sterile unless infected by ascending bacteria or hematogenous spread
Lower tract
colonized with a mixture of commensal and pathogenic flora, which are similar to skin and fecal flora
Lactobacilli
species predominate Þ produce and thrive in acid environment (pH 3.8-4.2)
changes in bacterial environment can affect pregnancy; Bacterial vaginalis (BV)
Þ associated with preterm delivery
Antibiotics Contraindicated During Pregnancy
Chloramphenicol
Grey Baby Syndrome; Tetracyclines bone effects, dental stains; Quinolones animal arthropathy/stunting; Sulfonamides risk of neonatal jaundice (unsafe at term, but safe otherwise); Nitrofurantoin G6PD deficient anemia; Aminoglycosides otoxtocity Þ used in neonates for gram negative bacteria; no alternatives
Infections During Pregnancy
Most infections are no more severe during pregnancy than in the absence of pregnany; none are less severe
some are more severe (reason unknown): polio, influenza, varicella, amebioasis, listeria, malaria, coccidiomycosis
Maternal Changes
minimal changes in immunoglobulins; no clear immune dysfunction
Ý
risk of upper respiratory tract infections(URI) and urinary tract infections(UTI), tendency toward earlier systemic invasion, and Ý risk for sepsis and life-threatening pulmonary fluid shift and adult respiratory distress syndrome (ARDS)
Ý
risk of URI: possibly due to ß plasma oncotic pressure, Ý O2 demands, ß difference in alveolar closing pressures
Ý
risk of enteric infections: possibly due to altered gastric acidity and motility
Teratogenic Infections
acronym "TORCH" Þ Toxoplasmosis, Other (Syphilis), Rubella Cytomegalovirus, and Herpes virus
also trypanosomiasis, coxsackie virus, common colds, varicella, parvovirus B19, Venezuelan Equine Encephalitis (VEE)
Toxoplasmosis
protozoan with tachyzoite, tissue cyst and oocyst phases: oocyst is infectious form
acquired from undercooked meat and aerosolized cat feces
Þ "Kitty Litter Disease"
Maternal Symptoms
often asymptomatic; adenopathy malaise; only primary infection is dangerous to fetus unless immunosuppression causes recurrent attacks Þ fetal lesions and life-threatening maternal disease
no effective treatment; vaccination program(RA 27/3 live virus); pregnancy interruption
Cytomegalovirus
DNA herpesvirus; most prevalent cause for neonatal infections Þ 0.2 2 % of all live births; 10% result in clinical disease, 60% seroprevelance; spread by secretions, transfusion or vertically
Maternal Symptoms
asymptomatic, mild mono-like illness with or without jaundice, primary infections most dangerous but reactivation accounts for almost ½ of infections; life threatening in immunosuppressed
Neonatal Symptoms
hepatosplenomegaly, petechial skin lesions "blueberry muffin" chorioretinitis, hydrocephaly, hydrops, CNHS calcifications, growth restriction, deafness, neurobehavioral damage and death
Diagnosis
serologic testing, antibody fixation testing, ultrasound PCR testing of amniotic fluid and fetal blood
Treatment
no clearly effective treatments; future drugs
Þ anti-retrovirals and hyperimmune gamma globulin
Sexually Transmitted Diseases
similar risk as other sexually active women
Herpes Simplex Type 2
rarely teratogenic; vertical intrapartum transmission, primary infection in mother most dangerous
Neonatal Symptoms
cataracts, microcephaly, growth restriction, encephalitis, pneumonia and skin lesions
Treatment
cesarean if active lesions present; antiviral therapy for newborns and mothers; 25% of babies at risk infected
Gonorrhea
dissemination more common if pregnant
Congenial Symptoms
Neonatal opthalmitis can lead to blindness, sepsis, meningitis or death;
Diagnosis
DNA probe and confirmatory culture
Treatment
treat with 2nd generation cephalosporins
Chlamydia
late onset endometritis in mother and conjunctivitis and pneumonia in the newborn
Diagnosis
DNA probe and confirmatory culture
Treatment
Erythromycin; Tetracycline is contraindicated during pregnancy
Human Papilloma Virus (HPV)
Ý lesion growth may be enhanced by estrogen, may obstruct canal and bleeding may be sufficient to require cesarean section; pediatric laryngeal papillomatosis may occur
HIV
4th leading cause of death in women of childbearing age; maternal course is unaffected by pregnancy
vertical transmission is 30% without maternal treatment; maternal antiviral therapy reduces vertical transmission
Diagnosis
serologic testing, PCR for viral load
Urinary Tract Infections
more common in pregnancy because of hormonally mediated ureteral motility changes and mechanical obstruction
usually caused by a single organism (gram negative enteric bacilli: E. coli, Klebsiella species, Group B Strep etc.)
2-7 % incidence of UTI; 25 progress to pyelonephritis if untreated
Maternal Sympt.
can be asymptomatic, dysuria, frequent urination, fever, pain, urosepsis, associated with UTI and prematurity
Treatment
oral antibiotics for lower tract infection; IV antibiotics for inpatients Þ emergency
Pregnancy Specific Diseases
Chorioamnionitis 1-2% pregnancies; usu. polymicrobial, occasionally single strain (group B strep, gonococcus, listeria)
Risk Factors
amniorrhexis, cerclage, labor duration, internal monitoring, exams, colonization by common pathogens
Maternal Symptoms
fever, labor tachycardia, tenderness
Neonatal Symptoms
cerebral palsy
Diagnosis
WBC, CRP, amniocentesis and post facto placental culture and pathology
Treatment
delivery and broad spectrum antibiotics
Group B strep
gram positive bacterium with 10-20% colonization, frequent status change in women
Maternal Symptoms
asymptomatic, urinary infections and endometritis
Neonatal Symptoms
sepsis, pneumonia, late meningitis
Diagnosis
culture with antenatal screening protocols; prophylactic treatment with intrapartum N penicillin
Episiotomy Complications
uncommon; infections (0.05%), dehiscence (3-4%)
polymicrobial pathogens with enteric anaerobes producing more sever cases