Infection control measures in intensive care units

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PRE-PREGNANCY COUNSELING
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Objectives

1. Being able to council females before pregnancy.
2. Identification of Risk factors in female before
   pregnancy.
3. Being able to select high risk cases for further
   screening test.

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• The aim of pre-pregnancy care is to give a woman
  enough information for her pregnancy to occur
  under the optimal possible circumstances.

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• Areas to cover are

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Diet

• Folate rich foods prior to pregnancy and in the
  first l2 wk. of pregnancy .
• Avoidance of un-pasteurized dairy products,
  uncooked eggs, pre-prepared salads to prevent
  infection (e.g. Listeriosis, salmonella) during
  pregnancy.

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• When preparing food keep cooked and raw meats
  separately.
• Wash all soil off fruit and vegetables before
  eating.
• Wash hands before and after preparation.
• Only eat well-cooked meat.

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Folate supplementation

• If no previous neural tube defects,
• folic acid 400 microgram supplementation prior to
  conception when pregnancy is being planned and
  for l3wk after conception
• decreases risk of neural tube defect by 72.

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Chronic disease

• Review of pre-existing medical conditions with
  referral for expert advice where necessary.
• Refer women who are diabetic for specialist
  diabetic review and change women taking oral
  hypo-glycemics to insulin.

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• Women with epilepsyreview medication. Heart
  diseaserefer for specialist advice if situation
  not clear.
• GU disease (e.g. HIV, HSV, genital warts,
  bacterial vaginosis)refer for treatment advice
  on mode of delivery if necessary.
• Discontinue all known possible teratogens prior
  to conception

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Problems in previous pregnancies

• Recurrent miscarriage
• cervical incompetence
• congenital abnormalities
• inherited disorders
• pre-pregnancy counseling and detailed advice on
  genetic screening for high-risk pregnancies is
  available via regional genetics services.

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Rubella status

• If rubella status is unknown suggest it is
  checked.
• Rubella infection in early pregnancy carries a
  high chance (4070) of deafness, blindness,
  cardiac abnormalities or multiple fetal
  abnormalities.
• If the woman is not rubella immune, suggest
  immunization with avoidance of pregnancy for 3
  months afterwards (live vaccine).

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Contraception

• Women contemplating pregnancy are usually still
  using contraception.
• Discussion about how to stop/what to expect may
  be helpful (e.g. injectables, IUCD).

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Smoking

• Smoking decreases ovulation, sperm count sperm
  motility.
• Once the woman is pregnant, smoking increases
  miscarriage rate two times
• risk of pre-term delivery
• and low birth weight (by an average of200g).
• Explain risks and advise on ways to stop (this
  includes passive smoking).

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Work benefits

• Discussion of benefits available during pregnancy
  and employment law is necessary so that women
• may avoid possible hazards at work,
• attend for antenatal care and
• plan their maternity leave from early in
  pregnancy.

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Discussion of antenatal care and screening
available

• Brief discussion of antenatal screening and
  antenatal care procedures
• allows women to investigate their choices in
  pregnancy at their leisure.
• Brief discussion about miscarriage and
  possibility of infertility
• allows women to be more confident about asking
  for help if problems with conception/early
  pregnancy occur.

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SCREENING IN PREGNANCY

• Most women undergo some form of screening before
  or during pregnancy.
• It aims to identify, prevent and treat actual or
  potential problems.
• Women and their partners must be given unbiased
  information regarding screening and diagnostic
  tests, the meaning and consequences of both, what
  to expect in terms of results, and further
  options for management.

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• Family physicians need to be aware of the
  techniques of prenatal diagnosis in order to
• Identify all women who might benefit from genetic
  counseling and/or early assessment by the
  obstetrician
• Counsel patients about the accuracy and risk of
  prenatal diagnosis
• Make sure that the opportunity for prenatal
  diagnosis is not overlooked as certain tests are
  done at certain times.

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Pre-pregnancy genetic screening

• There are many inherited diseases and more are
  being discovered all the time.
• Refer before pregnancy couples who request
  referral or those with factors, which put them at
  high risk of having a baby with a genetic
  disorder to a trained obstetrician or genetic
  counselor.
• Risk factors that warrant pre-pregnancy genetic
  screening

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• Personal or past history of genetic abnormality
• e.g. Downs syndrome
• sickle cell
• other muscular dystrophies
• Huntingtons chorea
• polycystic kidneys.
• Diabetic mothers
• have an increased risk of feti with congenital
  anomalies.

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• Older women
• Risk of Downs syndrome increases with maternal
  age.
• Consanguineous couples
• 1st degree cousins who have a baby together have
  an increased risk of congenital malformations in
  their offspring.

