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INFECTIONS IN PREGNANCY

11th Lecture

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UTI During Pregnancy


Hormonal and mechanical changes put even a woman who is not pregnant at risk for urinary stasis and ureterovesical reflux along with a short urethra and difficulty with hygiene due a distended uterus, cause urinary tract infections (UTIs) to become a common occurrence for pregnant women. E.coli 77%, Klebsiella, Classifications:Asymptomatic bacteriuria, Cystitis ,30% symptomatic UTI (Pyelonephritis) UTIs occur in two general settings: community-acquired and hospital (nosocomially) acquired
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Risk Factors for UTI in women:


Hx of previous UTI < 15 years old Short urethra; close to anus Increased sexual activity Diaphragm and /or spermicide use (?) Failure to void after intercourse Chemical irritants/ poor hygiene Diabetes Pregnancy
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Clinical Features
Acute lower UTIs (Urithritis and cystitis): Infection of anterior urethral tract , Cystitis : Infection of urinary bladder Rapid sudden onset of: - Dysuria (burning pain on passing urine) - Urgency (the urgent need to pas urine) - Frequency of micturition; suprapubic pain Normal serum WBC, Upper UTIs (Pyelonephritis): Infection of kidney Gradual onset Fever; Elevated WBC - Chills; N&V; lion pain - Dysuria; Urgency - Frequency of micturition,

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Adverse Outcomes of UTI in Pregnancy


Perinatal: low birthweight <2500gms, and /or prematurity <37 weeks gestation Maternal: Preterm labor <37 weeks gestation Hypertension/preeclampsia Anemia Chorioamnionitis/ amnionitis Increase incidence for PROM & Miscarriage
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General Management of -Asymptomatic


Hydration to wash the bacteria Give paracetamol by mouth for pain and to lower temperature Antibiotics: Should do the culture first, otherwise the picture will be masked Types of Antibiotics given: Gram + (penicillin, ampicillin, Amoxicillin) Gram - (gentamicin), and Anaerobes (metronidazole) Measures for prevention: voiding after intercourse, good hydration, frequent and complete voiding, Avoid bladder irritants: caffeine, spicy foods. Hygiene: wipe front to back.
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Vaginitis
Inflammation of the vagina occurs when the natural PH (acidity) or vaginal flora is destroyed Causes include Use of Antibiotics Poor hygiene Diabetes mellitus Wearing tight and synthetic clothing Infection from a STI Signs & symptoms Increased vaginal discharge; Irritation and itching Frequent or painful urination; Low grade temperature; Reddened vaginal wall

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Common types of vaginitis 1. Bacterial Vaginosis


Causative Organisms: Vaginal bacteria normally present in the vaginal flora Gardnerella vaginalis Symptoms: Malodorous vaginal discharge ( Gray & fishy oder discharge) Pruritus vulvae Diagnosis: Symptoms Elevated vaginal pH (greater than 4.7) Treated by Metronidazole 250 mg three times daily for 7 days Or Clindamycin 300 mg twice daily for 7 days
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2. Monoliasis or Candidiasis
Yeast like fungal vaginal infection BY Candida

albicans
Occurs in diabetics,Corticosteroid therapy; Antimicrobial therapy; Poor hygiene; High-dose estrogen contraceptives; Pregnancy; IUD S&S include thick, curdy, white cottage cheese like vaginal discharge, small ulcers on vagina, abnormal Pap test; marked redness of vulva (Erythema), extreme pruritus, External dysuria and dyspareunia Treatment includes use of antifungal medications and avoiding sex during therapy Only topical (usually for 7 days)
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3. Trichomoniasis
Parasite infection of the genital area by Trichomonas vaginalis. Sexually transmitted, use of antibiotics or contamination from feces S&S include vaginal soreness, burning, itching, yellowdr.Shaban

green or gray frothy discharge with foul odor.

Strawberry appearance of cervix;Dysurea, dysparunia Treatment includes treating both partners with antibiotics and avoiding sex during treatment Can be cured with Metronidazole, if pregnant topical clotrimazole used. If untreated, it may lead to complications during pregnancy (PTL, PROM)

NURSING PROCESS OF PATIENTS WITH INFECTION


Assessment

(Do not douche ) Observe the area for: Erytherma; Edema; Discharge Describe symptoms Odor; Itching; Burning; Dysuria Prep vaginal smear Test pH of discharge

Examine

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Nursing process Patients w/ vaginal infection


Diagnosis Discomfort or pain related to burning, odor or itching from the infectious process Fear related to the possible long-term effects of the disease. Risk for infection or spread of infection Deficient knowledge about proper hygiene and preventive measures
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Nursing process Patients w/vaginal infection

Nursing Interventions
Admin. meds Sitz baths Cornstarch powder Educate patient Douching discouraged Loose fitting underwear = good Tight, synthetic, non-absorbent, heat-retaining underwear = bad
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What is a Sexually Transmitted Disease?


