K26 - Infections in Pregnancy

8/17/2019 K26 - Infections in Pregnancy

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Infections in Pregnancy

Dr.Tetty Aman Nasution,MMedSc

Departemen MikrobiologiF !S! Medan


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Infections in Pregnancy

"tiology #

$acteria

%irus

Fungi

&isk #

Mot'er Neonatus


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&eproducti(e tract infections #

A. %aginitis ) $acterial %aginosis *$%+

$. Disc'arge as maor manifestation #- onorr'oeae

- /'lamydia

- N! *Non onococcal

!ret'ritis+/. enital ulcer as maor manifestation #

- Syp'ilis

- /'ancroid

D. roup $ Streptococcus 0coloni1ation23t'er infections # Tetanus Mycobacterium tuberculosis

"rysipelas


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Vaginitis

An inflammation of t'e (agina,

most commonly caused by /andida

albicans.

%ul(o(aginal candidiasis nearly

al4ays an opportunistic infection.

5omen 4it' 6I% infection

e7perience fre8uently recurring

yeast infection


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Bacterial vaginosis

ardnerella is associated 4it' (aginosis t'at'as a disc'arge but no inflammation in t'e(agina.

%aginosis could lead to complications suc'as PID *Pel(ic inflammatory disease+

PMNs generally absent from e7udateMostly in 4omen 9:-;: years old/linical manifestation#

– decreased 6939 -producing Lactobacilli – increase of ot'er (aginal bacteria *esp.

anaerobes+< ram negati(e coccobacilliand cur(ed rods ad'ering to epit'elialcells *clue cells+


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Bacterial vaginosis

"tiology#Gardnerella vaginalis - small, non-motile,

gram negati(e=(ariable facultati(eanaerobic coccobacilli present in most

'ealt'y 4omenMobiluncus sp. - t'in, cur(ed, gram

negati(e anaerobic bacilli< recentlydemonstrated to be t'e c'ief cause *not

normal flora+Trichomonas vaginalis - parasite >east=fungi - mostly Candida sppMycoplasma hominis and !reaplasma,

etc .


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Bacterial vaginosis

Diagnosis criteria#

4atery, gray disc'arge - no PMNs

(aginal p6 ?.@ *normal ;.B-?.9+

positi(e amine *fis'+ odor 4it' C:

36

presence of 0clue cells2 - epit'elial

cells co(ered by Gardnerella like

organisms spreading past cell

boundries


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Neissseria GonorrhoeaMorp'ology and structure #

ram negati(e cocci Ekidney bean s'ape, appearin pairs, flattened opposing sides

&eadily p'agocytosed by polymorp'onuclearcell*PMN+

&apidly killed by drying, sun lig't, moist 'eat and

many disinfectantsSi1e (aries :.G - C.@ Hm depending on

species, source of isolates and age ofculture.

/ell 4all - typical of gram negati(e bacteria

- peptidoglycan backbone, endoto7icJPS comple7 and outer membraneprotein

/apsule and pili - may be demonstrated


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Neissseria Gonorrhoea

ro4 4ell on c'ocolate agar

- speciali1ed medium *enric'ed+

- &e8uire /39 supplement

- ?B 'ours incubation - 4ell de(eloped

- /olony smoot', non pigmented

smaller t'an ot'er spp

Produce autolytic en1yme- s4elling and lysis at 9@o/ and atalkaline p6


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Gonorrhoea

Symptoms - may be mild or absent

- 9 - K days after e7posure

Men # Primary site - uret'ra

Purulent uret'ral disc'arge and dysuriaJocal e7tension - epididymitis

Prostatitis

5omen # Primary site - endocer(i7

Increase (aginal disc'arge!rinary fre8uency, dysuria

Abdominal pain

Menstrual abnormalities


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GonorrhoeaTransmissions# • se7ual contact • Non se7ual transmission - e7tremely rareDifficult to control#

- c'anged se7ual modes and practices

- lack of effecti(e means to detectasymptomatic case

- increase antibiotic resistance- lack of appreciation of t'e importance of t'edisease

- asymptomatic reser(oir - @: infected4omen

- @ infected male

!ntreated symptomatic case 4ill becomeasymptomatic but infectious


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Gonorrhoea

3t'er locali1ed infections

&ectal gonorr'oea - rectal intercourse- infected (aginal secretion

- enerally asymptomatic

- May cause tenesmus, disc'arge or rectal bleeding

P'aryngeal gonor'oea

- Asymptomatic *maority+

- Soret'roat and cer(ical adenitis

- 3ro-genital se7

$art'olin abscess - Infection of bart'olin gland

- In 4omen/onuncti(itis - Se(ere, acute purulent

- Any age including neonates


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Gonorrhoea

Pel(ic Inflamatory Disease

Infection spread to#

Fallopian tube salpingitis

Pel(ic ca(ity pel(ic peritonitis andabscess

Fe(er,

Jo4er abdominal pain and rectaltenderness

Jeukocytosis

/omplication - ectopic pregnancy

- infertility.


