Items in AFP with MESH term: Pregnancy Complications, Infectious
ABSTRACT: Appropriate management of pregnant patients who have human immunodeficiency virus (HIV) disease can have a major impact on maternal and infant health. The goals of therapy are to properly manage the pregnancy, treat the maternal HIV infection and minimize the risk of vertical transmission of HIV. Early detection of HIV through aggressive screening programs is necessary to initiate timely therapy. Zidovudine therapy given antepartum and intrapartum to the mother and after birth to the newborn has been shown to decrease the risk of vertical transmission. Evidence suggests that more aggressive antiretroviral therapy for the mother, which allows suppression of viral loads to undetectable levels, may be safe and may provide significant additional benefits. However, treatment needs to be individualized, weighing the possible teratogenic risks against the benefits of decreased transmission. Multiple prospective cohort studies support elective cesarean section as an additional means to decrease vertical transmission, but its role in relation to other therapies has not been determined. As in nonpregnant patients infected with HIV, prevention of opportunistic infections and adequate psychosocial support are essential.
ABSTRACT: Genitourinary tract infections are one cause of preterm delivery. Prematurity is one of the leading causes of perinatal mortality in the United States. Uterine contractions may be induced by cytokines and prostaglandins, which are released by microorganisms. Asymptomatic bacteriuria, gonococcal cervicitis and bacterial vaginosis are strongly associated with preterm delivery. The role of Chlamydia trachomatis, Trichomonas vaginalis and Ureaplasma urealyticum is less clear. By adopting a rational approach to the diagnosis and treatment of genitourinary infections, family physicians can substantially decrease a patient's risk of preterm delivery.
Neonatal Herpes Simplex Virus Infections - Article
ABSTRACT: Neonatal herpes simplex virus infections can result in serious morbidity and mortality. Many of the infections result from asymptomatic cervical shedding of virus after a primary episode of genital HSV in the third trimester. Antibodies to HSV-2 have been detected in approximately 20 percent of pregnant women, but only 5 percent report a history of symptomatic infection. All primary episodes of HSV and secondary episodes near term or at the time of delivery should be treated with antiviral therapy. If active HSV infection is present at the time of delivery, cesarean section should be performed. Symptomatic and asymptomatic primary genital HSV infections are associated with preterm labor and low-birth-weight infants. The diagnosis of neonatal HSV can be difficult, but it should be suspected in any newborn with irritability, lethargy, fever or poor feeding at one week of age. Diagnosis is made by culturing the blood, cerebrospinal fluid, urine and fluid from eyes, nose and mucous membranes. All newborns suspected to have or who are diagnosed with HSV infection should be treated with parenteral acyclovir.
ABSTRACT: The management of infants whose mothers are infected with the human immunodeficiency virus (HIV) involves minimizing the risk of vertical transmission of HIV, recognizing neonatal HIV infection early, preventing opportunistic infections, and addressing psychosocial issues. Maternal antiretroviral drug therapy during pregnancy and labor, followed by six weeks of neonatal zidovudine therapy, can significantly decrease the risk of vertical transmission. Additional antiretroviral drugs may be needed in some high-risk newborns. Elective cesarean section also may prevent vertical transmission of HIV. Virologic tests allow early diagnosis of HIV infection, facilitating the timely initiation of aggressive treatment and the prevention of opportunistic infections. Even when tests are negative, infants must be closely monitored until age 18 months to completely rule out HIV infection. Prophylaxis for Pneumocystis carinii pneumonia should be initiated when HIV-exposed infants are six weeks old and should be continued for at least four months, regardless of negative virologic tests, because P. carinii pneumonia is often the initial presentation of HIV infection in infants. Laboratory monitoring, screening for perinatal infections, appropriate social support, and other modifications of standard infant care are also necessary.
Management of Vaginitis - Article
ABSTRACT: Common infectious forms of vaginitis include bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. Vaginitis also can occur because of atrophic changes. Bacterial vaginosis is caused by proliferation of Gardnerella vaginalis, Mycoplasma hominis, and anaerobes. The diagnosis is based primarily on the Amsel criteria (milky discharge, pH greater than 4.5, positive whiff test, clue cells in a wet-mount preparation). The standard treatment is oral metronidazole in a dosage of 500 mg twice daily for seven days. Vulvovaginal candidiasis can be difficult to diagnose because characteristic signs and symptoms (thick, white discharge, dysuria, vulvovaginal pruritus and swelling) are not specific for the infection. Diagnosis should rely on microscopic examination of a sample from the lateral vaginal wall (10 to 20 percent potassium hydroxide preparation). Cultures are helpful in women with recurrent or complicated vulvovaginal candidiasis, because species other than Candida albicans (e.g., Candida glabrata, Candida tropicalis) may be present. Topical azole and oral fluconazole are equally efficacious in the management of uncomplicated vulvovaginal candidiasis, but a more extensive regimen may be required for complicated infections. Trichomoniasis may cause a foul-smelling, frothy discharge and, in most affected women, vaginal inflammatory changes. Culture and DNA probe testing are useful in diagnosing the infection; examinations of wet-mount preparations have a high false-negative rate. The standard treatment for trichomoniasis is a single 2-g oral dose of metronidazole. Atrophic vaginitis results from estrogen deficiency. Treatment with topical estrogen is effective.
