Republic of the Philippines UNIVERSITY OF NORTHERN PHILIPPINES Tamag, Vigan City

Graduate School

NG 201: CARE OF CHILDBEARING WOMAN AND HER FAMILY

Ruby Rafanan,RN MAN Student

Infectious diseases during pregnancy

WHAT ARE STIs?
Sexually transmitted infections (STIs) are infections that are spread primarily through person-to-person sexual contact (vaginal, anal and oral). There are more than 30 different sexually transmissible bacteria, viruses and parasites. The most common conditions they cause are gonorrhoea, chlamydial infection, syphilis, trichomoniasis, chancroid, genital herpes, genital warts, human immunodeficiency virus (HIV) infection and hepatitis B infection. Most STIs can be cured while others can only be treated and can be lifelong infections. Some STDs can have severe consequences, especially in women, if not treated, which is why it is so important to go for STD testing. Some STDs can lead to pelvic inflammatory disease, which can cause infertility, while others may even be fatal. STDs can be prevented by refraining from sexual activity, and to a certain extent, some contraceptive devices, such as condoms.

HOW CAN PEOPLE GETTING AN STI?

PREVENT

THEMSELVES

FROM

A - Abstinence, no sexual contact. B - Be mutually monogamous. Stick to one sex partner only. C - Correct and consistent condom use and practice safer sex. D - Dont use drugs; dont share syringes when injecting drugs.

Chlamydia
Organism Chlamydia trachomatis-an obligate-intracellular, bacteria-like parasite, is the organism responsible for chlamydia. Transmission Chlamydia is transmitted by close sexual contact. Risk -women who are young (less than 24 years), Single, or poor or who are using an oral contraceptive method or non barrier contraceptive method; who have contact with a man with nongonococcal urethritis; and who have histories of new partners in the preceding few months or multiple sexual partners. -C. trachomatis infection causes a variety of clinical conditions including cervicitis, endometritis, irregular menses, acute salpingitis, urethritis, bartholinitis, Fitz-Hugh-Curtis syndrome (perihepatitis), and possibly infertility. Pelvic inflammatory disease (PID) may lead to infertility and ectopic pregnancy. Women with chlamydia infections have two to three times risk of ectopic pregnancy. During pregnancy, cervical chlamydia infection has been associated with premature labor ,premature rupture of membranes (PROM), and preterm birth. Neonatal risk -if Chlamydia are present at the time of vaginal birth, 50% to 60% of infants become infected. Chlamydia conjunctivitis develops within the first week of life among 20% to 50% of exposed infants, and pneumonia will develop in 10% to 20% of exposed infants within the first 3 months of life. Signs: -Women with cervical chlamydial infection frequently are symptom free or may have non-specific symptoms such as increased discharge. On pelvic examination the presence of a mucopurulent cervical discharge and friable cervix (bleeding when cervix is touched) indicates chlamydial infection. With endometritis signs are evident at about 2 days after vaginal delivery. Neonatal signs: -Conjunctivitis consists of edema of eyelids, conjunctival redness, and mucopurulent discharge. Untreated, the cornea may become scarred. C. Trachomatis pneumonia occurs within 2 to 3 months of birth. Signs are afebrile cough and tachypnea, malaise, cyanosis and poor weight gain. Diffuse bacterial infiltrates appear on the chest x-ray film.
Treatment: Three major groups of infections caused by different types of C. trachomatis 1. lymphogranuloma venereum 2. trachoma 3. oculogenital infections

Clinical Management Laboratory methods

1. Doxycycline oral for several days. 2. Azithromycin in single

-cell culture -antigen detection -enzyme linked immunosorbent assay (ELISA) -the partner usually will be infected and also should be treated. Condoms must be used during treatment to prevent reinfection although sexual intercourse should be avoided during treatment. -primary prevention strategies, screening for chlamydial cervical infection of all pregnant women at their first prenatal visit. Additional screening at 36 weeks for high-risk women is recommended. Neonatal treatment. -best prevention is maternal treatment in the last trimester. Topical prophylaxis with the mandated erythromycin ointment does not treat other sites of infection. Nursing Responsibilities: -the woman should be instructed to insist on use of a condom therapy and to encourage the partner to go for treatment. If he does not, condom prophylaxis should be continued during pregnancy. -The woman should be informed about the signs of recurrence; increased vaginal mucus, abdominal aching, and preterm labor.

-She needs to be taught that chlamydial infection leads to PID, ectopic pregnancy and spontaneous abortion. After birth she should be instructed to look for signs of infection in herself and her infant. When the infant is diagnosed with chlamydial infection, the parents should be referred for examination, treatment and counselling. -ensure that the partner is treated at the same time; recent partners should receive treatment despite lack of symptoms and (-)chlamydia result.

