Infections in pregnancy and the puerperium.pptx

Infections in pregnancy and
the puerperium
Themba Hospital DipObs Tutorials
By Dr N.E Manana

SEXUALLY TRANSMITTED INFECTIONS
ABNORMAL VAGINAL DISCHARGE
• Vaginal discharge should be considered abnormal if it is itchy, excessive, yellow or green, or
offensive-smelling.
• Wherever possible, use a vaginal speculum to observe the discharge and inspect the cervix.
Vaginal Candidiasis
• Vaginal Discharge Syndrome, Thick, white vaginal discharge with itch.
• Give a clotrimazole pessary to insert into vagina that evening.
• If vulval burning/itching give a clotrimazole cream to vulva twice daily, continue for three days
after symptoms resolve for maximum of two weeks.
Treat syndromically for gonorrhoea, chlamydia and trichomonas, with triple antibiotics:
• Ceftriaxone 250 mg IM as a single dose
• Azithromycin one gram orally as a single dose (azithromycin 1 g stat is an alternative to
amoxicillin; stat dose would be preferable compared to prolonged course of amoxicillin.)
• Metronidazole two grams stat (can be used in all trimesters of pregnancy)

SEXUALLY TRANSMITTED INFECTIONS
Severe penicillin allergy, Avoid ceftriaxone. This includes a history of any of the following:
• Angioedema
• Anaphylactic shock
• Bronchospasm
• Steven-johnsons syndrome
• Replace ceftriaxone with high dose azithromycin two grams orally as a single dose
(Spectinomycin 2 g IM currently recommended for gonorrhoea in penicillin allergic patients;
• However increasing the dose of azithromycin would be simpler.
• This high dose will treat both gonorrhoea and chlamydia.
• If symptoms persist after seven days, repeat treatment if possible reinfection or poor
adherence to treatment; otherwise refer the patient to specialist care.
• Notify the partner to come for examination and treatment.
• Doxycycline is not part of these guidelines and should be avoided in pregnant women.

GENITAL WARTS
• These are caused by the human papilloma virus (HPV) and are sexually
transmitted.
• They can be external on the vulva or perineum, or internal in the vagina or
on the cervix.
Treatment
• Podophyllin is contraindicated in pregnancy.
• If small (<10 mm), soft and involve the skin, no treatment is indicated in
pregnancy and can be treated postpartum.
• If very large, bleeding or infected, refer to a doctor.
• Consider elective caesarean delivery if warts are very large and may obstruct
vaginal delivery.
• Do a Pap smear (if not done within the past year); this can be done up to 30
weeks’ gestation.

GENITAL ULCERS
Painful small ulcers, Treat for genital herpes:
• Acyclovir 400 mg orally eight hourly for seven days
• Pain relief if necessary; keep lesions clean and dry
• Counsel that HSV infection is life long and recurrent episodes may occur
• If the first ever episode of genital herpes (primary infection) occurs in the third trimester,
there is a risk of
• neonatal herpes. Refer the patient: caesarean section may be advised
• Patients should be advised to inform their partners.
• Sexual transmission of HSV can occur even in the absence of symptoms
Painless ulcer with or without swollen inguinal lymph nodes, Take blood for syphilis tests
• Treat for primary syphilis and chancroid:
• Benzathine penicillin 2.4 million units IM single dose and azithromycin 1 g orally single dose

GENITAL ULCERS
Penicillin allergy
• Refer for further investigation of primary syphilis; if primary syphilis
proven, admit to hospital for penicillin desensitization.
• Only penicillin will adequately prevent transmission to the foetus, and
prevent congenital syphilis.
• There are no proven alternatives. If no improvement within a week
• Refer
• Notify partner to come for examination, syphilis and HIV testing, and
treatment.

