PREGNANCY AND INFECTIOUS DISEASE

1. PREGNANCY ANDINFECTIOUS DISEASE Presenter : Anil K Malik Moderator : Dr V. Darlong www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. Most infection are no more serious than in non-pregnant woman. • Transmitted to fetus in utero or during or immediately after delivery. • Serious illness in mother can have nonspecific fetal or obstetric effects.

3. major causes of neonatal death were: 1. Infection (35%) 2. Preterm birth (28%) 3. Asphyxia (23%)

4. Infectious diseases and pregnancy Infections with anesthesia implications: HIV Varicella zoster virus Syphilis Hepatitis Malaria Tuberculosis Borreliosis (Lyme disease)

5. Other infections: Toxoplasma Rubella CMV Herpes simplex virus Parvovirus B19 Group B streptococcus STI UTI Listeria

6. Human immunodeficiency virus (HIV) • young women account for 66% of infections among young people • leading cause of death and disease among women of reproductive age worldwide • One half of people living with HIV globally are women

7.  In 2006, CDC published "Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings". -opt-out HIV screening for all pregnant women, -repeat HIV screening in the 3rd trimester for women who are at high risk

8. Women whose HIV status is unknown at the time of labor should be offered opt-out screening with a rapid HIV test. • Opt-out HIV testing: women are told that an HIV test will be included in the standard group of prenatal tests but that they may decline HIV testing. • Opt-in HIV testing: women are provided pretestcounseling and must specifically consent to an HIV test.

9. current recommendations are: • HIV screening, included in the routine panel of prenatal screening tests • opt-out screening • Separate written consent for HIV testing should not be required • Repeat screening in the third trimester is recommended

10. SYSTEMIC EFFECTS Nervous system: • Myelopathy • Aseptic meningitis • HIV encephalopathy • Dementia complex • Peripheral neuropathy • Autonomic neuropathy

11. Respiratory system: • Oppertunistic infections -pneumocystisjiroveci -mycobacterium tuberculosis -MAC Cardiovascular system: • Pericardial diseases • DCM

12. GI System: • Oropharyngealcandidiasis • Aphthous ulcer • Leukoplakia • Esophagitis • Hepatobilliary involvement • HIV enteropathy with chronic diarrhoea • vascular kaposi sarcoma of pharynx

13. Musculoskeletal system • AIDS-related wasting syndrome Renal system • FSGS • ESRD Immunological system • Depressed immunity • lymphadenopathy

14. Hematologicasustem • Normocyticnormochromic anemia • Thrombocytopenia • Neutropenia • Coagulation abnormality Endocrine system • Adrenal insufficiency • Hypothyroidism • SIADH

15. anesthetic consideration Anesthetic implication of drugs Thrombocytopenia: -zidovudine -isoniazide -rifampin -phenytoin

16. Peripheral neuropathy: -didanosine -stavudine -lamivudin -zalcitabin Neutropenia: -ganciclovir -cotrimoxazole

17. Hepatic dysfunction: Phenytoin Ethambutol Others: Pentamodine: bronchospasm, arrythmias, electrolyte abnormalities

18. Preoperative assesment: -past social/medical history(IV drug abuse) -associated diseases(syphilis, HBV etc.) -carefull physical examination -documentation of any neurological deficits -presence of AIDS-related dementia

19. -oropharyngeal pathology -oppertunistic pulmonary infections -CVS(subclinical cardiomyopathy) -renal system(nephropathy) -hematological studies

20. Anesthesia technique: • Necessary safety measures • Universal/standard precautions Neuroaxial techniques: -Safe -Tailored to individual obstetric indications • No evidence of increased infectious complications with neural anesthesia & analgesia • Complication of aneuroaxial anesthesia doesn’t differs

21. GA: • Dose adjustment for -h/o drug abuse -compromised liver & kidney function -generalised muscle wasting • Higher fraction inspired O2, with lung pathology • Increased sensitivity to opioids & BZD

22. VARICELLA-ZOSTER VIRUS • Herpes group virus(I & II) • spread by respiratory transmission or direct contact • severe maternal varicella cause intrauterine death of fetus • Infection in 1st & 2nd trimester lead to congenital varicella syndrome -its risk is 2% in 1st half

23. Symptoms: -skin lesion in dermatomal distribution -neurologic defecit -eye disease -skeletal anomaly • About 30% of infant born with these lesions die in the 1st month of life

24. primary varicella: -chiken pox -encephalitis -pneumonia -occaissionally with respiratory failure • Secondary varicella: -herpes zoster(shingles)

25. Anesthesia concerns • Patient in acute primary varicella at the time of delivery: -current debate about the optimum anesthetic technique • GA may exacerbate varicella pneumonia. • SAB- theoritical risk of transmitting the virus from skin lesion to the CNS. • Epidural may be safer than spinal

26. Neuraxial anesthesia: • A site free of cutaneous lesion should be choosen for needle placement. • Maternal risks like bleeding , thrombocytopenia, DIC & hepatitis • Pain management is also difficult in these patient • Risk of contracting infection

27. Syphilis • Caused byTreponemapallidum. • Transmission: -sexual -maternal-fetal -rarely by other means. • increases the risk of both transmitting and getting infected with HIV • Do HIV testing in all patients with syphilis.