Gonorrhea
Organism The organism responsible for gonorrhoea is Neisseria gonorrhoeae, a bacterium that is a gram-negative intracellular diplococcus. Transmission Transmitted by all types of sexual activity; neonates can acquire the infection by exposure to the bacteria in the birth canal. Diagnosis All pregnant women should be screened at their initial prenatal visit and at-risk women should be screened again at 36 weeks gestation. Thayer-Martin Culture of the endocervix, rectum, or pharynx is completed for diagnosis. The medium is inoculated with discharge by a cotton swab. 1st the media must be at room temperature before inoculation (colder temperatures kill the gonococcus). Then, after inoculation, the culture must be placed in a carbon dioxide atmosphere to ensure bacterial survival. Results may be affected by douching within 24hours of specimen collection; contamination of the specimen with fecal material, lubricants, disinfectants or menstrual blood can also affect results. Clinical Management Although gonorrhoea has traditionally been treated with amoxicillin and probenecid, the incidence of penicillinase-producing strains has made this traditional therapy ineffective. Cefixime (Suprax)-one-time intramascular injection is the current recommended therapy. This drug can be safely administered during pregnancy. (preg.risk category B) Avoid tetracyclines and quinolones during pregnancy because of their injurious effect on fetal teeth and cartilage.(CDC,1998) Sexual partners within the preceding 60 days should be identified, examined, cultured and treated. Installation to the affected eyes of 1% silver nitrate or 0.5% erythromycin (credes prophylaxis)-for opthalmia neonatorum. Nursing Responsibilities & Prevention Strategies to prevent gonorrhoea infection involve methods of personal prevention. Secondary prevention includes screening all pregnant women for gonococcal infection early in pregnancy and again during the third trimester for those of high-risk populations. Women with (+) cultures are reported to ensure treatment and counselling of sexual contacts. Isolation precautions for gonorrhoea. Maternal and infant isolation: Careful hand washing. Avoid genital contact until initiation of therapy.

Signs
Vaginal discharge: may be profuse, purulent, yellow-green or the woman may be asymptomatic Rectal examination-anal discharge, bleeding or tenderness Itching or swelling of vulva Dysuria Dyspareunia

Breast-feeding -avoid sexual promiscuity or multiple sexual partner. Permitted if antibiotic regimen safe -abstinence from casual sex or suppression of commercialized prostitution. -health and sex education -urination before and after sexual intercourse -rapid treatment of sick persons -credes prophylaxis for all newborns to prevent opthalmia neonatorum -eradicating infection by early diagnosis and treatment -disinfection of rectal thermometers Effect on pregnancy: Gonorrhoea can affect outcome in any trimester, causing spontaneous abortion, preterm delivery, or PROM. If the organism is present at the time of delivery, the greatest neonatal risk is an eye infection

called gonococcal opthalmia, which can cause blindness. This is one of the reasons all newborns eye should be treated with either erythromycin or tetracycline ophthalmic ointment as soon as possible after birth. If the organism is known to be present in the birth canal at delivery, the infant is treated with single-injection of ceftriaxone IV or IM. Pregnancy Considerations Gnorrhea is an ascending infection. Left untreated, 10% to 40% of the time gonorrhoea causes a PID. PID causes infertility. Untreated gonorrhoea is a significant cause of postpartum endometritis.

Human Papillomavirus
Organism Organisms responsible for HPVs are human wart viruses. Transmission Sexual contact is the most common form of transmission, with a higher transmission rate in young adolescents. Risk The overall rate is thought to be as high as 20% in pregnant women. During pregnancy, papillary lesions of HPV infection may increase in size and number. Decrease in cell-mediated immunity and growth factors present during pregnancy may be responsible. Lesions may become more vascular and friable during pregnancy, and, in a few cases, extreme growth on vulva and vagina may be noticed. HPV transmission to the infant occurs. Perinatal transmission occurs during the passage through the contaminated birth canal, although ascent from the cervix and vagina into the uterus, transplacental passage, and postnatal transmission also are possible means for infection. Diagnosis

Signs

Visualization Application of acetic acid (vinegar) to wart to magnify its presence on the early or flat cervical lesions Cytology: Pap smear is the most important screening tool; Thin prep Hybrid capture HPV DNA assay

Most are asymptomatic and can be transmitted before lesions. Visible warty growths are single or multiple growths, fleshy colored, pale pink or red, raised or flat, and small or large. If clustered together, they may have a cauliflower shaped appearance. Mucosal warts located on non-hairy areas of the genital tract are softer. Hyperkeratotic warts located in outer hairy skin of the vulva are more firm. Clinical Management Most HPV infections are controlled by the bodys immune system. However, reactivation or reinfection occurs. No treatment has been shown to eradicate HPV. Therefore the goal is to remove the visible lesions and ameliorate the signs and symptoms only, not to eliminate the virus. After removal of visible lesions, wait for the immune response to control replication of the virus. Various treatments are used to do this. Trichloroacetatic acid(TCA) or cryotherapy with liquid nitrogen is safe during pregnancy. Xylocaine jelly can be applied to the surrounding skin to decrease the burning sensation of TCA. Topical podophyllum resin, interferon, and 5-fluorouracil have been frequent treatments among non-pregnant women but are contraindicated during pregnancy because increased potential for maternal and fetal toxicity. Electrocautery effectively removes small lesions throughout pregnancy. Surgical removal during pregnancy has an increased risk of haemorrhage related to the increased vascularity. If the patient smokes, instruct her regarding the effect that smoking has on the immune system, which can decrease the effectiveness of any HPV treatment.

All sexual partners should be examined for any evidence of warts and instructed to use condoms to decrease transmission. Pregnancy considerations Warts tends to proliferate and become friable during pregnancy. During delivery, condylomata can cause pelvic outlet obstruction and severe hemorrhage related to lacerations of the friable condylomatous tissue. HPV especially types 6 and 11 causing laryngeal papillomas in infants and children exposed during delivery through an infected birth canal. These laryngeal papillomas usually appear between 2 and 5 years of age, causing such symptoms as an abnormal cry, voice changes, stridor, or evidence of airway obstruction. Cesarean delivery is indicated only when warts are so large at the time of delivery that the risk of dystocia and hemorrhage is great and to avoid exposure of the fetus to the virus in the birth canal. Nursing Responsibilities & Prevention Health educate at risk women to have a healthy lifestyle with exercise, a healthy diet low in fat and high in vegetables and fruits, and without smoking enhances the immune system and is important in decreasing the cervical cancer risk of progressive development of invasive carcinoma in the presence of HPV. Yearly pap smear for those who has one episode of infection.