ABSTRACT: Group B streptococcus (GBS) is a leading cause of morbidity and mortality among newborns. Universal screening for GBS among women at 35 to 37 weeks of gestation is more effective than administration of intrapartum antibiotics based on risk factors. Lower vaginal and rectal cultures for GBS are collected at 35 to 37 weeks of gestation, and routine dindamycin and erythromycin susceptibility testing is performed in women allergic to penicillin. Women with GBS bacteriuria in the current pregnancy and those who previously delivered a GBS-septic newborn are not screened but automatically receive intrapartum antibiotics. Intrapartum chemoprophylaxis is selected based on maternal allergy history and susceptibility of GBS isolates. Intravenous penicillin G is the preferred antibiotic, with ampicillin as an alternative. Penicillin G should be administered at least four hours before delivery for maximum effectiveness. Cefazolin is recommended in women allergic to penicillin who are at low risk of anaphylaxis. Clindamycin and erythromycin are options for women at high risk for anaphylaxis, and vancomycin should be used in women allergic to penicillin and whose cultures indicate resistance to clindamycin and erytbromycin or when susceptibility is unknown. Asymptomatic neonates born to GBS-colonized mothers should be observed for at least 24 hours for signs of sepsis. Newborns who appear septic should have diagnostic work-up including blood culture followed by initiation of ampicillin and gentamicin. Studies indicate that intrapartum prophylaxis of GBS carriers and selective administration of antibiotics to newborns reduce neonatal GBS sepsis by as much as 80 to 95 percent.
ABSTRACT: All pregnant women should be offered screening for asymptomatic bacteriuria, syphilis, rubella, and hepatitis B and human immunodeficiency virus infection early in pregnancy. Women at increased risk should be tested for hepatitis C infection, gonorrhea, and chlamydia. All women should be questioned about their history of chickenpox and genital or orolabial herpes. Routine screening for bacterial vaginosis is not recommended. Influenza vaccination is recommended in women who will be in their second or third trimester of pregnancy during flu season. Women should be offered vaginorectal culture screening for group B streptococcal infection at 35 to 37 weeks' gestation. Colonized women and women with a history of group B streptococcal bacteriuria should be offered intrapartum intravenous antibiotics. Screening for gestational diabetes remains controversial. Women should be offered labor induction after 41 weeks' gestation.
ABSTRACT: Chlamydia trachomatis infection most commonly affects the urogenital tract. In men, the infection usually is symptomatic, with dysuria and a discharge from the penis. Untreated chlamydial infection in men can spread to the epididymis. Most women with chlamydial infection have minimal or no symptoms, but some develop pelvic inflammatory disease. Chlamydial infection in newborns can cause ophthalmia neonatorum. Chlamydial pneumonia can occur at one to three months of age, manifesting as a protracted onset of staccato cough, usually without wheezing or fever. Treatment options for uncomplicated urogenital infections include a single 1-g dose of azithromycin orally, or doxycycline at a dosage of 100 mg orally twice per day for seven days. The recommended treatment during pregnancy is erythromycin base or amoxicillin. The Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend screening for chlamydial infection in women at increased risk of infection and in all women younger than 25 years.
Asymptomatic Bacteriuria in Adults - Article
ABSTRACT: A common dilemma in clinical medicine is whether to treat asymptomatic patients who present with bacteria in their urine. There are few scenarios in which antibiotic treatment of asymptomatic bacteruria has been shown to improve patient outcomes. Because of increasing antimicrobial resistance, it is important not to treat patients with asymptomatic bacteriuria unless there is evidence of potential benefit. Women who are pregnant should be screened for asymptomatic bacteriuria in the first trimester and treated, if positive. Treating asymptomatic bacteriuria in patients with diabetes, older persons, patients with or without indwelling catheters, or patients with spinal cord injuries has not been found to improve outcomes.
ABSTRACT: Many sexually transmitted infections are associated with adverse pregnancy outcomes. The Centers for Disease Control and Prevention recommends screening all pregnant women for human immunodeficiency virus infection as early as possible. Treatment with highly active antiretroviral therapy can reduce transmission to the fetus. Chlamydia screening is recommended for all women at the onset of prenatal care, and again in the third trimester for women who are younger than 25 years or at increased risk. Azithromycin has been shown to be safe in pregnant women and is recommended as the treatment of choice for chlamydia during pregnancy. Screening for gonorrhea is recommended in early pregnancy for those who are at risk or who live in a high-prevalence area, and again in the third trimester for patients who continue to be at risk. The recommended treatment for gonorrhea is ceftriaxone 125 mg intramuscularly or cefixime 400 mg orally. Hepatitis B surface antigen and serology for syphilis should be checked at the first prenatal visit. Benzathine penicillin G remains the treatment for syphilis. Screening for genital herpes simplex virus infection is by history and examination for lesions, with diagnosis of new cases by culture or polymerase chain reaction assay from active lesions. Routine serology is not recommended for screening. The oral antivirals acyclovir and valacyclovir can be used in pregnancy. Suppressive therapy from 36 weeks' gestation reduces viral shedding at the time of delivery in patients at risk of active lesions. Screening for trichomoniasis or bacterial vaginosis is not recommended for asymptomatic women because current evidence indicates that treatment does not improve pregnancy outcomes.