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Objectives

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.

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Objectives

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  1. Maternal LabsGBS, Hep B, hiv, rpr, hsv, blood type, gc, chlamydia ByTracey Causer, BSN, RN-NICkatie Ferrell, BSN, RNLeann 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

  2. 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 & treatment of the infant

  3. Testing in Texas • Clinicians in Texas must test every pregnant woman for HIV, syphilis, and hepatitis B unless she objects. The tests must take place during the pregnant woman's first prenatal visit and at delivery. • Effective January 1, 2010, the woman must be tested for HIV during her third trimester unless she objects. • If there is no record of her test result from the third trimester, then the woman must be tested at delivery unless she objects The law also provides for expedited testing of the mother and newborn at delivery. (Texas Department of State Health Services (TDSHS), n.d.)

  4. Testing in Texas • Why we test in Texas • Testing and treatment for HIV, HBV and Syphilis prevents infected infants. • HIV • When a mother does not know her HIV status, she has an approximately 25 percent chance of transmitting HIV to her unborn child. • The transmission rate can be decreased to 2% or less if HIV-positive pregnant women are tested and treated during pregnancy, labor, and delivery (and the newborn is treated as well) (TDSHS, n.d.)

  5. Testing in Texas • HIV (cont’d) • Antiretroviral medications and Cesarean delivery are needed for women with high HIV viral loads (>1,000 copies/ml). • Statistics show even when medicine is not started until labor and delivery, transmission rates are reduced to 10 percent. • Syphilis and HBV • Screening in 2012 for perinatal syphilis allowed Texas clinicians to identify 79 cases of congenital syphilis, allowing them to provide treatment and follow up. • Infants born to women with HBV, 70-95 % will not be infected if they receive HBV vaccine and treatment within 12 hours of delivery. (TDSHS, n.d.)

  6. Testing in Texas • GBBS • Guidelines for the testing and treatment of perinatal group B streptococcal disease were first published by CDC in 1996 (CDC, 2002). (TDSHS, n.d.)

  7. Blood Type

  8. Blood Type • Background • Prenatal labs for pregnant women should include blood type and Rh factor identification. • The four major Blood groups are A, B, AB and O. Rh factor is either + (meaning this protein is present on the RBC) or – (meaning it isn’t). • Prenatally, these tests are used to determine if an infant may be at risk for ABO or Rh factor incompatibility. • Incompatibility between blood groups or Rh factor may lead to Hemolytic Disease of the Newborn. Lucile Packard Children’s Hospital, 2013

  9. Blood Type • ABO incompatibility • Although usually not as severe as Rh incompatibility, incompatibility can occur between the major blood groups A, B and O. • Rh Sensitization and Incompatibility • A more common and severe form of incompatibility is Rh factor. When a woman’s Rh factor is negative, and a developing infant’s Rh factor is positive, the mother may develop IgG-Rh antibodies against the infant’s blood she is exposed to during amniocentesis, miscarriage or birth. Lucile Packard Children’s Hospital, 2013

  10. Blood Type • Potential Complications with Rh incompatibility and Sensitization • During pregnancy – • anemia, hyperbilirubinemia, and jaundice • severe anemia with enlargement of the liver and spleen • hydropsfetalis (erythroblastosisfetalis) • After delivery – • severe hyperbilirubinemia and jaundice • kernicterus • death Lucile Packard Children’s Hospital, 2013

  11. ErythroblastosisFetalis

  12. Blood Type Screening and Treatment During Pregnancy: • Once Rh negative status has been determined: • Indirect coombs test to determine if sensitization exists (detects presence of antibodies. • If indirect coombs negative (not sensitized), • RhoGAM at 28 weeks gestation in the absence of sensitization, and within 72 hrs of delivery (Gomella, Cunningham, & Eyal, 2013) RhoGAM is a specially developed blood product that prevents Rh neg mother’s antibodies from reacting to Rh positive cells (Lucile Packard Children’s Hospital, 2013).