SYPHILIS AND POSITIVE RPR TESTS
SYPHILIS SCREENING IN PREGNANCY
• Rapid syphilis screening must be done at the first antenatal visit.
• If the first test is performed before 20 weeks and is negative, a second test
should be done at 32-34 weeks.
• A rapid card test, done in the antenatal clinic, gives a result before the woman
goes home.
• This allows immediate treatment.
Treatment
• Treat all women with a positive screening test, irrespective of titre.
• Give benzathine penicillin, 2.4 million units IM once weekly, for three doses

URINARY TRACT INFECTION CYSTITIS
• This presents with urinary discomfort and/or frequency. There may be some lower abdominal tenderness.
• The patient usually has no fever and does not appear ill. Urine dipstick testing may show any of leucocytes, nitrites
or protein.
• Asymptomatic bacteriuria is a condition in pregnancy that sometimes precedes acute pyelonephritis, and may be
associated with preterm labour.
• If detected on urine culture, it should be treated in the same way as cystitis.
Management
• If possible, send a midstream urine specimen for microscopy, culture and sensitivity (MC&S).
• Treat empirically with a suitable oral antibiotic. The first line choice of antibiotic should be guided by advice from
• the local microbiologists, based on sensitivity patterns of UTIs in the local area.
• Possible choices include: Cephalexin 500mg qid for five days, Nitrofurantoin 100 mg orally four times daily for
seven days (only before 36 weeks), Cotrimoxazole two tablets twice daily for five days
• If urine culture is positive, change antibiotics according to sensitivity results.
• Avoid use of co-amoxyclav as first line empirical therapy, as it should be reserved for cases of severe sepsis, and it
has been associated with an increased risk of necrotising enterocolitis when given in cases of pre-labour preterm
rupture of the membranes.
• Encourage a high oral fluid intake.

ACUTE PYELONEPHRITIS
This is a common and serious cause of pyrexia in pregnancy, and may precipitate pre-term labour.
The patient usually appears ill and has a pyrexia and tachycardia. There is almost always renal angle tenderness.
• Admit to hospital.
• Obtain a midstream urine specimen for MC&S.
• Take blood for urea and creatinine, FBC and smear, and blood culture.
• Ciprofloxacin is contraindicated in pregnancy. Therefore the following empiric antibiotics should be used, with
de-escalation to narrower spectrum antibiotics once organism and sensitivities available:
Cystitis or mild pyelonephritis:
– Coamoxiclav one g po 12 hourly
– Duration five days for cystitis, 14 days for pyelonephritis
• If urine culture is positive, change antibiotics according to sensitivity results.
• Discuss with microbiologist at your laboratory if advice needed on antibiotic choice.
• Ensure a high oral fluid intake: give Ringer-Lactate solution IV 3 L/day, or more if dehydrated.
• Give anti-emetics if vomiting.
• Refer the patient if renal impairment, or not responding to treatment within 48 hours.
• Following treatment, take two further urine specimens for MC&S to ensure that the infection is eradicated.

ACUTE PYELONEPHRITIS
Penicillin allergy
• Ciprofloxacin 400 mg IV 8 hourly; change to oral ciprofloxacin 500 mg bd
24-48 hours after fever subsides.
• Treatment with ciprofloxacin requires only seven days in total.
Alternative
• Gentamicin five to six mg/kg intravenous daily; treat for 14 days; should
only be given if therapeutic drug monitoring is available.
• Do not give in renal impairment.

MALARIA
• Malaria in pregnancy is associated with serious complications.
• These are due both to the effects of a severe febrile illness in pregnancy
• And to the malaria parasite itself, which becomes sequestered in the placenta,
and in the small blood vessels of the brain, kidneys and other organs.
• Foetal complications include miscarriage, preterm delivery, foetal growth
restriction, and perinatal mortality.
• Severe maternal complications include cerebral malaria, hypoglycaemia, ARDS
and maternal death.
• Most severe malaria in South Africa is due to Plasmodium falciparum; drug
treatments below are for falciparum malaria.
• For treatment of non-falciparum malaria, consult local guidelines.
• If unsure of species, treat for P falciparum.
• Malaria is a notifiable disease.

