococci.

52. Transmission:
 sexual intercourse and improper wiping after
defecation.

53. Signs and symptoms
 Urinary frequency
 Urinary urgency
 Dysuria
 Hesitancy and dribbling
 Suprapubic tenderness
 Gross hematuria
 Accompanying symptoms with pyelonephritis
usually are chills, fever, and backpain with
costovertebral angle tenderness.

54. Screening
 Microscopic examination shows WBC, bacteria may
or may not be present.
 Dip urine may be positive for nitrates and leukocyte
esterase
 Clean catch midstream specimen for culture and
sensitivity.

55. Treatment in pregnancy for
asymptomatic bacteriuria and acute
cystitis:
 antibiotic therapy for asymptomatic bacteruria is
effective in lowering the risk of pyelonephritis and
preterm labour. Usually 7-10 day course is preferred

56. Treatment in pregnancy for
pyelonephritis:
 The usual treatment is amoxicillin clavulanate(
augmentin) 875 mg bd for 7-10 days
 Cephalosporin

57. Effect on pregnancy outcome
 The endotoxins released from gram negative bacteria
may stimulate the production of prostaglandins and
thus cause preterm labour.

58. VIRAL INFECTIONS IN
PREGNANCY

59. AIDS

60.  Organism:
 the HIV organism is a retrovirus of the lentivirus
family that has an affinity for the T- lymphocytes,
macrophages and monocytes.

61. Transmission
 infected blood or body secretions of semen or vaginal
fluid.
 unprotected sexual activity
 sharing of contaminated needles.
 Pediatric HIV primarily results from perinatal or
breast feeding transmission

62. Immunopathogenesis
 leads to slow but progressive destruction of T cells
 The incubation period is about 1 to 3 weeks.
 After a peak viral load there is gradual fall
 more destruction of host cells  progressive
immunosupression  opportunistic infections and
cancers

63. Clinical presentation:
 fever, malaise, headache, sore throat,
lymphadenopathy and maculopapular rash.
 constitutional symptoms like weight loss,
lymphadenopathy or protracted diarrhea.
 multiple opportunistic infections with candida,
tuberculosis, pnemocystitis, and others

64. Diagnosis:
 enzyme immunoassay
 Western blot test or immunofluroscence assay

65. Management:
 Prenatal care
 Voluntary serological testing for HIV
 Counseling
 assessed by – CD4+ T lymphocyte counts and HIV
RNA at every 3 to 4 months interval

66.  Highly active antiretroviral therapy(HAART)
(1) Nucleoside reverse transcriptase inhibitors
(Zidovudine, Zalcitabine, Lamivudine, Stavudine)
(2) Nonnucleoside reverse transcriptase inhibitors
(Nevirapine, Delavirdine) (3) Protease inhibitors
(Indinavir, Saquinavir, Ritonavir) (4) Entry
inhibitors (Efavirenz).

67.  Intrapartum care
 Zidovudine is given IV infusion starting at the onset
of labour or 4 hours before caesaren section. Loading
dose 2 mg/kg/hr until cord clamping is done.
 Amniotomy and oxytocin augmentation for vaginal
delivery should be avoided whenever possible.
 Elective caesarean delivery is recommended at 38
weeks of women receiving HAART

68.  Postpartum care
 Breast feeding
 Zidovudine syrup- 2mg/kg, is given to the neonate 4
times daily for first 6 weeks of life.

69. TORCH INFECTIONS
 Toxoplasmosis
 This is a systemic infection caused by the protozoan
Toxoplasma gondii

70. Consequences of fetal infection
 The classic triad of hydrocephalus, intracranial
calcification and chorioretinitis.
 The common manifestations are mental retardation,
seizure disorder, hepatosplenomegaly and central
nervous system (CNS) involvement.

71. Management
 Prenatal counselling
 Prevention
 Medications: Pyrimethamine and sulphadiazine
plus folinic acid.

72. Rubella
 RNA toga virus
 spread by nasopharyngeal droplets, with an
incubation period of 14- 21 days.
 A disease prodrome of malaise, fever, headache,
conjunctivitis and pharyngitis, lasting 1-5 days,
precedes the classic manifestations of widespread
pink/red maculopapular rash and generalized
lymphadenopathy.

73. Effect of maternal infection on the fetus
and newborn
 Spontaneous abortion
 Congenital rubella syndrome causing symmetric
IUGR, congenital heart disease, hepato-
splenomegaly and thrombocytopenic purpura.
 CNS manifestations include deafness, eye lesions
such as congenital cataract, retinopathy,
microphthalmia, microcephaly, pan-encephalitis,
brain calcification and psychomotor disorders.

