MATERNAL LABS

GBS, HEP B, HIV, RPR, HSV, BLOOD TYPE, GC, CHLAMYDIA BY TRACEY CAUSER, BSN, RN-NIC KATIE FERRELL, BSN, RN LEANN HENSON, BSN, RN COURSE GNRS 5303 ADVANCED NEONATAL HEALTH ASSESSMENT Instructors L. A. Cates MSN, RN, NNP-BC, RRT-NPS D. Armentrout PhD, MSN, RN, NNP-BC

Objectives

 To identify proper maternal labs to be obtained during pregnancy  To identify pre-existing maternal conditions important to pregnancy  To identify potential pregnancy complications affecting the infant  To identify proper prenatal care  To be able to recognize the importance of maternal history for impending delivery

Chlamydia

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Background

 Chlamydia is an obligate intracellular organism.

 It’s the most common cause of sexually transmitted disease  It may cause urethritis cervicitis and salpingitis in the mother  It may cause conjunctivitis and pneumonia in the infant (Gomella, Cunningham, & Eyal, 2013).

Chlamydia

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Incidence

 Prevalence in pregnant women varies at 2-15%  Risk of transmission to the infant is high  Conjunctivitis occurs in 25-50%  Pneumonia occurs in 5-20% 

Risk Factors for the Infant

 Vaginal delivery with an infected mother  Cesarean delivery with early rupture of membranes of an infected mother (Gomella et al., 2013).

Chlamydia

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Potential Complications

 Premature rupture of the membranes (PROM)  Preterm labor and birth  Low birth weight  Intrauterine growth retardation  Stillbirth (Gomella et al., 2013).

Chlamydia – Lab Testing

     Specimen must be a tissue culture containing epithelial cells. This is the gold standard. Also diagnosed by use of nucleic acid amplification tests (NAAT).

Most commonly used is the polymerase chain reaction (PCR) due to its higher sensitivity and specificity (Gomella et al., 2013). Other methods include antigen detection tests by direct fluorescent antibody method or enzyme immunoassay (Venkatesh, Merenstein, Adams & Weisman, 2006). These tests have mostly been replaced by NAAT (Gomella et al., 2013).

Chlamydia – Prognosis

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Screening and Treatment

 Recommendation of the American College of Obstetricians and Gynecologists (ACOG) is to test women at first prenatal visit that are high risk  Treat those that are positive with erythromycin, 500mg q.i.d. for 7 days  Treat again in the third trimester

Vertical Transmission

 In one study, infection seen in the neonate was 50% for untreated mothers and only 7% in mothers receiving treatment (Allaire, Nathan, & Martens, 1995)

GC

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Background

 Infection is with Neisseria gonorrhoeae  A gram negative oxidase-positive diplococcus  An infection of the reproductive tract can be transmitted to the fetus or the neonate (Gomella et al., 2013).

GC

 Incidence  In 2010, US incidence was 1:1000  Rate is highest in females aged 15-24 (Gomella et al., 2013).  Risk factors for the infant  Babies with gonorrhea can develop eye and joint infections  They can also develop life-threatening sepsis (March of Dimes, n.d.)

GC

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Potential Complications

 Miscarriage before 20 weeks  Premature rupture of the membranes (PROM)  Preterm labor and birth (March of Dimes, n.d.)

GC - Lab Testing

    Culture, nucleic acid hybridization tests, and NAATs are available for the detection of genitourinary infection with N. gonorrhoeae Diagnosis is done by endocervical scrapings for culture.

NAATs allow testing of the widest variety of specimen types including endocervical swabs, vaginal swabs, and urine and they are FDA-cleared for use.

The sensitivity of NAATs for the detection of N. gonorrhoeae is superior to culture but varies by NAAT type (Centers for Disease Control and Prevention, n.d.)

GC - Prognosis

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Screening and Treatment

  Recommendation by the CDC is to screen all women at risk at first prenatal visit Rescreen high risk women during the third trimester  Treat those that are positive with a cephalosporin (Centers for Disease Control and Prevention, n.d.) 

Vertical Transmission

  In women not treated, if ophthalmic prophylaxis is not used, about one third of newborns will become infected Treatment for infants born to mothers with gonococcal infection are given a single injection of ceftriazone (Gomella et al., 2013).

Herpes (HSV)

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Background

 A virus that has two distinct types, HSV-1 and HSV-2.

