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13 Group B Streptococcal Infection
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Group B streptococci frequently colonize the lower female genital tract, with an asymptomatic carriage rate in pregnancy of 5 30% This rate depends on maternal age, gravidity, and geographic variation Vaginal carriage is asymptomatic and intermittent, with spontaneous clearing in approximately 30% and recolonization in about 10% of women Adverse perinatal outcomes associated with group B streptococcal colonization include urinary tract infection, intrauterine infection, premature rupture of membranes, preterm delivery, and postpartum endometritis Women with postpartum endometritis due to infection with group B streptococci, especially after cesarean section, develop fever, tachycardia, and abdominal distention, usually within 24 hours after delivery Approximately 35% of these women are bacteremic Group B streptococcal infection is a common cause of neonatal sepsis Transmission rates are high, yet the rate of neonatal sepsis is surprisingly low at less than 4:1000 live births Unfortunately, the mortality rate associated with early-onset disease can be as high as 50% in premature infants and approaches 25% even in those at term Moreover, these infections can contribute markedly to chronic morbidity, including mental retardation and neurologic disabilities Late-onset disease develops through contact
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Epileptic women contemplating pregnancy who have not had a seizure for 5 years should consider a prepregnancy trial of withdrawal from treatment Those with recurrent epilepsy should use a single drug with blood level monitoring Trimethadione and valproate are contraindicated during pregnancy; phenytoin and carbamazepine may be teratogenic in the first trimester and should not be used unless absolutely necessary There is limited information available on the safety of newer antiepilepsy drugs (eg, lamotrigine), and they should only be used if unavoidable Phenobarbital is considered the drug of choice Serum levels should be measured in each trimester and dosage adjustments made to keep serum levels in the low normal therapeutic range Pregnant women taking phenobarbital
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no known adverse effects of VZIG administration during pregnancy Infants born within 5 days after onset of maternal infection should also receive VZIG (125 units) Infected pregnant women should be closely observed and hospitalized at the earliest signs of pulmonary involvement Intravenous acyclovir (10 15 mg/kg every 8 hours for 7 10 days) is recommended in the treatment of VZV pneumonia
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Tan MP et al Chickenpox in pregnancy: Revisited Reprod Toxicol 2006 May;21(4):410 20 [PMID: 15979274]
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with hospital nursery personnel Up to 45% of these health care workers can carry the bacteria on their skin and transmit the infection to newborns CDC recommendations for screening for and prophylaxis of group B streptococcal colonization are set forth in this chapter in the section on tests and procedures
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Akker-van Marle ME et al Cost-effectiveness of different treatment strategies with intrapartum antibiotic prophylaxis to prevent early-onset group B streptococcal disease BJOG 2005 Jun;112(6):820 6 [PMID: 15924544]
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Commonly known as chickenpox, varicella-zoster virus (VZV) infection has a fairly benign course when incurred during childhood but may result in serious illness in adults, particularly during pregnancy Infection results in lifelong immunity Approximately 95% of women born in the United States have VZV antibodies by the time they reach reproductive age The incidence of VZV infection during pregnancy has been reported as up to 7:10,000 The incubation period for this infection is 10 20 days A primary infection follows and is characterized by a flulike syndrome with malaise, fever, and development of a pruritic maculopapular rash on the trunk which becomes vesicular and then crusts Pregnant women are prone to the development of VZV pneumonia, often a fulminant infection sometimes requiring respiratory support After primary infection, the virus becomes latent, ascending to dorsal root ganglia Subsequent reactivation can occur as zoster, often under circumstances of immunocompromise, although this is rare during pregnancy Two types of fetal infection have been documented The first is congenital VZV syndrome, which typically occurs in 04 2% of fetuses exposed to primary VZV infection during the first trimester Anomalies include limb and digit abnormalities, microphthalmos, and microcephaly Infection during the second and third trimesters is less threatening Maternal IgG crosses the placenta, protecting the fetus The only infants at risk for severe infection are those born after maternal viremia but before development of maternal protective antibody Maternal infection manifesting 5 days before or after delivery is the time period arbitrarily determined to be most hazardous for transmission to the fetus Diagnosis is commonly made on clinical grounds Laboratory verification of recent infection is made most often by antibody detection techniques, including ELISA, fluorescent antibody, and hemagglutination inhibition Serum obtained by cordocentesis may be tested for VZV IgM to document fetal infection Varicella-zoster immune globulin (VZIG) has been shown to prevent or modify the symptoms of infection in some women Treatment success depends on identification of susceptible women at or just following exposure Women with a questionable or negative history of chickenpox should be checked for antibody, since the overwhelming majority will have been exposed previously If the antibody is negative, VZIG (625 units intramuscularly) should be given within 96 hours after exposure There are
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