MALARIA
PITFALLS IN THE DIAGNOSIS AND TREATMENT OF MALARIA
• Not recognizing the diagnosis
• Malaria presents as a febrile illness, with a wide differential diagnosis. There are no
specific symptoms or signs. It can often be mistaken for influenza, or another viral
infection.
• Jaundice or anaemia and thrombocytopenia may be the leading symptoms.
• Cerebral malaria and eclampsia may be difficult to distinguish. If in doubt, treat for
both.
• People from endemic areas are a major risk group when moving to a country where
malaria is not endemic: their immunity wanes over time, and they do not realise that
returning to their home country can result in severe malaria.
• The ‘VFR’ group of patients (Visiting Friends and Relatives) are often not recognised
by healthcare workers as at risk. Always ask patients about travel history
• Delay in laboratory testing, Alert the laboratory to test the specimen urgently

MALARIA
Severe malaria is a medical emergency
• All pregnant women with malaria should be admitted to hospital.
• All pregnant women with severe malaria should be admitted to the highest
possible level of care: preferably an intensive care or high care unit in a
tertiary hospital.
• Disease severity can easily be underestimated: if a patient is diagnosed
with uncomplicated malaria, regular and repeated examination is
necessary.
• Not ensuring that the first dose of malaria treatment is given when it is
prescribed
• Do not just write the prescription chart – ensure the medicine is given.
• The best rule is that the prescribing doctor gives the first dose.

MALARIA
DIAGNOSIS OF MALARIA
• Thick and thin blood film: for parasite count, and to confirm the species and stage of parasites.
• The parasite count is also used for monitoring response to treatment.
• Rapid diagnostic test (RDT) using a finger prick blood sample, for diagnosis of malaria antigen.
• These are less sensitive than the malaria blood film; a blood film should always be requested.
• RDTs are very useful in hospitals where may be readily available, with an offsite laboratory needed to
read a blood film.
• In a febrile patient where suspicion of malaria is high, a single blood film cannot rule out malaria.
• Three blood films over 12-24 hours are necessary to rule out the diagnosis.
MALARIA SEVERITY
• Uncomplicated malaria
• Patient shows none of the clinical or laboratory features below.
• Patients have mild symptoms, are ambulant, with normal mental function and no organ dysfunction.
• Severe malaria: If the patient has any clinical evidence of severe malaria, start treatment. Do not
wait for the laboratory tests

Clinical features
• Impaired consciousness
• Convulsions
• Severe weakness (unable to sit)
• Hypotension (systolic BP < 80 mmHg)
• Respiratory distress (acidotic breathing or RR > 30 breaths/minute)
Visible jaundice
• Macroscopic haematuria
• Abnormal bleeding: (eg retinal haemorrhages, DIC)
Laboratory features
Hyperparasitaemia (>4% parasites)
Severe anaemia (Hb< 5 mg/dL)
Hypoglycaemia (Hgt < 2.2 mmol/L)
• Acidosis (pH < 7.25 or plasma bicarbonate < 15 mmol/L)
• Renal impairment (serum creatinine >250 μmol/L)
Hyperlactataemia (venous lactate > 4 mmol/L)
Figure 12.1: Assessing malarial severity

MALARIA
Management of uncomplicated malaria (none of the features of severity are present)
• If a patient with uncomplicated malaria is vomiting, give an antiemetic, e.g. metoclopramide. Repeated
vomiting after antiemetic treatment is an indication for intravenous treatment.
Oral artemether-lumefantrine (Coartem)
• Four tablets (80mg artemether and 480 mg lumefantrine) immediately (if > 35 kg).
• Repeat dose after eight hours on day one. Then repeat dose 12 hourly on following two days: five doses in
total.
• Give each dose with fat containing food/drink to ensure adequate absorption.
If artemether-lumefantrine is not available
• Oral quinine, 600 mg eight hourly for seven to ten days.
• Add oral clindamycin 10 mg/kg 12 hourly for seven days, two to three days after starting quinine.
General measures for treating uncomplicated malaria
• Admit all pregnant women with malaria to hospital, monitor blood sugar four hourly.
• Monitor regularly for clinical and laboratory markers of severity; if any deterioration, change to IV treatment
and refer.
• Ensure adequate hydration, but avoid over-hydration.
• Control pyrexia; fan or tepid sponge, paracetamol may be given, avoid NSAIDS (nephrotoxic).