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GonorrhoeaSpecimens#

Pus and secretion from appropriate site

uret'ra, cer(i7, rectum, conuncti(a, t'roat,syno(ial

C. ram smear

Direct smear of specimen from

genital siteMultiple gram negati(e diplococci

Ebeen s'apedL

Intra or e7tracellularly

Male # @ sensiti(e and

specificFemale # @: - K: sensiti(e and @

specific

Positi(e uret'ral smear and conuncti(aare diagnostic

3t'ers need culture confirmation


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Gonorrhoea/ulture

Fragile organism, often mi7ed 4it' normalflora

Protect specimen from ad(erseen(ironmental effect

/ulture on appropriate enric'ed selecti(e

media*Modified T'ayer-Martin medium+

Direct streaking at t'e bed side

3r transport to t'e lab *O? 'ours+ in suitabletransport medium

Specify t'e re8uest for culture

Incubated at ;Ko/ containing @ /39 for 9?-?B 'ours


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Chlamydia

@-K reproducti(e population

Pre-term labour, PP&3M,

/'orioamniionitis, "ndometritis

/onuncti(itis *CB-@:+, Pneumonia

*CB+

Most are asymptomatic

Screening needed


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CHLAMYDIACHLAMYDIA JIF" />/J"JIF" />/J"


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Chlamydia

5omen – Intermenstrual or postcoital bleeding

– Jo4er abdominal pain

– Fe(er *in PID+

– No symptoms in B:Men

– !nilateral pain and s4elling of t'e scrotum

– Fe(er

– Asymptomatic in @:Neonates

– Inected conuncti(ae

– Mucopurulent disc'arge from eyes

– $ilateral in(ol(ement of t'e eyes


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ChlamydiaP'ysical#

Men may 'a(e any, all, or none of t'e follo4ing#

– Mucopurulent uret'ral disc'arge

– !nilateral epididymal tenderness and s4elling

– Mucopurulent rectal disc'arge *from analintercourse+

5omen may 'a(e any, all, or none of t'e follo4ing# – Mucopurulent cer(ical or (aginal disc'arge

– /er(ical motion tenderness

– Adne7al tenderness

– Jo4er abdominal tenderness – !pper rig't 8uadrant abdominal tenderness *Fit1-

6ug' and /urtis syndrome+

– Mucopurulent rectal disc'arge *from analintercourse+


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Chlamydia

Neonates - $ilateral purulent

conuncti(itis

Jymp'ogranuloma (enereum

– Jocali1ed inguinal adenopat'y orbuboes

– enital ulceration

– roo(e sign - Separation of inguinaland femoral lymp' nodes by t'e

inguinal ligament *C@-9: of patients)


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Chlamydia

Diagnosa Jab#

/'lamydia membentuk sitoplasmikinklusi 'anya dpt dili'at dgnpe4arnaan k'usus spt pe4arnaaniemsa atau denganimmunofluorescence

Pe4arnaan ram tidak dapat dili'at

Qika dalam cairan e7udat, bakteri dlm selepitel diidentifikasi dengan pe4arnaanFluorescent Antibody atau DNA probeassay


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Chlamydia

Diagnosa Jab#

Antigen /'lamydia di dalame7udat=cairan tubu' atau urine dapatdideteksi dengan "JISA

DNA dari /'lamydia dalam e7udat=cairantubu' atau urine dapat dideteksi denganP/& *Polymerase /'ain &eaction+

ultur /'lamydia suda' arangdilakukan untuk mendeteksi bakteri ini


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Chlamydia

Diagnosa Jab #

Qika kultur, dilakukan kultur sel denganpenamba'an cyclo'e7imide *in'ibitorprotein sintesis pd sel 'ost tp tdk padac'lamydia replikasi+

C trachomatis membentuk inklusimengandung glikogen dpt dili'at dgn

pe4arnaan Iodine."7udat dr mata, sal.nafas atausal.genital kultur positif pada @:kasus


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Non Gonococcal Urethritis (NGU)

