INFECTIONS DURING PREGNANCY - NURSING ASSIGNMENT

INTRODUCTION

        Sexually transmitted infections during pregnancy are an important cause of morbidity and mortality throughout the world. Many infections are often asymptomatic and are consequently not diagnosed. Some individual may not assess sexual health services.

INFECTION DURING PREGNANCY

BACTERIAL INFECTIONS

CHLAMYDIAL INFECTIONS

        Chlamydial infection is becoming the common sexually transmitted pathogen. The organism are found in urethra, endocervix and rectum.

ADVERSE EFFECTS

        The adverse effects in pregnancy are preterm labour, chorio amnionitis, still birth, perihepatitis neonate may develop conjunctivitis or pneumonia.

CONFORMATION TEST

        Tissue culture method (the culture materials taken from both cervix and urethra) serological detection of chlamydial antigen by ELISA.

TREATMENT

        Erythromycin 5g 4 times in a day for 7-10 days

Azithromycin 1 gm in a single dose.

GONORRHOEA

        If the infection takes place during pregnancy it tends to be more acute.

SIGNS AND SYMPTOMS

        The most common symptom is increased vaginal discharge, lower abdominal pain, dysuria, intermenstrual uterine bleeding are also experienced.

ADVERSE EFFECTS

        Infection increases the risk of preterm babies PROM, intrapartum and post partum infections. Disseminated infection includes arthritis, meningitis, endocarditis. The baby also offered ophthalmia neonatrom.

DIAGNOSIS

        Bacteriological identification of intracellular gram negative bacteria from urethral or cervical smear serological test

TREATMENT

        Single dose injection of ceftriaxone 125mg IM

SYPHILIS

        Syphilis is a sexually transmitted disease caused by Treponema palladium

INCIDENCE

·        Due to upsurge HIV infection

·        IV Drug Abuse

·        The infection does not occur before 4 month of pregnancy

The symptoms may be suppressed during pregnancy.

EFFECT ON MOTHER

        Syphilis accelerate the course of HIV infection the pregnant women untreated syphilis in pregnancy may result inspontaneous abortion, preterm birth, still birth, neonatal death.

DIAGNOSTIC EVALUATION

        Serological Test

        VDRL Test

        Detection of spirochetes from cutaneous lesion

TREATMENT

Treatment should started as soon as the diagnosis is established. For primary or secondary or latent syphilis benzathine pencilin 2.4 million units intramuscularly.

GROUP B STREPTOCOCCUS INFECTIONS

        Maternal infections with GBS is an important cause of high perinatal mortality. Vaginal and anorectal colonization of GBS is the main source of infection.

ADVERSE EFFECTS

        Preterm delivery, prolonge rupture of membrane, maternal pyrexia during labour.

TREATMENT

        Effective treatment is antepartum therapy with ampicillin.

VIRAL INFECTION

RUBELLA

       Rubella or German measles is transmitted by respiratory droplet exposure. Fetal affection is by transplacental route throughout pregnancy.

        The virus predominantly affects the fetus and extremely teratogenic if contraindicated within the first trimester.

ADVERSE EFFECTS

        There is increased chance of abortion, still birth, congenital malformed babies.

TEST FOR RUBELLA

        Test for rubella specific antibody should be done within 10 days of exposure to know whether the patient immune or not.

VACCINATION

        Active immunity can be conferred in non immune subjects by giving line attenuated rubella vaccine preferably during 11-13 years. It is not recommend in pregnant women

MEASLES

        The virus is not teratogenic however high grade fever, still birth or premature delivery.

TREATMENT

        Nonimmunized women coming in contact with measles may be protected by intramuscular injection of immune serum globulin.

INFLUENZA

ADVERSE EFFECTS

        It may cause abortion, still birth, premature labour outbreak of asian influenza should increased incidence of congenital malformation when the infection occurred in 1^st trimester.

TREATMENT

        Influenza vaccine safe in pregnancy after the 1^st trimester.

CHICKEN POX (VARICELLA)

        Varicella zoster does cross the placenta may cause congenital or neonatal chicken pox. Maternal mortality is high due to varicella pneumonia,

ADVERSE EFFECTS

        Varicella zoster will cause the fetal congenital malformations are : hypoplasia of limb, limb deformity, cataracts, microcephaly

TREATMENT

        Varicella zoster immunoglobulin should be given to exposed nonimmune patients to reduce morbidity. Varicella vaccine is not recommend in pregnancy.

CYTOMEGALOVIRUS

        It is a DNA virus. Transmission may be sexual, respiratory droplet, or transplacental. Virus is also excreted through urine, milk fetus is affected transplacental route, unless rubella CMV may damage fetal organs throughout gestation.

ADVERSE EFFECTS

        The consequence of infection include still birth, abortion, IUGR, microcephaly, intracranial calcification, hepatosplenomegaly.

DIAGNOSIS

        Infection is confirmed by viral culture of urine and nasopharyngeal secretions. Prenatal diagnosis by cordocentasis is possible.

PARVO VIRUSES

        Parvovirus is associated with human infection during pregnancy fetal infection is done by transplacental route.

ADVERSE EFFECTS

        It mainly affects the crythroid precursor cells resulting in anemia, aplastic crises, congenital heart failure. Fetal loss is more when infections occurs early pregnancy.

        Diagnosis is made by detection of virus specific 1gm

MUMPS

·        Maternal mumps has got no ill on the course of pregnancy. The virus is not teratogenic

·        Incidence is expected to be low with the introduction of measles mumps rubella vaccine to childhood vaccination programme. MMR vaccine contraindicated during pregnancy.