Candidiasis
Organism Candida albicans is the most common cause of candidiasis. Candida tropicalis and Candida glabrata are two other possible causes of candidiasis, a fungal Risk (yeast) infection. Transmission

Candidiasis is not considered an STD. it usually results from a disturbance in normal vaginal flora and conditions that cause vaginal pH to be more alkaline, such as being pregnant, using antibiotics, eating large amounts of simple sugars, douching, wearing tight clothing, having uncontrolled diabetes, or using estrogen oral contraceptives.

Pregnant women Women treated with an antibiotic for another infection Women with gestational DM Women with HIV infection

Diagnosis Signs Saline or KOH wet mount microscopically examined: shows hyphae, pseudohyphae and budding yeast Usually pH lower than 4.7 Whiff test absent amine (fishy) odor Pruritic, white, curdlike vaginal discharge often described as having a cottage cheese appearance. Yeast odor Dysuria Dyspareunia

Nursing Responsibilities, prevention & treatment in Pregnancy Only symptomatic women should be treated for candidiasis. Use antifungal, intravaginal agent, such as butoconazole, clotrimazole,miconazole. These drugs comein vaginal suppository or cream form. Duration of treatment is 7 days during pregnancy. Sitz baths twice daily may decrease the external irritation. Instruct the patient to abstain from intercourse, avoid bubble baths, wear cotton undergarments, and practice good perineal hygiene. To treat recurrent yeast infections or to prevent yeast infections when taking antibiotics, eating yogurt or inserting a tampon dipped in commercial yogurt can help restore Lactobacillus acidophilus in the vagina. Echinacea has been demonstrated by research to decrease the recurrence rate of candida infections as well.

Candidiasis is the 2nd most common vaginal infection. The risk of acquiring candiasis during pregnancy is increased; the highest risk is in patients with DM and patients receiving antibiotic therapy because they have decreased levels of lactobacilli. Candidiasis may be more resistant to treatment during pregnancy. Treat all symptomatic pregnant vigorously to avoid neonatal thrush.

Trichomoniasis
Organism An organism responsible for trichomoniasis is Trichomonas vaginalis, a flagellated protozoan that is sexually transmitted. Transmission Trichomoniasis generally is caused by sexual activity. Swimming in contaminated water, contaminated towels or sitting in contaminated hot tubs. Pathophysiology Trichomoniasis is caused by the anaerobic, flagellated parasitic protozoan Trichomonas vaginalis. The organism is almost always transmitted sexually. T. vaginalis prefers an alkaline environment (pH 6 to 7), and alterations in the vaginal flora make a woman more susceptible to infection. Trichomoniasis can be very resistant to treatment and recurrence is common. Diagnosis If the pregnant women is symptomatic for trichonomiasis, a saline wet mount shows motile trichomonads with an increased number of white blood cells. The amine odor (Whiff test)may or may not be positive for a fishy odor, and the vaginal pH is greater than 4.5 and is often greater than 6.0. The routine Pap smear may detect trichonomiasis. Signs and symptoms The pregnant women with trichomoniasis may be asymptomatic, or she may exhibit some or all of the following signs and symptooms: Frothy, yellow-green or gray, foul discharge Constant perineal itching Erythema (strawberry spots) Vaginal pH alkaline (>4.5) Vaginal mucosa erythematous Cervix with punctate hemorrhages

Clinical Management

DOC-metronidazole (Flagyl) may be teratogenic during the 1st trimester of pregnancy. Thus, the disorder is usually treated with topical clotrimazole, a drug with a lesser effect. No alcoholic beverages or vinegar products are allowed for 48 hours after therapy No intercourse allowed for 2 weeks to allow pelvic and cervical rest During breastfeesing, instruct the woman to pump and discard breast milk for 24 hours All sexual partners should be treated also

Effect on Pregnancy Outcome Trichomoniasis vaginalis is diagnosed in 20% of all pregnancies and has been implicated in PROM, post caesarean infection and preterm delivery.

Syphilis (Sy, bad blood, the pox)

Organism Spirochete Treponema pallidum-capable of penetrating intact skin or mucous membranes and is transmitted by direct contact with skin lesions or blood, primarily during sexual intimacy, including kissing. A chronic infectious sexually transmitted disease, syphilis begins in the mucous membranes and quickly becomes systemic, spreading to nearby lymph nodes and the bloodstream.

Risk Increased in lower socioeconomic group, urban, poor, unmarried and among young persons including also those infected with HIV. Diagnosis Serologic test or direct microscopic examination of lesion exudates for spirochetes. Fluorescent treponemal antibody-absorption test (FTA-ABS) is the most commonly used specific test. Results of the FTA-ABS remain (+) for the persons lifetime in spite of adequate treatment. Dark field illumination test-provides immediate diagnosis of syphilis. This method is most effective when moist lesions are present, as in primary ,secondary, and prenatal syphilis. Kalm test Veneral Disease Research Laboratory (VDRL) slide test and rapid plasma reagin test detect nonspecific antibodies. Signs and symptoms Incubation period: 10 days-3 months, with average of 21 days.
Primary syphilis

Develops a painless chancre, ulcerated , firm lesion with a raised border. The chancre appears at the site of spirochete penetration and highly infectious. It last for 3 to 6 weeks, possibly longer There may be swollen glands The chancre is not always observed for women because it occurs on the cervix or vagina rather than the external genitalia and produces no irritating symptoms. The chancre resolves spontaneously even without treatment

Secondary syphilis Develops 6 to 8 weeks after the chancre has appeared and may first occur up to 6 months later There is bacteremia and involvement of all organ systems Skin and mucuos membrane lesions and generalized lymphadenopathy are common. Short lived malaise, fever, sore throat, headache, anorexia and arthralgia also occur. Generalized maculopapular rash involving palms and soles of feet helps to identify sypihilis.