MALARIA
Follow up
• All women with ongoing pregnancies need follow up at hospital antenatal clinic due to the risk of impaired foetal growth.
Management of severe malaria
• Severe malaria is a medical emergency, ideally requiring intensive care unit treatment.
• After rapid clinical assessment and confirmation of the diagnosis, give correct dose of IV treatment immediately.
Transfer urgently for specialist care.
• Good nursing care is vital.
• If it is not possible to transfer the patient immediately discuss with an Infectious Diseases Specialist, Intensive Care Specialist or
Physician
Treatment of severe malaria while preparing the patient for transfer
• Start intravenous quinine: loading dose of 20 mg/kg stat, in 5 mL/kg of 5 per cent dextrose saline, by slow intravenous infusion over
four hours.
• This is followed by quinine 10 mg/kg given over four hours, every eight hours. Give IV treatment for at least 24 hours.
• Monitor blood glucose for hypoglycaemia
• Monitor respiratory rate and oxygen saturation
• Monitor all intake and output
• Add broad-spectrum antibiotics to treat secondary bacterial infection
• Reduce high body temperatures (> 39°C) by tepid sponging and anti-pyretics

Penicillin V (250mg/5ml strength) suspension
concentration:
Resulting
concentratio
n (units/mL)
Amount in ml of the
concentration to be
swallowed (add to
~30ml water for easier
drinking)
Units
Cumulative
dose
(units)
1 Dilute 1ml suspension into 80ml of water 1,000 0.1ml 100 100
2 Dilute 1ml suspension into 80ml of water 1,000 0.2 ml 200 300
3 Dilute 1ml suspension into 80ml of water 1,000 0.4 ml 400 700
4 Dilute 1ml suspension into 80ml of water 1,000 0.8 ml 800 1,500
5 Dilute 1ml suspension into 80ml of water 1,000 1.6 ml 1,600 3,100
11 Use undiluted suspension 80,000 1.0 ml 80,000 176,700
14 Use undiluted suspension 80,000 8.0 ml 640,000 1,296,700
Figure 12.2: Outpatient oral desensitisation protocol for patients with penicillan allergy

MALARIA
• Use oral penicillin V (phenoxymethyl penicillin) suspension (250mg/5ml strength; 5
ml is equivalent to 400 000 Units).
• Dilute as follows and administer orally every 15-20 minutes:
• Observe for 30 minutes after last oral dose before parenteral administration of
penicillin.
• Can be performed in an outpatient setting with emergency resuscitation
equipment ready to manage anaphylactic reactions; it must be prescribed by a
doctor.
• Start early in the morning so that the procedure is completed long before the clinic
closes. Stop if there are any skin reactions, vomiting or severe itching/flares.
• Example: first step: take 1ml Pen V oral solution (250mg/ml) and add it to 80ml of
water.
• Take 0.1ml of this solution, add it to 30ml of water and give to the patient to drink

TUBERCULOSIS (TB) IN PREGNANCY
• Non-pregnancy related infections remain the most common cause of maternal mortality in
South Africa.
• TB is the single most common cause. The national consolidated guidelines strongly
emphasise that screening for TB is an essential component of antenatal care.
• Deaths from TB also occur in HIV negative women.
• All pregnant women should be symptom screened for TB at every visit, with early detection,
and prompt initiation of TB treatment essential.
• All HIV positive pregnant women who are acutely or chronically unwell need investigating
for TB.
Symptom screening for TB at all antenatal visits– ask the following:
• Cough of any duration
• Fever
• Night sweats
• Loss of weight, or not gaining weight in pregnancy