74. Management
 Immunization of all adult women.
 Education of parents about the dangers of rubella
infection.
 All pregnant women should be screened for rubella
antibodies at the first prenatal visit.

75. Cyto megalo virus
 It is a double stranded DNA virus that belongs to the
herpes virus family. Humans are the only known
hosts of this virus.

76. Transmission
 CMV is transmitted through blood via transfusion or
transplacental route commonly and droplet
infection. Body fluids: semen, vaginal secretions,
saliva, urine, breast milk (rare), organ transplant and
rarely through direct contact.

77. Effect of maternal infection on the fetus
and the newborn
 About 15% of the infants are symptomatic
non-immune hydrops, symmetric IUGR,
hepatosplenomegaly, CNS sequeale like
chorioretinitis, microcephaly, hydrocephaly and
calcifications.
 Almost 85% of infants are asymptomatic

78. Management
 Prenatal counselling is highly recommended.
 Drugs such as ganciclovir, forcarnet and cidoforvir.

79. Herpes simplex virus
 simplex virus is a member of the herpes virus family.
It is a DNA virus

80. Transmission
 Transmission is through intimate mucocutaneous
contact. It is one of the most contagious sexually
transmitted diseases (STDs).

81. Significance:
 Spontaneous abortion
 Intra uterine growth retardation
 Fetal death
 Preterm labour
 Neonatal infection
 Neonatal herpes

82. Management
 Acyclovir administered 200mg, four times daily for
14 days.
 Topical application of acyclovir cream
 Severe infections : IV administration of Acyclovir 5
mg/kg body weight/ 8 hourly for 5 days.

83. HEPATITIS B
 The virus is transmitted by parenteral route,
sexual contact, and vertical transmission and also
through breast milk.

84. Maternal infection
 The acute infection is manifested by flu like illness as
malaise, anorexia, nausea and vomiting. There may
be arthralgia and skin rash.

85. Diagnosis
 Diagnosis is confirmed by serological detection of
HBsAg (denote high infectivity) and antibody to
hepatitis B core antigen (HBcAg).

86. Management
 Rest
 Isolation
 Nutrition
 Drugs
 Prevention of complications

87. HUMAN PAPILLOMA VIRUS ( HPV)
 Condylomata acuminate

88. Effect in pregnancy
 can grow more rapidly during pregnancy and are
located over the genital tract and the perineal
regions.
 They can grow so large as to cause dystocia and
severe hemorrhage when disruption occurs during
vaginal delivery.

89. Management
 Excisions of the lesions by cautery or use of
cryosurgery

90. PARASITIC AND PROTOZOAL
INFESTATIONS
 MALARIA

91. Effects of malaria on the mother
 Anaemia
 Hypoglycemia
 Metabolic acidosis
 Jaundice due to hepatic dysfunction
 Renal failure- due to block of renal micro circulation
 Pulmonary edema and respiratory distress
 Convulsions and coma- cerebral malaria

92. Effects on the fetus
 Abortion
 Preterm labor
 Pre maturity
 IUGR
 IUFD

93. Management
 Prevention from mosquito bites using mosquito nets
and repellents.
 Prophylaxis with chloroquine ( 300mg base) orally
once a week

94. INTESTINAL WORMS

95. CHLAMYDIA
 Organism:
 Chlamydia trachomatis

96. NURSING MANAGEMENT

97.  Primary prevention of STI
 Secondary prevention
 Tertiary prevention

98. Nursing diagnosis
 Acute pain related to excoriation from scratching
pruritic areas, ulcerations etc.
 Impaired skin integrity related to presence of skin
infections.
 Risk for complications, IUGR; spontaneous abortion;
PROM; preterm labour and fetal death related to
presence of STDs or other infections.
 Risk for fetal or neonatal infections, fetal
malformations and anomalies related to
complications of maternal TORCH or STDs.

99.  Sexual dysfunction or ineffective sexuality patterns
related to perineal discomfort and prescribed abstinence
during treatment.
 Self esteem disturbance related to the diagnosis of
sexually transmitted disease.
 Ineffective coping related to diagnosis of STDs.
 Knowledge deficit related to disease condition, mode of
transmission, fetal outcome, possible treatment
opportunities etc.
 Fear and anxiety related to the possible fetal outcome
secondary to the infections.

101. THANK YOU……