Latent (dormant) phase: The early latent phase (first 1-2 years) is characterized by occasional relapses back to symptoms of the secondary phase of syphilis. More than 2 years after the start of the latent phase, you may have no symptoms and are generally not infectious. However, you can still transmit the infection from mother to fetus or through blood transfusions.

During this phase, the heart, brain, skin, and bones are at risk. Tertiary phase: Slowly progressive and may affect any organ. The disease is generally not thought to be infectious at this stage. Manifestations may include the following:
Altered mental status Focal neurologic findings, including sensorineural hearing and vision loss Dementia Symptoms related to the cardiovascular system or the central nervous system (CNS)

Clinical Management

Syphilis is bets treated with penicillin. Recommended for primary,secondary,and early latent syphilis is a one-time, intramascular dose of benzanthine penicillin G. Jarisch-Herxheimer reaction-is thought to be caused by the sudden released of spirochete cell wall lipids into the maternal and fetal bloodstream as the organism is destroyed. Within the hours of treatment high fever, chills, myalgia, tachycardia, and occasionally hypertension and shock may occur. This reaction is accompanied by uterine contractions, decreased fetal movement, and fetal distress.. After antibiotic treatment, pregnant clients should receive follow-up with monthly quantitative VDRL titers for the remainder of the pregnancy and should be retreated if a fourfold rise in antibody titer occurs.

Effects on preganancy:

Syphilis spirochete can cross the placenta at any time. However treatment is very effective if given before 16 weeks of gestation; this is related to fetal immune competence before the gestational age. Untreated syphilis can profoundly affect the fetus, depending on the stage of maternal infection and the length of exposure to organism. Consequences of congenital syphilis are the following: Spontaneous abortion Prematurity Stillbirth Multisystem failure of the heart, lungs,spleen,liver, and pancreas as well as structural bone damage and nervous system involvement and mental retardation. Hearing loss and death

Nursing Responsibilities & Prevention

Stress the importance of completing the course of therapy even after symptoms subside. Instruct those infected to inform their partners that they should be tested and if necessary, treated. Practice standard precaution In secondary syphilis, keep lesion clean and dry. If theyre draining, dispose of contaminated materials properly. In late syphilis, provide symptomatic care during prolonged treatment. Be sure to report all cases of syphilis to local public health authorities. Urge the patient to inform sexual partners of his infection so that they can receive treatment also.

Congenital Syphilis
Infants with congenital syphilis most often are born to mothers who received no prenatal care or did not complete treatment. To prevent such problem, early and adequate prenatal care is important. Infants do not pass through stages, but there is early widespread organ involvement. Congenital syphilis nearly always is preventable by early identification of maternal syphilis and treatment as early as possible during pregnancy. The fetus may be severely infected before treatment, however, and show signs in bones, teeth, and central nervous system even after treatment. Congenital syphilis also occur because of maternal relapses or reinfection from an untreated partner. Treatment before 15 weeks may prevent congenital syphilis.

Signs Infants with congenital syphilis most often are symptom free at birth. Symptoms often appear by 10 days to 2 weeks and nearly always are within the first 3 months of life. Clinical symptoms initially may be nonspecific: Watery rhinitis Enlarged liver, spleen Mucocutaneous rash, patches Without diagnosis and treatment the disease progresses. Multiorgan involvement includes purulent nasal discharge, maculopapular rash, desquamation, osteochondritis, jaundice, anemia, meningitis and hydrocephalus. Bone and soft tissue deformities are associated with late congenital syphilis, that is, diagnosed after 2 years of age.

Clinical management A cord sample may be tested or maternal tests as a screen.

Treatment of congenital syphilis

-Pen G IV daily for 10-14 days -Procaine penicillin IM qd for 10-14 days has been used, but there is risk of damage to small muscle sites.

Isolation precautions:Syphilis
-Mother: avoid contact with body fluids or chancre mucous patches -use blood precautions, careful hand washing

Herpes Simplex Virus Type 2 infection

Organism The organism responsible for genital herpes is herpes simplex virus (HSV-2), a double stranded DNA virus. There are two types of herpes simplex viruses (HSV). HSV type 2 is the one that most

commonly causes genital herpes. You can get HSV type 2 during sexual contact with someone who has a genital HSV-2 infection. The infection causes painful sores on the genitals in both men and women. HSV type 1 is the herpes virus that is usually responsible for cold sores of the mouth, the so-called "fever blisters." You get HSV-1 by coming into contact with the saliva of an infected person. However, HSV type 1 can cause genital herpes, usually caused by oral-genital sexual contact with a person who has the oral HSV-1 infection, and HSV type 2 can cause cold sores. Transmission -HSV type 11 is a STD transmitted by direct contact exposure to vesicular lesions on the penis, scrotum, vulva, perianal region, vagina or cervix; the infant is usually infected during the exposure to a lesion in the birth canal; the infant is most risk during primary infection in the mother. Pathophysiology Herpes viruses are composed of DNA material enclosed in a protein coat and surrounded by a lipid envelope. Herpesvirus infection occurs by attachement of the viral particle to the susceptible cell membrane, penetration into the cell, and subsequent release of the viral DNA into the cell cytoplasm. Viral DNA is transported to and incorporated into the cell nucleus. The cell then begins to produce viral proteins and to replicate viral DNA. These viruses are formed within the nucleus and then transported through the cell to the extracellular fluid. Risk Transmission to the infant occurs during passage through infected birth canal or by ascending infection after rupture or membranes. Primary HSV infection poses the greatest risk to the pregnancy. Diagnosis