HERES SIMPLEX VIRUS

·        Genital tract infection is due to HSV-2. It is transmitted by sexual contact. Primary contact may occur during pregnancy or reactivation or recurrent infections occurs resulting in virus shedding with or without symptomatic lesions

·        Effect on pregnancy: Increased risk of abortion is inconclusive. If the primary infection is acquized in the last trimester there is chance of premature labour.

TREATMENT

·         Acylovir 200mg five times daily is the drug of choice when virus culture is +ve.

HUMAN IMMUNO DEFIFICIENCY VIRUS INFECTION

·        Human immunodeficiency virus causes incurable infection that lead to ultimately to terminal disease acquired immunodeficiency syndrome.

·        The mode of transmission are sexual contact, transplacental, exposure of infected blood or tissue fluids, and through breast milk.

·        In pregnancy HIV infection cause increased incidence of abortion, prematurity, IUGR, perinatal mortality

·        The enzyme immunoassay is used as a screening for test for HIV antibodies.

MANAGEMENT

PRENATAL CARE

·        Voluntary serological testing for HIV infection to all pregnancy women’s.

        Inseropositive cases the following additional test should be done.

1.   Test for sexually transmitted disorders

2.   Serological test for cytomegalovirus

3.   Tuberculosis

4.   Counseling about the risk of HIV transmission to the fetus and neonates

5.   Progression of the disease is assessed by

a.    CD4+T lympholyte count

b.   HIV RNA viral assessment

6.   Antiviral therapy to HIV^-1 positivewomen is highly effective reducing the viral load.

INTRAPARTUM CARE

1.   Zidovudine is given IV infusion at the onset of labour

2.   Elective caesarean delivery reduces the risk of vertical transmission

3.   To avoid procedure that might result in break in the skin or mucous membrane of the infant

4.   Caps, masks, gowns and double gloves should be worn. Protective eye wear should be used

PYELONEPHRIUS IN PREGNANCY

·        There is increased chance of urinary tract infection in female as compared to male, it is more common in primigrovidae than multiparae

·        Acute aching pain over the loins, often radiating to the groin and costovertebral angle tenderness, fever with chills, rigor

·        Investigation apart from routine ones, serum level of creatinine, electrolyte and culture studies of urine and blood should be done

·        There may be increased fetal loss due to abortion, preterm labour, intrauterine fetal death.

·        Antimicrobial suppression therapy is continued till the end of pregnancy to prevent recurrence. Vitrofuration 100mg daily at bed time is effective.

INFECTIONS OF THE VAGINA AND VULVA

TRICHOMONIASSI

Trichomoniasis almost exclusively sexually transmitted.

ADVERSE EFFECTS

        Trichomoniasis has been linked with a small risk of preterm and low birth weight and an increase in risk of HIV via sexually intercourse.

DIAGNOSIS

        Cultural examination.

        Microscopic examination of a well film

TREATMENT

        Metronidazole daily for 5-7 days and pessaries daily for 7 days can be prescribed

BACTERIAL VAGINOSIS

        Bacterial vaginosis is the most common cause of vaginal discharge in women of child bearing age. The incidence is high in women with pelvic inflammatory disease.

        The main symptom is malodourous and grayish vaginal discharge and vulval irritation may occur in about one third of women other adverse outcomes include late miscarriage, low birth weight, preterm premature rupture of membranes.

DIAGNOSIS AND TREATMENT

        A diagnosis of BV is confirmed if three of the following criteria is present

·        Thin, white to grey, homogeneous discharge

·        Clue cells on microscopy

·        A vaginal PH of >4.7

·        A release of a fishy smell when adding potassium hydroxide

        Alternative treatment of oral clindamycin, intravaginal clinamycin cream, or metronidazole gel.

CANDIDIASIS

        Vaginal condidiasis is found 2-10 times more frequently in pregnant than non pregnant women candidal colonization rates rise from less than 10% of pregnant women in the first trimester to over 50% in the III trimester.

SIGNS AND SYMPTOMS

        Intense vulval pruritis and soreness and often thick white curdy discharge. The vulva, vagina and cervix may be erythematous and edematous.

DIAGNOSIS AND TREATMENT

        Vaginal culture is the most common sensitive method currently available for detecting candida cells. Candidiasis is treated primarily with antifungal pessaries or cream inserted high into vagina. Preparation that may include clotrimazole pessaries, nyslatin pessaries or gel.

NURSING CARE

·        Advice the mother to maintain perineal hygiene for to wear loose cotton clothing

·        Teach about comfortable measures

·        Avoid inter course until the disease cure

·        Nurse should do not vaginal examination to assess infection and inflammation of the vagina

·        Note the colour, quantity, of the vaginal discharge

·        Advice the mother to void urine frequently

·        Check the vital signs every 2^nd hourly

·        Maintain input output chart

·        Advice the mother to take more fluids

·        Advice the mother to avoid any garments that restricting ventilation

·        Cathererization of the patientif the patient is having dsysuria

CONCLUSION

        The diagnosis, treatment and care of women with sexually transmitted infections during pregnancy present on opportunity for a range of health professionals to work together collaboratively to cater for individuals needs, improve pregnancy outcomes and low maternal and neonatal morbidity and mortality.

BIBLIOGRAPHY

• Myles Text Book of Midwives, 14^th Edition, Edited by Diane M Fraser and Margaret A Cooper, Page No.373-387.

• Text Book Obstetrics of DC Dutta, 6^th Edition, Page No. 293-301