If positive for any symptom:
• Collect two sputum samples (ask the patient to cough outside), and send to laboratory for GeneXpert
and microscopy and culture, as per National TB guidelines
• Do this at the antenatal clinic; do not refer to a TB clinic to collect sputum, this causes avoidable
delays
• Ensure the patient has a follow up appointment for the results
• If she has not yet initiated ART, do not start until TB diagnosis made and treatment started
• ART should be initiated within two to eight weeks after starting TB treatment
• If CD4 < 50 cells/mm3, initiate ART within two weeks of TB treatment, when symptoms are improving
and TB treatment is tolerated
If symptom screen is negative for all symptoms:
• HIV positive pregnant women are eligible for Isoniazid Preventative Therapy.
• If sputum sample shows drug sensitive TB, Start TB treatment as per national guidelines.
• All of the oral drugs are safe to use in pregnancy.
• Women taking Aluvia based ART need to double the dose if they are taking rifampicin: increase to four
tablets twice a day.

If sputum sample shows rifampicin resistant TB:
• Drug resistant TB should be confirmed by culture and sensitivity
• Ensure that INH sensitivity and second line sensitivities are requested
• Discuss with local Infectious Diseases (ID) specialists or senior doctors at local TB hospital for advice on regimen
• Drug resistant TB has a high mortality, particularly without an aminoglycoside as part of the regimen; for this
reason ID specialists would generally recommend that an aminoglycoside should be included as part of the
regimen in pregnancy despite any potential risk to the foetus
If sputum sample is negative and there are ongoing symptoms of TB:
• HIV positive patients with TB and low CD4 counts more frequently have negative sputum smears, may have
normal CXR, and more often have disseminated TB.
• If symptoms persist, or there are additional clinical findings (for example, peripheral lymphadenopathy, pleural
effusion) refer promptly for inpatient or outpatient investigation; empiric TB treatment may be necessary.
• Do not delay initiation of ART in pregnant women due to long delays in diagnosis of TB or initiation of treatment:
discuss with local TB clinic or referral centre about starting empiric TB treatment if there is a strong suspicion of
TB.
Management of infants born to mothers with TB:
• If the mother has active TB, BCG vaccination at birth should not be given the infant should be screened for
congenital TB

Figure 13.6: Management of infants born to mothers with TB (Figure 10, National Consolidated
Guidelines).

Isoniazid Preventative Therapy (IPT) for pregnant and breastfeeding women
• IPT has been shown to reduce the incidence of TB in all people living with HIV,
• All HIV positive pregnant women who screen negative for TB are eligible for IPT.
• This can be started irrespective of whether she is on ART prior to the pregnancy, or whether ART is started in
pregnancy.
• Initiate once the patient is stable on ART.
Who is NOT eligible for IPT:
• People with confirmed or unconfirmed active TB
• Active liver disease, acute or chronic
• Excessive alcohol use, more than 21 units/week for women
• Symptoms of peripheral neuropathy
• People who have completed treatment for MDR or XDR TB
• History of adverse reaction to isoniazid
IPT regimen:
• Isoniazid 5mg/kg daily to a maximum of 300mg daily
• Pyridoxine 25mg daily

Duration of treatment:
• TST positive: 36 month
• TST negative or not available: 12 months
• For HIV positive pregnant women who have a positive TST, IPT can continue for
36 months
Symptom screening for TB should still continue at all visits to maternity services:
• If symptom screen is positive, discontinue IPT and send two sputum samples as
above.
Adverse effects of isoniazid, discontinue IPT and refer if any of the following occur:
• Drug induced liver injury: symptoms are jaundice, right upper quadrant pain or
tenderness, nausea and vomiting
• Skin rash
• Peripheral neuropathy (numbness and/or tingling of the feet)

Infections in pregnancy and the puerperium.pptx

In this document