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Intrauterine infections :tiger: (Congenital infection (TORCH) (:warning:…
Intrauterine infections :tiger:
:star:
Syphilis
Agents — Treponema pallidum
:earth_americas:
Epidemiology
12 million/year
90% found in developing countries
1 million pregnancies with syphyllis...
1/4 Congenital syphilis
1/2 Abortion or perinatal death
1/4 Premature or LBW
:flags: Thailand
Congenital syphilis in 0.1/1,000 live births
Pregnant women seropositive for Syphilis 0.16%
:popcorn:
Types
Acquired
Syphilis
Congenital
Syphilis
Infection when??
:grapes:
Prenatal: Placental transmission, Early stage of ds
Perinatal: Contact lesion at birth canal
Postnatal: Very rare
:crossed_swords:
Diagnostic test
:chipmunk:
Definite Dx
identify T. pallidum
Mucocutaneous lesion, Nasal D/C, LN, Placenta, Umbilical cord
Dark field microscopy
Direct fluorescent Ab (DFA)
Histopathology
DNA detect (PCR)
:chipmunk:
Presumptive Dx
Nontreponemal
tests :peanuts:
VDRL
(Venereal Disease Research Laboratory)
Negative can’t exclude Neurosyphilis
RPR
(Rapid Plasma Reagin)
False :heavy_minus_sign:
Early Primary syphilis (pre-chancre stage)
Latent Acquired syphilis (long duration)
Late Congenital syphilis
Prozone phenomenon
: High conc of Ab (diluting serum ➯ Positive test)
False :heavy_plus_sign:
Infection — EBV, hepatitis, varicella, measles, TB, malaria
Pregnancy, CNT ds, IVDU, Lymphoma,
Wharton jelly contamination
(
Don’t
uses Cord blood ➯ uses baby blood)
F/U values
:diamonds:
Adequate Rx
: Sustained 4x :arrow_down: in titer after Rx
(eg 1:32 ➯ 1:8)
Reinfection or Relapse
: Sustained 4x :arrow_up: in titer after Rx
Primary & Secondary syphilis
titers: :arrow_down: 4x in 6-12 months & Nonreative in 1 yr after Rx
Initial High tiers or Congenital infection
: Seroneg within 2 yrs after Rx
Serofast
: Stable low titers despite effective Rx
:eye: more common in Latent or Tertiary syphilis pt
VDRL ≤ 1:2 or RPR ≤ 1:4 beyond 1 yr after successful Rx
≠ Nontreponemal nonreactive
Treponemal
test :chestnut:
FTA-ABS
(Fluorescent treponemal Ab absorption)
(
More sensitive but less specific than VDRL
)
TPPA
(T. pallidum particle agglutination)
TPHA
(T. pallidum hemagglutination assay)
Exclude False :heavy_plus_sign: Non-treponemal test
:peanuts:
False :heavy_plus_sign:
Other spirochetal ds: Yaws, pinta, Lyme ds, Relasping fever, Leptospirosis
CSF
WBC > 5 cell/mm3, High protein > 40 mg/dL
Tho noted that normal CSF in newborn alrdy has high protein
:doughnut:
Evaluation
Evaluation in
:peanuts:VDRL :heavy_plus_sign: Mom
Evaluation & Rx of infants
with
Maternal reactive serologic tests
for SY
:heavy_heart_exclamation_mark_ornament:1. Adequate Rx before pregnancy & normal infant examination
:heavy_heart_exclamation_mark_ornament:2. Adequate Rx during pregnancy
:heavy_heart_exclamation_mark_ornament:3. Inadequate Rx or abnormal infant examination
:green_heart:
Mx
based on :doughnut:evaluation
Adequate Rx
before
pregnancy &
normal
infant examination :heavy_heart_exclamation_mark_ornament:
No evaluation
No Rx
Some experts would consider:
Benzathine penicillin G
50,000 U/kg single dose IM particularly if F/U is not certain
Adequate Rx
during
pregnancy :heavy_heart_exclamation_mark_ornament:
Evaluation
CBC
CSF cell count, protein, VDRL
Other tests as clinically I/C
:CXR, film long bone, eye exam, LFT, neuroimaging, ABR
Treatment
Option 1
:rabbit2:
Penicillin
10 days
course:
Aqueous penicillin G 50,000 U/kg IV q 12 hr (≤ 1 wk of age)
then q 8 hr (> 1 wk of age) x total 10 days
or
Procaine penicillin G 50,000 U/kg IM OD x total 10 days
Option 2
:rabbit2:
Penicillin
single
dose:
Benzathine penicillin G 50,000 U/kg IM single dose
In
adequate Rx or
Abnormal
infant examinationy
Treatment
Option 1
:rabbit2:
Penicillin
10 days
course:
Aqueous penicillin G 50,000 U/kg IV q 12 hr (≤ 1 wk of age)
then q 8 hr (> 1 wk of age) x total 10 days
or
Procaine penicillin G 50,000 U/kg IM OD x total 10 days
Option 2
:rabbit2:
Penicillin
single
dose:
Benzathine penicillin G 50,000 U/kg IM single dose
Evaluation
CBC
CSF cell count, protein, VDRL
Other tests as clinically I/C
:CXR, film long bone, eye exam, LFT, neuroimaging, ABR
Standard Precaution
Follow up at
2, 4, 6, and 12 months of age
:star: Congenital
R
ubella syndrome
Maternal rubella during pregnancy ➯ Miscarriage, fetal death or congenital rubella syndrome
:explode:
Effects
:eye:
Ophthalmologic
Cataracts
Pigmentary retinopathy
Microphthalmos
Congenital glaucoma
:<3:
Cardiac
PDA
Peripheral pulmonary a stenosis
:couple_with_heart:
Auditory
Sensorineural hearing impairment
:large_blue_diamond:
Neurologic
Behavior disorders
Meningoenceohalitis
Microencephaly
Mental retardation
:frame_with_picture:
Clinical (Neonatal)
Growth restriction (IUGR)
Interstitial pneumonitis
Radiolucent bone ds
Hepatosplenomegaly
Thrombocytopenia
Dermal erythropoiesis (blueberry muffin)
Mild forms: Few or No obvious manifestations at birth
Congenital defects occur
Up to 85%: Maternal infection occurs during GA ≤ 12 wks
50%: infection occurs during GA 13-16 wks
25%: infection during end of 2nd trimester
:warning: Rubella infection in preg — one of few known causes of
autism
:four_leaf_clover:
Dx
IgM
: positive at Birth - 3 months
IgG
: Stable or Increasing over 7-11 months
:frowning_face: Dx in children > 1 yr is difficult
:cry: Sero testing usu
not dx
Viral isolation
RNA
(real time RT-PCR): throat, nasal swab, blood, urine & cataract specimens
:green_heart:
Mx
Isolation of Hospitalized Pt
Contact isolation (proven or suspected case)
:diamonds:
≥ 1 yr of age
Unless 2 cultures of clinical specimens obtained 1 month apart after 3 months of age are negative for Rubella virus
Treatment
: supportive care
Congenital infection (TORCH)
:warning: usu
under-dx
due to
Low index of suspicion
Lack of public awareness
Lack of laboratory Dx test
High cost of work-up
No public funded program
Majority are Asymptomatic at birth
T
oxoplasmosis
O
thers:
Syphilis :star:
, Varicella-zoster, Parvovirus B19(:!: may causes hydrops fetalis in preg)
Congenital
R
ubella syndrome:star:
C
ytomegalovirus
H
erpes infection
Zika virus ➯ causing microcephaly & slow deve