viral culture-definitive diagnosis serologic tests-have a lower accuracy Cytology: multinucleated, giant cells with intranuclear inclusion bodies on a Pap smear ELISA-enzyme-linked immunosorbent assay

Signs and Symptoms

HSV-2 is an chronic infection characterized by periods of periods of remissions and exacerbations. There are three different infectious states: primary, first episode non primary, and recurrent infections. Signs and symptoms of primary infection are as follows: Primary (initial) HSV infection the virus ascends along peripheral sensory nerves, enters sensory or autonomic nerve root ganglia, and establishes latent infection. Non specific stimuli including fever, sunlight, and stress have been associated with stimulating recurrences of oral HSV-1. Such trigger mechanism have not been characterized for HSV-2 infection. Persons reporting their first episode of genital herpes generally have milder symptoms if they have serologic evidence (aantibodies) of either HSV1 or HSV2 infection. Symptomatic primary genital HSV infection often is accompanied by prolonged systemic and local symptoms. Fever, headache, malaise and myalgias are common and may persist for the first 3 to 4 days after lesions develop. Local symptoms include severe pain, itching, dysuria, vaginal or urethral discharge, and tender inguinal lymph nodes. Typical lesions appear as papules and progress to vesicles which rupture and ulcerate. Lesions may spread over the genital area. Ulcerated lesions of primary herpes may persist for 4 to 15 days, before healing.

Wet ulcer: last approximately 6 days Dry crust: lasts approximately 8 days Recurrent infections are usually less severe and of shorter duration.

Clinical Management

No therapy can eradicate HSV. There is no treatment that can cure herpes, but antiviral medications can shorten and prevent outbreaks during the period of time the person takes the medication. In addition, daily suppressive therapy for symptomatic herpes can reduce transmission to partners. Unlike other sexually transmitted diseases, herpes cannot be cured because medication that will attack the virus while it lies dormant in the nerve cells will also damage the nerve cells.

However, there is treatment available for acute outbreaks that involves the use of anti-viral drugs such as Acyclovir, Valaclovir or Famcyclovir. Acyclovir has been found to reduce the reproduction of the virus in initial outbreaks, thus possibly lessening the number of subsequent outbreaks. To be effective, therapy must be started immediately after the first sores appear. Every sexual partner of the infected person needs to be examined, and if necessary, treated. Famcyclovir has similar effects and may work to prevent a herpes infection from establishing itself if taken soon enough in the course of the illness. Valaclovir has similar effects. Long-term drug therapy ('suppressive treatment') may be helpful for individuals who suffer frequent recurrent outbreaks. Suppressive treatment will reduce outbreaks by 85 percent and reduces viral shedding by more than 90 percent. Topical antibiotic ointments also may be applied to prevent secondary bacterial infections.

Nursing Responsibilities & Prevention During an outbreak of genital herpes, a number of measures can be taken to make the patient more comfortable: Wear loose clothing Avoid excessive heat or sunlight Keep the sore area clean and dry Place cool or lukewarm cloths on the sore area for short periods of time Do not use perfumed soaps, sprays, feminine deodorants, or douches Take aspirin, acetaminophen or ibuprofen for the pain Avoid touching sores Wash hands if you do touch the sores

Group B Streptococcus Infection

Organism Streptococcus agalactiae is a gram-positive encapsulated coccus, a two-cell wall polysaccharide. Rick Factors An infant born to a woman who is carrying the bacteria can also be at risk. Some pregnant women are at more risk than others of having a baby who develops group B strep disease. A pregnant woman is at high risk if she: Has already had a baby with group B strep infection Has a urinary tract infection caused by group B strep Becomes colonized with group B strep late in pregnancy Develops a fever during labor Has rupture of membranes 18 hours or more before delivery Begins labor or has rupture of membranes before 37 weeks ("preterm") Positive prenatal culture for GBS this pregnancy

Transmission Pregnant women can transmit group B strep to their newborns at birth. Group B strep is the most common cause of blood infections and meningitis in newborns. Most cases of group B strep disease in newborns can be prevented by giving certain pregnant women antibiotics during labor. It is transmitted vertically from the birth canal of the infected mother to the fetus. How do people get infected with group B strep? Group B strep bacteria are different from many other types of bacteria that can cause disease. People can be "colonized" with group B strep. This means that they carry the bacteria in their bodies but are not infected and do not become sick. Adults can carry the bacteria in the gastrointestinal tract, genital tract, or urinary tract. About 10% to 30% of pregnant women are colonized with group B strep in the genital tract. Colonization with group B strep is usually harmless. The bacteria can become deadly, though, if something happens that allows them to invade the bloodstream. In adults, weakened immunity resulting from cancer treatment or a chronic illness can prompt an infection. More often, pregnant

women who carry the bacteria can unknowingly transmit group B strep to their newborns at birth. Newborns can acquire early-onset group B strep disease either before or during delivery. The cause of late-onset disease in babies is not well understood.