Mycoplasma hominis and !reaplasmaurealyticum

– $acteria 4it'out cell 4alls, fried eggcolonies slo4 gro4ers on

fat=c'olesterol enric'ed media – Post abortion fe(er, postpartum

sepsis and neonatalsepsis,pneumonia and meningitis

!reaplasma urealyticum – Also assoc 4it' c'orioamnionitis, lo4

birt' 4eig't, and nongonococcaluret'ritis in men


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Group B Streptococci

“colonization”

9@ 4omen are carriers

@: of babies born 4ill be

coloni1ed

C-9 4ill 'a(e rp $ Strep

infection

C#C::: babies

Pneumonia *early+, Meninigitis

*Jate+


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Female genital tract normal

floraLactobacilli

– ram positi(e rod in large numbers indicatea 'ealt'y (agina

– Produce lactic acid 4'ic' 'elps maintain p6

needed for t'eir sur(i(al – May play a role in protecting 4omen from

gonococcal infections

roup $ beta'emolytic "treptococcus

agalactiae coloni1ation – May be transmitted to neonate

– /an cause systemic disease


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"pidemiology#

/oloni1es t'e genital tract< risk groupsinclude#

– Infants# /oloni1ation during deli(erymay results in in(asi(e disease

– Pregnant and post-partum 4omen

– Non-pregnant adults

• "lderly• Indi(iduals 4it' c'ronic underlying

disease


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/linical Presentation#

Neonates – Sepsis, meningitis, pneumonia, cellulitis,

osteomyelitis, septic art'ritis

Pregnant and post-partum 4omen – Mild !TI, sepsis< less commonly

osteomyelitis, endocarditis, meningitis

Non-pregnant adults – $acteremia, skin or soft tissue infections

pneumonia urosepsis endocarditis peritonitis meningitis empyema


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Mother to Infant GBS

Transmission

$S coloni1ed mot'er

Non-coloni1edne4born

/oloni1edne4born

Asymptomatic "arly-onset sepsis,pneumonia, meningitis

@: @:

B 9

Neurologic

se8uelae

Deat'

@

C: ;@


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ram Stain /olonies on s'eep

blood agar plate

roup $ beta'emolytic "treptococcus agalactiae


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Syphilis

T#allidum

OC#C::: pregnant 4omen

/an infect trans placenta from C@t'

4eek

Second stage by birt' if not treated

Screening %D&J, &P&

Diagnostic tests TPI, FTA-Abs

6ig' dose PenicillinLs


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Primary Syphilis

During t'e Cst

C:-: days after se7ualencounter 4it' infected person disease

incubates 4it'in body.

Infected area 4ill de(elop a sore also called

a /'ancre or multiple soresT'e sore is 'ig'ly infectious

/'ancre sore 4ill resol(e in ;-B 4eeks if

left untreated

/'ancre sore may not be (isible and

may be painless


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Primary Syphilis


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Secondary Syphilis

Symptoms occur 6-8 weeks after initial

sore disappears and may include:

A ras' on t'e palms of t'e 'ands and

soles of t'e feet lasting 9-G 4eeks6air loss and patc'y areas

rayis'-4'ite sores in t'e mout's and

t'roatSense of not feeling good


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Secondary Syphilis

It can last for ;-G mont's 4it' symptoms

disappearing t'en reappearing

Person infected is still capable of

transmitting t'e diseaseSyp'ilis begins to affect t'e entire body


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Latent SyphilisLatent Syphilis/alled t'e 6iddenStage

$egins4'en t'eSecondary symptoms disappear

T'e bacteriabegins toinfest t'ebone marro4,lymp' glands,(italorgans, and t'e centralner(oussystem

Itmay lastup to amont' ora lifetime

C=; of t'e cases leftuntreated 4ill proceed to tertiarystage


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Tertiary Syphilis

Disease is not infectious at t'is stage

Jesions de(elop on t'e skin, bones, and (ital organs

Patient e7periences lack of coordination, paralysis,gradual blindness, dementia, and (omiting.

ummas or painful tumors may appear on t'e skin

Jate syp'ilis can result in mental illness, blindness,ot'er neurological problems, 'eart disease, and deat'.


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Diagnoses

Syp'ilis is diagnosed in ; 4ays

C+ First recogni1e t'e signs and symptoms of

eac' stage.

9+ $lood samples need to be obtained to testfor syp'ilis antibodies t'at t'e body

produces after t'e infection occurs.

;+ A microscopic e7amination may be

performed of an acti(e lesion to confirmdiagnosis.


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In t'e later stages of syp'ilis, blood or cerebrospinal

fluid for serological tests are necessary for

diagnosis.

Non-specific non-Treponemal tests &P&, %D&J May cross-react resulting in lo4-le(el false positi(e tests

during pregnancy, ot'er infections, drug abuse, connecti(e

tissue disease and aging.