Diseases you can get by having sex vaginal, oral, or anal with someone who is already infected Caused by bacteria or viruses that are spread through blood, semen, and vaginal fluids Also, spread simply by touching infected skin for certain STDs, like herpes and genital warts
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Maternal infections
TORCH infections: Diseases that cross the

placenta and affect the fetus during pregnancy are


T= toxoplasmosis O= other infections (Chlamydia , Gonorrhea Heb B, Syphilis , HPV; AIDS and HIV, UTI) R= rubella (German measles) C= cytomegalovirus H= herpes virus type 11

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STD Transmission
Sex Vaginal Anal Oral

Mother to Baby During Pregnancy During Delivery Through Breastfeeding

Blood Exposure Injecting Drugs Tattooing Body Piercing: toothbrushes and razors that have touched infected blood
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Not from hugging, touching, toilet seats, and swimming pools

DIAGNOSING SEXUALLY TRANSMITTED INFECTIONS


Swab

from the urethra, cervix, vagina, anus or throat Urine test


Blood

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test

T-oxoplasmosis
Toxoplasmosis is a disease caused by parasite called Toxoplasma gondii. Toxoplasmosis has been found in virtually all warmblooded animals including most pets. There are 3 principal ways Toxoplasmosis is transmitted: 1.Directly from pregnant mother to unborn child when the mother becomes infected with Toxoplasmosis during pregnancy. 2.Consumption and handling of undercooked or raw meat from infected animals. 3.Ingestion of food or water or inhalation of dust contaminated with a very resistant form of Toxoplasmosis called the oocyst.
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Avoiding toxoplasmosis
only eat meat which has been thoroughly cooked. Toxoplasma in meat can be killed by cooking at 152F (66C) or higher or freezing for a day in a household freezer. wash hands, chopping boards and utensils thoroughly after preparing raw meat wash all fruit and vegetables thoroughly to remove all traces of soil dont drink unpasteurised goats milk or eat dairy products made from it

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Others-Chlamydia
Most common of all bacterial STDs. Although chlamydia is usually asymptomatic in women, it may present with inflammation of the cervix. Symptoms may occur from two to six weeks after initial exposure to the bacteria.When symptoms do occur they include abnormal genital discharge and burning with urination; vaginal bleeding after intercourse or between menstrual periods; pain during intercourse If untreated, it may lead to pelvic inflammatory disease ( PID), tubal pregnancies, and infertility. Pre-term labour, PROM, Endometritis Treated by Erythromycin 500 mg qid for 7 days or Amoxicillin 500 mg three times daily for 7 days Infant can suffer conjunctivitis.
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Others-Gonorrhea
Bacterial infection of the genital area (gram-negative coccus Neisseria gonorrhoeae). When symptoms do occur they include burning during urination, green or yellowish discharge, abnormal vaginal bleeding, or pelvic pain. dysuria, dyspareunia Pre-term labour, PROM, Chorioamniionitis, Endometritis; It can be passed from an infected mother to her infant during birth causing an eye infection (Opthalmia neonatorum: blindness). Antibiotics can cure the infection (Cephalosporin )
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Human PapillomaVirus (HPV)


Viral infection primarily affecting the outer and inner genital areas. usually related to early onset of sex and multiple partners Symptoms are soft, itchy warts in and around the genitals, often called genital warts (cauliflower-like lesions). During pregnancy, warts may increase in size and number then regress/resolve after delivery. There is no cure for HPV, but warts can be removed through medication and surgery. There may be future outbreaks because the virus stays in the body permanently.
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Hepatitis B
Viral infection primarily affecting the liver. Up to eight weeks after exposure to the virus, some people experience flu-like symptoms including: fatigue, achiness, nausea, vomiting, loss of appetite, darkening of urine, abdominal tenderness, and yellowing of the skin and whites of eyes. Can be treated with antibiotics, but some people are contagious for the rest of their lives.
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Considerations and possible complications


All sexual and household contacts of people with hepatitis B should be advised to be vaccinated to prevent infection Chronic hepatitis B can lead to severe liver damage including cirrhosis (scarring of the liver) and cancer Individuals who develop chronic hepatitis B infection require liver-function monitoring Babies born to mothers with hepatitis B are at a high risk of becoming chronic carriers. They should receive an injection of antibodies immediately after birth, followed by the vaccine
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Rubeola (German Measles)


RNA virus Incubation - 14-21 days Fever, rash (3 days), cough, arthralgias Congenital cataracts, Glaucoma, heart disease, deafness, microcephaly and mental retardation are permanent abnormalities Prevention vaccine, however, contraindication during pregnancy Treatment antipyrexials; cough suppresants Antibiotics for bacteria;Suppress uterine contractions; Isolation precautions
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Herpes Simplex
Caused by herpes simplex virus (HSV) caused painful recurrent blisters of the genital area Transmission by direct contact with oral and genital lesions Increases the chance of transmission of other STDs such as HIV and Hepatitis B There is no cure for herpes, but medication can be used to reduce the frequency of future outbreaks (Zovirax). Herpes can be transmitted even when medication is used ;C/S birth is indicated for a women with active herpes Diagnosed by Enzyme-linked Immunosorbent Assay (ELISA) Sitz baths and applying warm moist tea bags relieve the pain Condom used to prevent infection to the partner.