Diagnosis The CDC recommends that all pregnant women be screened for streptococcus B at 35 to 38 weeks of pregnancy. Group B strep infection is diagnosed by a laboratory test of blood or spinal fluid. Polymerase chain reaction to demonstrate the genetic material of the virus and using antibodies to the genital herpes virus to demonstrate the presence of the virus in clinical specimens. Signs Although infection develops within the cervix or vagina the mother usually experiences no symptoms.Consequences can be urinary tract infection, inta-amniotic infection leading to preterm birth, and postpartal endormetritis. Fetal/neonatal effects: neonatal meningitis, sepsis, and septic shock; early onset GBS has a significant infant mortality rate.

Medical Management

A broad-spectrum penicillin such as ampicillin is the treatment of choice. Women who experience ROM at less than 37 weeks of pregnancy may be treated with IV ampicillin to reduce the risk of spreading the infection to newborn. Avoid excessive heat or sunlight, which makes the irritation more uncomfortable Wear comfortable, loose fitting cotton clothing Antiviral medications include: acyclovir (Zovirax), famciclovir (Famvir), valacyclovir (Valtrex)

Nursing Responsibilities & Prevention Most cases of group B strep infection in newborns can be prevented by giving certain pregnant women antibiotics during labor. Antibiotic treatment before labor does not prevent group B strep infection in newborns. Any pregnant woman who has already had a baby with group B strep infection or who has a urinary tract infection caused by group B strep should be given antibiotics during labor. Pregnant women who are colonized with group B strep should be offered antibiotics at the time of labor or rupture of the membranes. Colonization with group B strep can be detected late in pregnancy (35-37 weeks' gestation) by a special test of secretions from the vagina and rectum. Unfortunately, some babies still get group B strep infection despite testing and antibiotic treatment. Vaccines to prevent group B strep infection are being developed.

Bacterial Vaginosis (Gardnerella vaginitis)

Pathophysiology The cause of BV is not fully understood. BV is associated with an imbalance in the bacteria that are normally found in a woman's vagina. The vagina normally contains mostly "good" bacteria, and fewer "harmful" bacteria. BV develops when there is an increase in harmful bacteria. Not much is known about how women get BV. There are many unanswered questions about the role that harmful bacteria play in causing BV. Any woman can get BV. However, some activities or behaviors can upset the normal balance of bacteria in the vagina and put women at increased risk including: Having a new sex partner or multiple sex partners Douching It is not clear what role sexual activity plays in the development of BV. Women do not get BV from toilet seats, bedding, swimming pools, or from touching objects around them. Women who have never had sexual intercourse may also be affected.

In pregnant woman: The bacteria that cause BV can sometimes infect the uterus (womb) and fallopian tubes (tubes that carry eggs from the ovaries to the uterus). This type of infection is called pelvic inflammatory disease (PID). PID can cause infertility or damage the fallopian tubes enough to increase the future risk of ectopic pregnancy and infertility. Ectopic pregnancy is a lifethreatening condition in which a fertilized egg grows outside the uterus, usually in a fallopian tube which can rupture. Diagnosis A health care provider must examine the vagina for signs of BV and perform laboratory tests on a sample of vaginal fluid to look for bacteria associated with BV.

IA homogenous gray or white discharge that adheres to the vaginal wall Vaginal fluid pH higher than 4.5 (normal)pH is 4.0 to 4.5 Positive result of the whiff test- a test your doctor can perform called smell test . A drop of solution of potassium hydroxide test is added to the landfill. The result is usually a strong smell of fish. Presence of clue cells (desquamated vaginal epithelial cells characteristically stippled by the adherence of coccobacilli to their surfaces) on either a saline wet mount or a Grams stain of vaginal fluid.

Signs Women with BV may have an abnormal vaginal discharge with an unpleasant odor. Some women report a strong fish-like odor, especially after intercourse. Discharge, if present, is usually white or gray; it can be thin. Women with BV may also have burning during urination or itching around the outside of the vagina, or both. However, most women with BV report no signs or symptoms at all.

Clinical Management Although BV will sometimes clear up without treatment, all women with symptoms of BV should be treated to avoid complications. Male partners generally do not need to be treated. However, BV may spread between female sex partners. Treatment is especially important for pregnant women. All pregnant women who have ever had a premature delivery or low birth weight baby should be considered for a BV examination, regardless of symptoms, and should be treated if they have BV. All pregnant women who have symptoms of BV should be checked and treated. Some physicians recommend that all women undergoing a hysterectomy or abortion be treated for BV prior to the procedure, regardless of symptoms, to reduce their risk of developing an infection. BV is treatable with antibiotics prescribed by a health care provider. Two different antibiotics are recommended as treatment for BV: metronidazole or clindamycin. Either can be used with nonpregnant or pregnant women, but the recommended dosages differ. Women with BV who are HIVpositive should receive the same treatment as those who are HIV-negative. BV can recur after treatment. Prevention BV is not completely understood by scientists, and the best ways to prevent it are unknown. However, it is known that BV is associated with having a new sex partner or having multiple sex partners. The following basic prevention steps can help reduce the risk of upsetting the natural balance of bacteria in the vagina and developing BV: Be abstinent. Limit the number of sex partners. Do not douche. Use all of the medicine prescribed for treatment of BV, even if the signs and symptoms go away. What are the complications of bacterial vaginosis? In most cases, BV causes no complications. But there are some serious risks from BV including: Having BV can increase a woman's susceptibility to HIV infection if she is exposed to the HIV virus. Having BV increases the chances that an HIV-infected woman can pass HIV to her sex partner. Having BV has been associated with an increase in the development of an infection following surgical procedures such as a hysterectomy or an abortion.