Je(els usually relate to disease acti(ity and are used for

monitoring treatment. After effecti(e treatment of syp'ilis t'ese tests usually

become negati(e but in some people, may retain positi(e at

lo4 le(els

Laboratory Tests


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Laboratory Tests

Specific anti-treponemal antibody tests TP6A,"IA

T'ese detect antibody due to past or present

infection 4it' Treponema pallidum or

anot'er treponema species. T'ey cannot distinguis' bet4een different

types of Treponema infection e7. >a4s

Syp'ilis of t'e duration of t'e infection.

Most people 4it' reacti(e treponemal tests4ill continue to 'a(e reacti(e tests for t'e

remainder of t'eir li(es, regardless of

treatment or disease acti(ity.


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Chancroid

An ulcerati(e disease caused by a

pleomorp'ic gram-negati(e rod

called 6aemop'ilus ducreyi

Transmitted e7clusi(ely t'roug'direct-mainly se7ual-contact


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• Tetanus is an acute,often fatal,diseasecaused by an e7oto7in produced by t'e

bacterium /lostridium tetani

•/an be pre(ented by immuni1ation 4it'

tetanus to7oid.

•/'aracteri1ed by generali1ed rigidity and

con(ulsi(e spasms of skeletal muscles.T'e

muscle stiffness usually in(ol(es t'e a4*locka4+and neck and t'en becomes

generali1ed.

Tetanus


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Courtes ! Google Image on tetanus


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Tetanus

Ctetani is a slender,gram-positi(e,anaerobicrod t'at may de(elop a terminal spore,gi(ing ita drumstick appearance.

T'e organism is sensiti(e to 'eat and cannot

sur(i(e in t'e presence of o7ygen.T'e spores,incontrast,are (ery resistant to 'eat and t'e usualantiseptics.

T'ey can not sur(i(e autocla(ing at 9?.B RF

*C9C R/+for 9: minutes.T'e spores are also relati(ely resistant to

p'enol and ot'er c'emical agents.


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Tetanus

T'e spores are 4idely distributed in soil and in t'e intestines and faeces of'orses,s'eep,cattle,dogs,cats,rats,guinea pigs. Spores may persist for

mont's to years.C tetani produces t4o e7oto7ins,tetanolysin and tetanospasmin. T'efunction of tetanolysin is not kno4n 4it'certainty. Tetanospasmin is a neuroto7in

and causes t'e clinical manifestations oftetanus.

Tetanospasmin estimated 6uman let'aldose 9.@ ng=kg


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•3ccurrence# Tetanus occurs 4orld4ide but is most

fre8uently encountered in densely populated regions in

'ot,damp climates 4it' soil ric' in organic matter.

•&eser(oir#3rganisms are found primarily in t'e soil and

intestinal tracts of animals and 'umans.

•Mode of Transmission#Transmission is primarily by

contaminated 4ounds,Tissue inury* surgery,burns,deep

puncture 4ounds,crus' 4ounds,3titis media ,dental

infection,animal bites, abortion,and pregnancy+.

•/ommunicability

Tetanus is not contagious from person to person.It ist'e only (accine-pre(entable disease t'at is infectious

but not contagious.

Temporal pattern#Peak in 4inter and summer season

Incubation Period# B DA>S * ;-9C DA>S+


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•Maternal tetanus, defined as tetanus occurring duringpregnancy or 4it'in G 4eeks after any type of

pregnancy termination, is one of t'e most easily

pre(entable causes of maternal mortality.

•It includes postpartum or puerperal tetanus*i+ postpartum or puerperal tetanus, usually resulting

from septic procedures during deli(ery,

*ii+ postabortal tetanus, follo4ing septic maneu(ers

during induced abortion

and *iii+ tetanus during pregnancy, generally resulting

from inoculation t'roug' a nongenital portal of entry

Maternal Tetanus


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TETANUS TOXOID


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Tetanus to7oid 4as de(eloped by Descombey inC9?,

Tetanus to7oid immuni1ations 4ere usede7tensi(ely in t'e armed ser(ices during 5orld 5arII.

Tetanus to7oid consists of a formalde'yde-treatedto7in.

T'ere are t4o types of to7oid a(ailable adsorbed*aluminum salt precipitated+to7oid and fluid to7oid.

Alt'oug' t'e rates of serocon(ersion are aboute8ual,t'e adsorbed to7oid is preferred because t'eantito7in response reac'es 'ig'er titers and islonger lasting t'an t'at follo4ing t'e fluid to7oid.

TETANUS TOXOID


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K26 - Infections in Pregnancy

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