 Enveloped, double stranded DNA virus  HSV infection is the most prevalent of all viral infections encountered by humans  Infections of the newborn can be of either type, but most are caused by HSV-2 (Gomella et al., 2013)

HSV

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Incidence

   Overall incidence is 9.6 per100,000 Infants incidence is 1 per 3000 to 1 per 20,000 In pregnant women, seroprevalence of HSV-1 is 63% and HSV-2 is 22%

Risk Factors for the Infant

   If no visible lesions at the onset of delivery, vaginal birth is acceptable Cesarean delivery is recommended for those with clinical symptoms Debate exists for mothers who have been ruptured for >4 hours (Gomella et al., 2013).

HSV

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Potential Complications

 High rate of fetal demise  Microcephaly, hydrocephalus, and chorioretinitis  Infants with disseminated and SEM disease generally present at 10-12 days of life  Infants with CNS disease usually present at 16-19 days of life  Infants with disseminated disease and infants with encehalitis never have skin vesicles in 20 % and 30-40% respectively (Gomella et al., 2013).

HSV– Lab Testing

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Viral Culture

The gold standard and preferred test if genital ulcers or mucous membrane lesions are present. Lesions are scraped and transferred to the appropriate viral transport media on ice. Highly specific (Genital and Perirectal Herpes Simplex Virus Infection Slides. ,2009)

HSV– Lab Testing

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Polymerase chain reaction (PCR)

More sensitive and has been used to detect HSV DNA in CSF and blood specimens (Gomella et al., 2013).   

Antigen detection

Fairly sensitive in symptomatic shedders Rapid results (2-12 hours) May be better than culture in detection of HSV in healing lesions (Genital and Perirectal Herpes Simplex Virus Infection Slides. ,2009)

HSV – Prognosis

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Screening and Treatment

  A history of genital herpes in a pregnant woman or her partner should be obtained during the prenatal visit Treat those with a primary episode or an active infection near or at the time of delivery with Acyclovir  Prophylactic treatment with acyclovir beginning at 36 weeks reduces the risk of transmission at delivery

Vertical Transmission

  With current antiviral treatment, mortality has been reduced to 29% for disseminated disease and 4% for CNS disease For neonates who survive HSV infection, developmental assessments should be done on a regular basis.

(Gomella et al., 2013).

CDC Recommendations for Screening

Disease

Chlamydia Gonorrhea Syphilis Bacterial Vaginosis Trichomoniasis Herpes (HSV) HIV Hepatitis B

CDC Recommendation Screen all pregnant women at first prenatal visit; 3rd trimester rescreen if younger than 25 years of age and/or high risk group Screen all pregnant women at risk at first prenatal visit; 3rd trimester rescreen women at continued high risk Risk factors include: young women aged 25 years or younger, living in a high morbidity area, previous GC infection, other STDs, new or multiple sex partners, inconsistent condom use, commercial sex work, drug use Screen all pregnant women at first prenatal visit; during 3rd trimester rescreen women who are at high risk for syphilis or who live in areas with high numbers of syphilis cases, and/or those who were not previously tested or had a positive test in the first trimester Test pregnant women who have symptoms or are at high risk for preterm labor Test pregnant women with symptoms Test pregnant women with symptoms Screen all pregnant women at first prenatal visit; rescreening in the third trimester recommended for women at high risk for getting HIV infection Screen all pregnant women at first prenatal visit Retest those who were not screened prenatally, those who engage in behaviors that put them at high risk for infection and those with signs or symptoms of hepatitis at the time of admission to the hospital for delivery Risk factors include: having had more than one sex partner in the previous six months, evaluation or treatment for an STD, recent or current injection-drug use, and an HBsAg-positive sex partner Human Papillomavirus There is not enough evidence to make a recommendation

Hepatitis C

All pregnant women at high risk should be tested at first prenatal visit

Conclusion

 Add your conclusions here.

References

Allaire, A., Nathan, L., Martens, M.G. (1995). Chlamydia trachomatis: Management in Pregnancy. Infectious Diseases in Obstetrics and Gynecology 3:82-88 Centers for Disease Control and Infection (CDC). (n.d.). Sexually transmitted diseases (STDs): Treatment guidelines 2010. Retrieved from http://www.cdc.gov/std/treatment/2010/gonococcal infections.htm#preg Genital and Perirectal Herpes Simplex Virus Infection Slides. (2009). HSV curriculum. Retrieved from www2a.cdc.gov/stdtraining/ready-to use/Manuals/HSV/hsv-slides-2009.pdf

Gomella, T. L., Cunningham, M. D., & Eyal, F. G. (2013). Neonatology. (7 th United States: McGraw Hill Education.

ed). Venkatesh, M., Merenstein, G.B., Adams, K.M., & Weisman, L.E. (2006). Infection in the neonate. In G.B. Merenstein & S.L. Gardner (Eds,), Handbook of neonatal intensive care (pp.576 -579). St.Louis, MO: Mosby Elsevier