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Syphilis
A systemic disease caused by bacteria that spread throughout the body Stage 3 can result in (Treponema pallidum) damage to the brain, heart, nervous system, Appears in stages. and death. Stage 1 symptoms are painless sores on the genitals If untreated, it may lead to complications during or mouth ( chancre). pregnancy. Stage 2 symptoms are a rash VDRL ,Venereal on the palms of the hands, Disease Research soles of the feet, or genital Laboratory is preformed area. to diagnose syphilis
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Syphilis
Treatment of all stages is Penicillin After treatment all women are positive for VDRL for 8 months From an infected mother to her fetus, which can result in fetal death or congenital syphilis (causing birth defects) Infected newborn may remain positive for 3 months
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CytoMegaloVirus
DNA virus Infection may remain asymptomatic in pregnant women, and the prognosis is favorable. The risk of transmission to the fetus and of congenital abnormalities is highest when acute infection occurs in the first 22 weeks of pregnancy. 5-10% of those infected show clinical illness at birth Neonatal MR - 20-30% 90% of survivors get late complications
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CMV Congenital Infection


Hepatomegaly Spleenomegaly Jaundice Thrombocytopenia Petechiae Microcephaly Intrauterine growth retardation } } }TORCH }Syndrome } } }
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HIV and AIDS


Caused by the human immune-deficiency virus (HIV), which destroys the bodys ability to fight off infection (Effects T-cells, inhibits immune response). Incubation period can be up to 10 years Diagnosed with ELISA ( CD4 200 ( NORMAL 900-1200). Can be passed to infants in utero and through breast milk

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WHAT ARE THE SIGNS AND SYMPTOMS?


Two

to four weeks after exposure, some infected individuals may experience mild flu-like symptoms that last a few weeks then disappear. For most people, symptoms dont emerge until years after exposure. Once the immune system is weakened, the following may develop: Frequent fever Joint or muscle pain Persistent skin rashes Swollen glands, Sore throat Fatigue or lack of energy Headaches, Rapid, unexplained weight loss Nausea, vomiting, or diarrhea
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AIDS
Maternal Effects Vag candidiasis PID Genital herpes HPV
Fetal Effects
Asymptomatic at birth Candidal diaper rash Thrush Diarrhea Recurrent bacterial infections FTT Development delay
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AIDS- Treatment:
Women

are monitored at each prenatal visit for signs of complications. Also for serologic evidence of progression of the disease Weekly non-stress testing of the fetus begun at 32 weeks ZDV (zidovudine) in pregnancy, labor (and 1st 6 weeks for baby) and Cesarean at 38 weeks decreases transmission Avoid breastfeeding Follow up testing for the newborn

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Nursing Care
Counseling Teach S/S of progression of disease Always practice universal precautions Facilitate use of social services as social isolation the most important nursing diagnosis.
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Measures to Reduce MTCT


During Labor and Delivery:
Delay rupturing of membranes (ROM) Do only minimal digital examinations after ROM Cleanse the vagina with hibitane or other viricides if available Reduce use of assisted delivery with forceps, Reduce use of episiotomy Elective caesarean section has a more protective effect against MTCT than vaginal delivery Avoid mechanical nasal suction Clean the newborn immediately of all maternal secretions and blood
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In Summary
Diseases that cross the placenta and affect the fetus during pregnancy are collected in term TORCH Infection harmful if present at the time of birth Gonorrhea; Candidiasis; Chlamydia; Hepatitis B. Chlamydia, gonorrhea, syphilis, trichomonas, and bacterial vaginitis (BV) can be treated and cured with antibiotics during pregnancy. There is no cure for viral STDs, such as genital herpes and HIV, but medication may reduce symptoms in the pregnant woman

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Ways to avoid STDs


Avoid direct contact by abstinence or practice safe sex by using a condom. Toxoplasmosis- prevent contact with uncooked meat or handling cat product. Rubella- pregnant women should avoid contact with children with rashes Cytomegalovirus (CMV)- hand washing. Syphilis- safer sex, early detection (before 18 wk) by screening (VDRL) and immediate Rx with AB.
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