 Having BV while pregnant may put a woman at increased risk for some complications of pregnancy, such as preterm delivery. BV can increase a woman's susceptibility to other STDs, such as herpes simplex virus (HSV),chlamydia, and gonorrhea.

Human Immunodeficiency Virus

Organism

RNA retrovirus

Pathophysiology

HIV attaches to and invades selected host cells. Viral RNA is translated by enzymes into DNA; this DNA can insert the viral code into the host cell genome. This code for viral DNA will be reproduced each time the cell divides. The code may remain silent (latent), instruct the host cells to begin to produce additional virus, or cause the cell to be destroyed. Antibodies to the viral coat proteins are produced, and all parts of the immune response are activated during HIV infection; yet these responses are unable to protect the host from infection. HIV appears to replicate only in certain white blood cells types, including cells of the central nervous system, intestinal tract, and possibly bone marrow. HIV attachs to the glycoprotein antigen (CD4) receptors on the T4 cells, B-lymphocytes , macrophages and monocytes as well as other cells in the immune system and CNS and enters these cells. HIV is unique among human viruses in that it infects and destroys helper T lymphocytes and macrophages, cells that are integral to the bodys defense system.

Risk High-risk groups include homosexual and bisexual men IV drug users who shares needles, transfusion recipients before 1985 and sexual partners of these persona. Sexual penetration between men, bet. women and men, and bet. women. Nonsexual transmission may occur by inoculation with contaminated blood, blood products, and possibly other selected bodily fluids. Pregnancy increases susceptibility to opportunistic infections. An emigrant from an HIV endemic area such as Haiti or Africa

Transmission

Vertical transmission- from mother to infant may occur transplacentally, during the intrapartum period from contamination with vaginal secretions and blood, or during breastfeeding.

Fetal and newborn risk

HIV infection is transmitted to approximately 30% of exposed infants. Infants who do have HIV infection appear to develop end-stage disease or AIDS after a much shorter incubation period. At the time of birth the baby may be inoculated with a virus load by contact with maternal blood and vaginal fluids. Nurses need to advocate for procedures to accomplish the following: 1. no skin puncture before skin cleansing 2. early bath with soap or dilute chlorhexidine (Hibiclens) before eye prophylaxis or IM injection.

Screening ELISA Western blot or immunofluorence assay P24 antigen capture assay-can be used as early as 2 to 6 weeks after infection and is used to diagnose neonatal HIV infection, to detect HIV before seroconversion, and to determine the progression of AIDS; viral cultures provide the best diagnostic tool for neonates; however it is expensive and requires 4 to 6 weeks for results.

Signs Initial HIV infection -may be accompanied by mononucleus-like illness, with symptoms that include fatigue, fever, and swollen glands. Rashes may develop. Symptoms may resolve completely within 3 to 14 days. HIV infection may remain silent, yet transmissible for 2 to 10 years in a latent period before progressive symptoms of immunodeficiency develop.

AIDS-related complex (ARC)-may be considered a pre-AIDS condition. Affected persons may experience a variety of non specific symptoms, including weight loss, malaise, lethargy, central nervous system dysfunction, unexplained fever, generalized lymphadenopathy and opportunistic infections such as herpes simplex or candida. AIDS is the end stage of HIV. Persons with AIDS show evidence of a severely compromised immune system. They have life threatening illnesses from microorganisms or malignancies that seldom cause problems among healthy persons.

Management during pregnancy

Use of antiretroviral theraphy (ART) to reduce and maintain the viral load, the risk of perinatal transmission can be significantly lowered. Zidovudine (AZT) has shown promise in prolonging lives of some clients. Pregnant women are treated when the CD4 counts fall below 200 cells/ul even though risks are still unclear. Sulfamethoxazole-trimethoprim (Bactrim)-a combination drug is routinely given during pregnancy to women whose history or need for prophylaxis against Pneumocystis carinii pneumonia (PCP) requires treatment.

Treatment in Pregnancy, during Intrapartum, and of the newborn

Initial assessment includes the CD4 + count and percentage, viral load, history of medication use, and gestational age. Then monitor CD4+ counts each trimester. To reduce perinatal transmission offer all HIV positive pregnant women the three part ZDV regimen or ART For women who are on highly active antiretroviral theraphy (HA ART) before pregnancy, the current thought is to add or substitute ZDV to her current regimen avoiding incompatible drug combinations and known teratogenic drugs. Counselling regarding scheduled caesarean at 38 weeks should take into consideration the viral load and gestational age confirmation, as well as the risk to the mother.

Pregnancy considerations during Antepartum If HIV infection is diagnosed during pregnancy, the woman needs initial and ongoing counselling for the social, emotional, and economic ramifications. She also needs education as to potential consequences of pregnancy on HIV disease progression as well as risk of transmission and consequences to her child. During health promotion the woman needs adequate instructions in ways to enhance the immune system such as (1) adequate sleep (2) decreased stress (3) adequate protein (4) balanced intake of polyunsaturated fatty acids and vit E (5) adequate zinc and Vitamin A (6) adequate pyridoxine (7) avoidance of infections.

