This presentation is the ... - UT Health San Antonio

Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine ?June 10-12, 2011

Deena E. Sutter, MD, FAAP LtCol, USAF

Pediatric Infectious Disease Service Brooke Army Medical Center

Deena E. Sutter, MD, FAAP has no relevant financial relationships with commercial interests to disclose.

Why Prenatal Screening for an Infectious Disease?

Effective intervention for prevention Effective intervention (pre- or post-natal) for

treatment If the incidence of disease is common enough that

it is cost-effective If transmission is common enough to warrant

screening

If significant sequelae are rare, though, it's a problem

If there is high risk of severe effects if transmitted

Preparing the parent Elective termination

Ensure vaccination of mother post-partum

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Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine ?June 10-12, 2011

Who makes the guidelines?

ACOG ACIP/CDC IDSA USPSTF USPHS DoD/VA AAP AAFP

Surprise, surprise, they often have different recommendations!

How about TORCH titers?

Cytomegalovirus Ab, IgM Herpes simplex Ab, IgM

Rubella Ab, IgM Toxoplasma Ab, IgM

False-positive rate for titers obtained without specific clinical indication is high

Accurate diagnoses are rare with these ? JUST DON'T ORDER THEM!

Congenital/Perinatal Infections

High risk /non-immune

Routine Testing (variable)

Directed Testing

HIV* Syphilis* Hepatitis B*

?GC/Chlamydia* ?VZV ?Rubella

CMV Toxoplasma Herpes Simplex

Group B Strep

Parvovirus B19

UA/Urine culture

Hepatitis C

HTLV

T cruzi (Chagas)

M tuberculosis

Test immediately and again in 3rd trimester if high-risk

This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute.

Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine ?June 10-12, 2011

Congenital/Perinatal Infections

High risk /non-immune

Routine Testing (variable)

HIV* Syphilis* Hepatitis B*

?GC/Chlamydia* ?VZV ?Rubella

Group B Strep

UA/Urine culture

Directed Testing

CMV Toxoplasma Herpes Simplex Parvovirus B19 Hepatitis C HTLV T cruzi (Chagas) M tuberculosis

Test immediately and again in 3rd trimester if high-risk

Serologic Assays

Antibody response as simple measure of immunity

Not always best measure Windows of IgG vs IgM presence highly variable IgM may be cross-reactive (nonspecific)

LOTS of different types of serologic tests! Sensitivity and specificity vary based on test PPV and NPV related to overall prevalence of infection

Nonspecific screening assays may need specific/sensitive assays to follow (HIV, syphilis)

Some extremely complicated (toxoplasma)

Tests for Pathogens or Antigens

Viral or bacterial cultures ? only a few of the pathogens (GBS, HSV, CMV)

Nucleic acid testing (PCR, other) ? amniotic fluid, placenta, or fetal body fluids/tissue

Occasionally ID from maternal or infant blood

Antigen tests ? HBSAg (blood), HSV or VZV DFA (vesicles)

This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute.

Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine ?June 10-12, 2011

Congenital/Perinatal Infections Vaccine-Preventable

High risk /non-immune

Routine Testing (variable)

HIV* Syphilis* Hepatitis B*

?GC/Chlamydia* ?VZV ?Rubella

Group B Strep

UA/Urine culture

Directed Testing

CMV Toxoplasma Herpes Simplex Parvovirus B19 Hepatitis C HTLV T cruzi (Chagas) M tuberculosis

Test immediately and again in 3rd trimester if high-risk

Rubella "screening only" No intervention

Rubella IgG ? is mom immune?

>90% seroresponse to vaccine Live-virus vaccine contraindicated in pregnancy Goal to immunize women of childbearing age who are not pregnant

Documentation of 1 or more doses is sufficient evidence of immunity in pregnancy (CDC)

DoD guidelines recommend universal serology Recommendation to avoid exposure (limited evidence) Immunization of susceptible women post-partum

Congenital Rubella Syndrome

99% decline after implementation of vaccine in 1969

Few cases per year, essentially all imported

Wkly Epidemiol Rec. 2010 Oct 15;85(42):413-8. Controlling rubella and preventing congenital rubella syndrome ? global progress, 2009.

This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute.

Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine ?June 10-12, 2011

Cohen & Powderly: Infectious Diseases, 3rd ed.

Congenital Varicella

Rare development of congenital varicella even when pregnant women infected

Rates of natural disease decreased with vaccine (90-95% response) ? congenital infection even more rare

Of more concern ? severe varicella in infants exposed perinatally or preterm infants without maternal immunity

VZV ? screening, with potential intervention in case of exposure

Obtain test if proof of immunity does not exist

IgG negative - vaccinate after delivery Birth before 1980 NOT an accepted proof of

immunity Most women of childbearing age - screening if

immunization records not available

Varizig ? (IND hyperimmune globulin)

If suspected infection = immunoglobulin for mom For neonates with maternal symptoms 5 days prior

to or 2 days post-delivery Neonates with presumed lack of maternal antibody

and post-natal exposure

This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute.

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