  13. Blood Type • Incidence • Historically, Rh hemolytic disease has accounted to one third of symptomatic cases, with a detectable antibody of about 15% of Rh-incompatible mothers. • Use of Rh immunoglobulin (RhoGAM) prophylaxis has reduced to <1% of Rh-incompatible pregnancies. (Gomella, Cunningham & Eyal, 2013)

  14. Blood Type In Summary: • Infants whose mothers with blood types are A, B, or O or whose Rh factor is negative are at risk for blood incompatibilities and will require prenatal monitoring and possible maternal intervention. • At delivery, these infants should be monitored for complications arising from these incompatibilities. (Gomella, Cunningham, & Eyal, 2013)

  15. Chlamydia

  16. Chlamydia • 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)

  17. Chlamydia • 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, Cunningham & Eyal, 2013)

  18. Chlamydia • Potential Complications • Premature rupture of the membranes (PROM) • Preterm labor and birth • Low birth weight • Intrauterine growth retardation • Stillbirth (Gomella, Cunningham & Eyal, 2013)

  19. 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, Cunningham & Eyal, 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, Cunningham & Eyal, 2013).

  20. Chlamydia – Prognosis • 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)

  21. Group Beta Streptococcus (GBS)

  22. GBS • Background • Group B streptococcus is a gram-positive cocci • Found in the gastrointestinal tract, urinary tract and genital tract, as well as the respiratory tract in infants Buckler, Bell, Sams, Cagle, Bell, Allen, Sutherland & Bhatia, 2010)

  23. GBS • Incidence • At least 30% of women have asymptomatic GBS colonization at some point during their pregnancy • About 20% remain colonized at birth • Risk Factors for the Infant • One of the most common causes of early onset neonatal sepsis • Occurs within the first 6 days of life (Buckler et al, 2010)

  24. GBS- Testing • Recommendations • The CDC recommends GBS rectovaginal screening cultures for all pregnant women 35-37 weeks of gestation, with 2 exceptions • Woman with GBS bacteriuria during the current pregnancy • Women who previously gave birth to an infant with invasive GBS disease (Baker, 2013)

  25. GBS-Testing • Culture Sampling • Cultures are preformed near term because many transient or intermittent disease; GBS status in early pregnancy may not be predictive if status in late pregnancy • Swabs for culture should be obtained, prior to digital examination or use of lubricants, from both the lower vagina and rectum • Cultures require 24-48 hours to show positive results (Baker, 2013)

  26. GBS- Prognosis • Intrapartum Prophylaxis for GBS positive mothers • Antibiotics are prescribed for: • Positive screening culture for GBS (either vagina or rectum) • Positive history of birth of an infant with early-onset GBS disease • GBA bacteriuria during the current pregnancy • Unknown antepartum culture and • Intrapartum fever (>100.4 F), or • Preterm labor (< 37 weeks of gestation), or • Prolonged rupture of membranes (> 18 hours), or • Intrapartum NAAT positive for GBS • Antibiotics • Penicillin, Ampicillin, and Cefazolin, 4 or more hours, prior to delivery (Byington & Baker, 2010)

  27. GBS- Prognosis • Newborn Care • Observation of the infant for > 48 hours after birth • If maternal GBS is indicated and the mother received prophylactic antibiotics • A blood culture at birth should be obtained, along with CBC at birth and at 6-12 hours of life • GBS prophylaxis is indicated for the mother, and the mother did not receive prophylactic antibiotics • A blood culture at birth should be obtained, along with CBC at birth and at 6-12 hours of life & CBC with differential at 6-12 hours of life • GBS prophylaxis is indicated for the mother and the mother is either <37 weeks or rupture of membranes is >18 hours (Byington & Baker, 2010)

  28. GBS-Prognosis • Newborn Care (cont.) • A blood culture at birth should be obtained, along with CBC at birth and at 6-12 hours of life & antibiotic therapy, Ampicillin 100 mg/kg/dose q 12 and Gentamicin 4 mg/kg/dose q 24 • Presence of maternal chorioamnioitis • A full diagnostic evaluation including a blood culture, complete blood count, chest x-ray and lumbar puncture should be ordered, along with broad spectrum antibiotics, Ampicillin 100 mg/kg/dose q 12 and Gentamicin 4 mg/kg/dose q 24 • If the infant shows signs of neonatal sepsis (temperature irregularity, change in behavior, feeding problems, or cardiopulmonary, metabolic or skin problems) (Byington & Baker, 2010)

  29. Gonnorhea

  30. GC • 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, Cunningham & Eyal, 2013).

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

  32. GC • Potential Complications • Miscarriage before 20 weeks • Premature rupture of the membranes (PROM) • Preterm labor and birth (March of Dimes, n.d.)