Pregnancy considerations during Intrapartum

Elective caesarean delivery before rupture of membranes. If vaginal delivery is chosen, care should be taken to decrease risk of inoculation of the virus into the neonate during labor by not using a scalp electrode for fetal monitoring or doing a scalp blood sampling for fetal pH. Delay amniotomy to possibly decrease the transmission rate of HIV bec. of the evidence that increasing duration of membrane rupture is associated with an increasing transmission risk. Avoid such invasive procedures as forceps-or vacuum-assisted delivery.

Pregnancy considerations during Postpartum Case management coordination of care by the primary care provider, OB, Pediatrician and HIV clinical specialist. Re-emphasis on safe-sex practices and referral for family planning

Counselling regarding importance of adherence to use of antiretroviral agents and prophylactic drugs against opportunistic infections. HIV DNA PCP test is used to determine whether the neonate received the virus from the mother. The test is usually performed within 48 hours after birth, at 14 days of life, at age 1 to 2 months and at age 4 to 6 months.

Nursing Responsibilities & Prevention Preconceptional screening is ideal for women who are increased risk for HIV infection. Women are advised about their risk for HIV infection, the benefits of antibody testing, the procedure for testing, the meaning of possible test results, and the confidentiality of results, and the psychologic and social impact of positive result. The importance of medical care is stressed and resources for psychologic support are given. Breast-feeding is not encouraged. Maintain confidentiality.

Toxoplasmosis
Is a systemic, usually asymptomatic illness contracted by at least one third of human beings in most geographic regions.

Causative agent: Toxoplasma gondii

Pathophysiology: the toxoplasma tachyzoite invades muscle and central nervous system tissues and forms cysts in tissue after the development of the host immune response. These cysts persist for the persons lifetime. Acute infections may cause significant complications in immunocompromised or pregnant persons. During pregnancy, Toxoplasma may be transmitted across the placenta and cause severe infection in the developing embryo or fetus. Transmission: 1) From ingesting the cyst stage from inadequately prepared meat 2) from ingesting the oocyst stage from feline feces contaminated soil or food 3) from transplacental or blood product transmission of tachyzoites. Methods for prevention of congenital Toxoplasmosis
The woman should take these precautions:
Cook meat properly Use frozen meat kept at -20C for at least 24 hours. Home refrigerators may not achieve at -20C. Avoid touching mucous membranes of mouth and eyes while handling raw meat Wash hands thoroughly after handling raw meat Avoid eating uncooked eggs and unpasteurized milk Wash fruits and vegetables before consumption Prevent access of flies and cockroaches to fruits and vegetables Avoid contact with materials that are potentially contaminated with cat feces Wear gloves and wash hands for tasks if exposure to cat feces cannot be avoided.

Risk: -transmitted to the fetus across the placenta only when the organism is spread through the blood stream during primary maternal infection. Prior Toxoplasma infection appears to offer nearly complete protection against intrauterine infection.

-intrauterine infection may result in chorioretinitis, strabismus, blindness, hearing loss, microcephaly, hydrocephalus, nephrotic syndrome, bony defects, epilepsy, psychomotor disorders, severe learning disabilities, stillbirth, neonatal death, or symptomatic infection. The occurrence of fetal infection is related directly to the time during the pregnancy that the first maternal infection occurs. First-trimester fetal infection occurs less frequently but is more likely to result in severe infection. Diagnosis: -serologic testing -indirect fluorescent antibody test-commonly used -IgG titers greater than 1:256 suggest a recent infection, whereas IgM titers greater than 1:256 indicate an acute infection Maternal effects: flu-like symptoms in acute phase Fetal/neonatal effects: miscarriage is likely in early pregnancy; in neonates central nervous system lesions can result in hydrocephaly, microcephaly, chronic retinitis, and seizures.

Measles
Childbearing families are likely to come in contact with small children and exposed to childhood illnesses such as measles. Therefore the nurse should be aware of the signs and symptoms of infection, mode of transmission, incubation period, and potential complications of measles during pregnancy. Risk: Measle virus is transmitted to the fetus across the placenta at any gestational age. IUFD, premature birth, perinatal death, and congenital measles.
Isolation precautions: Measles Mother -No history of measles-no isolation for first 7 days; respiratory isolation for next 7 days. -mask until 4 days after onset of rash; careful hand washing; cover gown; avoid contact with lesions and fomites Infant -none for first 5 days after exposure; respiratory isolation for next 7 days; give measles hyperimmune globulin Breast-feeding Not recommended by some authorities, little information available.

Rubella
Is caused by a highly contagious virus spread by airborne droplets, which generally produces a mild disease in children and adults. Risk During pregnancy rubella causes significant fetal loss through spontaneous abortion, as well as a wide spectrum of congenital anomalies. Defects associated with congenital rubella include myopia, deafness, cataracts, glaucoma, heart disease, and mental retardation. Congenital rubella syndrome -is characterized by cataracts, patent ductus arteriosus, and deafness. There also may be IUGR, microcephaly, and mental retardation. Signs Initially a low grade fever and tender lymph nodes occur Then rash lasting 3 days appears over the face and behind the ears.

Clinical Management Prevention is critical. All pregnant women are tested for rubella antibodies as early in prenatal care as possible. A negative titer signals that the woman is susceptible and must do the following: 1. Avoid exposure during pregnancy 2. Be immunized just after the birth 3. Delay any future pregnancy for 3 months after immunization 4. Vaccination is done only after birth to avoid the chance of viral infection of the fetus.

A Report on Infectious Diseases During Pregnancy

MCN 203 Advance Maternal And Child Nursing

Report by: Ruby Rafanan,RN MAN Student Submitted to: Marciana P. De Vera, RN,MAN,Ed.D Professor