28. STAGES OF SYPHILIS • Primary • Secondary • Latent Early latent Late latent • Late or tertiary May involve any organ, but main parts are: Neurosyphilis Cardiovascular syphilis Late benign (gumma)

29. Primary syphilis • Incubation period 9-90 days, usually ~21 days. • Develops at site of contact/inoculation. • Classically: single, painless, clean-based, indurated ulcer, with firm, raised borders. - Atypical presentations may occur.

30. Mostly anogenital, but may occur at any site (tongue, pharynx, lips, fingers, nipples) • Non-tender regional adenopathy • Very infectious. • May be darkfield positive but serologically negative. • Untreated, heals in several weeks, leaving a faint scar.

31. Secondary syphilis • Seen 6 wks to 6 mos after primary chancre • Usually w diffuse non-pruritic, indurated rash, including palms & soles. • May also cause: • Fever, malaise, headache, sore throat, myalgia, arthralgia, generalized lymphadenopathy • Hepatitis (10%) • Renal: an immune complex type of nephropathy with transient nephrotic syndrome • Iritis or an anterior uveitis • Bone: periostitis • CSF pleocytosis in 10 - 30% (but, symptomatic meningitis is seen in <1%)

32. Latent syphilis Positive syphilis serology without clinical signs of syphilis (& has normal CSF). • It begins with the end of secondary syphilis and may last for a lifetime. • Pt may or may not have a h/o primary or secondary syphilis. • Is divided into early and late latency.

33. LATE SYPHILIS‘Tertiary Syphilis’ • Is the destructive stage of the disease. • Lesions develop in skin, bone, & visceral organs (any organ). • The main types are: • Late benign (gummatous) • Cardiovascular & • Neurosyphilis

34. Can be crippling and life threatening • Blindness, deafness, deformity, lack of coordination, paralysis, dementia may occur • It is usually very slowly progressive • Late syphilis is noninfectious

35. neurosyphilis • Divided into 5 groups, which may overlap: • Asymptomatic neurosyphilis • Syphilitic meningitis • Meningovascular syphilis • General paresis • Tabesdorsalis

36. diagnosis • Dark field Microscopy • VDRL, RPR • FTA-ABS, MHA-TP • Direct Fluorescent Antibody (DFA)

37. Pregnancy and syphilis • pregnancy usually does not affect the course of syphilis • But syphilis may affect pregnancy and can cause: -IUGR -pre term birth -still birth -neonatal death -congenital malformations

38. Anesthesia concerns • Mainly related to late stage syphilis affecting aorta, dorsal column, nerve roots. • For aortic involvement: -special care must be taken to minimize aortic wall stress(with beta blocker) • For CNS involvement: -neuroaxial analgesia may not be ideal -sensory testing compromised

39. Hepatitis • Acute hepatitis: -one of the most serious infection durig pregnancy -HEV associated with 20% mortaliy -cause: hepatitis virus group EBV HSV CMV rubella

40. Chronic hepatitis: -may be associated with: -cirrhosis -hepatic failure -HCC • All pregnant woman should undergo screening for hepatitis B, as recommended by CDC

41. Anesthesia concerns Preoperative assesment: - severity of hepatitis -Coagulation abnormality Neuraxial anesthesia: -no coagulopathy, if present prior replacement of clotting factors -metabolism of local anesthetics is also of concern(amide LA) -decreased hepatic pseudocholinesterase

42. Theoritical risk of LA toxicity with large dosage in epidural • spinal is prefered over epidural • GA : indications: -coagulopathy -severe haemorrhage -umbilical cord prolapse • Intravascular volume, evaluated with consideration for invasive monitoring when ascitis or CVS compromise are present

43. Avoid hepatotoxic drugs • Judicious use of opioids • Avoid hypoxia & reduction in hepatic blood flow • RSI can be done with succinylcholine

44. MALARIA • The disease is almost always symptomatic • Potentially lethal in non immune, particularly gravid females • Possible pregnancy complications: -IUGR -preterm -spontaneous abortion -eclampsia -PPH -puerperal fever

45. Anesthesia concern • Patient may be present with complications of malaria like -pulmonary edema -ARDS -seizure -severe anaemia -ARF

46. Tuberculosis • Pregnancy doesn’t change its course • Serious risk to mother, neonate & health care provider • Active disease treated with firstline therapy • Isoniazide causes hepatitis & risk increased in pregnancy

47. Anesthesia concern • LFT monitored very closely • Precautions: - placing the patient in negetive pressure room -wearing particulate filter mask • Anesthesia technique as per indication

48. Borreliosis • caused by Borrelioburgoderferi • Spread by ticks • A spirochetaldiease • Affect cardiovascular & neurological syste

49. Anesthesia concern: - If there is neurological involvement then avoid neuroaxial anesthesia - Thorough cardiac evaluation

50. STI in pregnancy Syphilis - 2.4-17% Chlamydia - 5.3-21.5% Gonorrhea - 2.0-20% Bacterial vaginosis - 9-48.5% Trichomoniasis - 9.9-27.5% HSV - 6.7-53.4% HIV - 15- 42.5%