  33. 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. gonorrhoeaeis superior to culture but varies by NAAT type (Centers for Disease Control and Prevention, n.d.)

  34. GC - Prognosis • 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, Cunningham & Eyal, 2013).

  35. Hepatitis B

  36. Hepatitis B - Background • Blood born illness caused by a DNA-containing hepadnavirus that leads to serious infection of the liver, and for some, liver failure, liver cancer or cirrhosis (Mayo, 2011). • Risk factors include: 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 (CDC, 2010). • If infected, pregnancy presents unique challenges relating to management of the mother and prevention of perinatal transmission (Lee & Lok, 2013).

  37. Hepatitis B • Incidence • Each year in United States - 20,000 infants are born to HBV infected mothers. • Perinatal transmission can occur transplacentally, during pregnancy or at time of delivery from placental leaks (<25% of infections), or natally, by exposure to in amniotic fluid, vaginal secretions, or maternal blood (up to 90%). (Gomella, Cunningham, & Eyal, 2013)

  38. Hepatitis B • Risk Factors for Increased Transmission • Presence of HBeAg and absence of Anti-Hbe in maternal serum • Asian race, particularly Chinese • Acute hepatitis in the mother during the third trimester or immediately postpartum • Higher-titer HBsAg in maternal serum • Antigenemia present in older siblings • Particular HBV subtype in mother • Presence or absence of HBsAg in amniotic fluid • Presence or titer of anti-HBc in cord blood (Gomella, Cunningham & Eyal, 2013)

  39. Hepatitis B – Lab Testing • Screen at first prenatal visit and at delivery • Tests performed on maternal serum: • HBsAg - Hepatitis B Surface Antigen (Gomella, Cunningham & Eyal, 2013)

  40. Hepatitis B - Transmission Prevention • Treatment • If mother is HBsAg positive infant should be treated: • hepatitis B immune globulin (HBIG), 0.5 ml IM, within 12 hrs of delivery • hepatitis B vaccine, 0.5 ml given at birth, 1 mo, & 6 mo. (If Hep B Vaccine is given simultaneously, give in different site, preferably opposite leg) • For preterm infants <2 kg, initial dose of Hep B vaccine at birth is not counted in the required 3-dose immunization schedule. (Gomella, Cunningham & Eyal, 2013)

  41. Hepatitis B - Transmission Prevention • Treatment (cont.) • If mother is HBsAg unknown, • Test mother as soon as possible • While awaiting results, infant should be given hepatitis B vaccine within 12 hrs of birth • If mother found to be positive, give HBIG (0.5 ml) within 7 days of life If preterm and maternal cannot be determined within 12 hrs • Give HBIG & Hep B Vaccine (Gomella, Cunningham, & Eyal, 2013)

  42. Hepatitis B • Prognosis • Infection rate of infants who do not receive prophylaxis treatment is as high as 90% (Lee & Lok, 2013). • Infected infants remain relatively healthy, 30-50% develop persistently elevated liver function tests, 5% have moderate histopathologic changes on liver biopsy, late complications of the disease are rarely seen during infancy (Gomella, Cunningham, & Eyal, 2013).

  43. Herpes Simplex Virus (HSV)

  44. Herpes (HSV) • 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, Cunningham & Eyal, 2013)

  45. HSV • 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, Cunningham & Eyal, 2013)

  46. HSV • 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, Cunningham & Eyal, 2013)

  47. HSV– Lab Testing • 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)

  48. HSV– Lab Testing • Polymerase chain reaction (PCR) • More sensitive and has been used to detect HSV DNA in CSF and blood specimens (Gomella, Cunningham & Eyal, 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)

  49. HSV – Prognosis • 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, Cunningham & Eyal, 2013)

  50. Human Immunodeficiency Virus (HIV)

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