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Tools of antenatal screening

• After referral to the specialist, certain tools
  may be used for optimal counseling.
• Basic screening tests
• Blood e.g. Hb estimation and blood group
• Urine dipstick screening of urine for proteinuria
  and glycosuria

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• rubella immune status screening
• hepatitis B screening
• syphilis screening.
• Many women are not aware these tests have been
  done let alone their purpose or results. Ensure
  women are given information about the reasons
  for, significance of and results of routine
  tests.

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• Ultrasound scan
• High resolution anomaly scan is routinely
  offered to pregnant women at 18 weeks of
  gestation.
• Its purpose is to detect structural abnormalities
  e.g.
• Cardiac,
• GIT,
• Skeletal abnormalities, etc.

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a-fetoprotein (AFP)

• measured in the maternal blood and amniotic
  fluid.
• Its level increases with twins or fetal
  malformation (10)
• neural tube defect,
• exomphalos,
• posterior urethral valves,
• nephrosis,
• or Turners syndrom

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• Decreased levels are associated with
• diabetic mothers and
• chromosomal abnormality e.g. Down syndrome.
• Routinely offered in many centers.
• AFP alone is a non-specific test requiring those
  with abnormal values to undergo further
  investigation.

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• Chorionic villi sampling (CVS)
• At 10-L2wk gestation the developing placenta is
  sampled per abdomen or trans-cervically with US
  guidance.
• Used to detect genetic or metabolic abnormality
  in high risk pregnancies.

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• Advantages.
• Undertaken earlier than amniocentesis to allow
  termination of affected pregnancies at an earlier
  stage.
• Risks.
• 4 miscarrage,
• limb defects (rare).

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• At Amniocentesis
• Sampling of amniotic fluid via a transabominal
  needle under ultrasound guidance.
• When undertaken for screening purposes,
• it takes place from 16-l9wk gestation.
• May be routinely offered to women
• at high risk of fetal abnormality (e.g. women gt35
  years of age to exclude Downs syndrome)
• or to clarify abnormalities found with other
  screening tests e.g. abnormal AFP.

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Fetoscopy

• Fibreoptic visualization of the fetus.
• Carried out from l5wk.
• Enables
• external abnormalities to be detected,
• fetal blood sampled and
• organs biopsied.
• Fetal loss rate 4.

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For certain disorders, some standard tests are
offered
Spina bifida

• U/S at 1719 wk gestation detects 9095 spina
  bifida and 100 anencephaly.
• AFP detects 80 of open defects and 90 of those
  with anencephaly.
• Confirmation with U/S in required.

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Downs syndrome

• The commonest single cause of mental handicap in
  children of school age. incidence 3/2000 births.
  
• Numerous methods of antenatal screening have been
  tried but it is unclear which is best.
  Clarification is awaited.
• Options are
• Age Incidence with age1365 at age 35, rising
  to 1110 at age 40 and 130 at age 45.
• Offering amniocentesis to all pregnant women gt35
  y combined with routine anomaly scanning
  identifies 70 of all cases of Downs syndrome.

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• AFP alonenon-specific test. Necessitates further
  evaluation in all cases.
• Double/triple test Blood test which measures AFP
  and hCG estriol. Blood is taken at l6wk.
  gestation and a risk value calculated for the
  individual woman taking into account age, exact
  gestation and weight.
• The result is expressed as a risk assessment
  (e.g. 1300) or as a ve or -ve result.
• A ve result usually means the risk of having a
  Downs syndrome baby is gt1250 and amniocentesis
  is recommended.
• A ve test does not indicate the presence of
  Downs syndrome but just an increased risk.

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• Nuchal translucency test U/S measurement of the
  translucency of the nuchal fold in the neck of
  the fetus at 10-l4wk. gestation. Detection rate
  80, false ve rate 8.
• integrated test Combines blood tests and U/S to
  produce a single estimate of the womans risk of
  having a child with Downs syndrome.
• Uses Womans age measurement at 10l3wk.
  gestation of nuchal translucency and maternal
  serum level of AFP, un-conjugated estriol, hCG.
• Detection rate 85. Only 1 of women require
  unnecessary amniocentesis.

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Hemoglobinopathies

• Antenatal screening is routinely offered to all
  women in areas where gt15 of the population are
  in high risk ethnic groups
• (Black ethnic groups for Sickle cell disease
• and Mediterranean for thalathemias).

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• In other areas hemoglobinopathy screening should
  be offered to people whose racial background of
  hemoglobinopathies predominately occur.
• Ideally screening should be carried out
  pre-conceptually.
• Otherwise perform as early as possible into
  pregnancy.
• All women identified as having a trait, or the
  disorder, should be referred for specialist
  counseling and their partners offered screening.

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Pre-eclampsia

• Risk factors
• Age lt20y. or gt35y.
• First pregnancy
• Pre-eclampsia in a previous pregnancy or FH
• Multiple pregnancy
• Past history of increased BP
• Renal disease
• SLE

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• Diagnosis
• BPgt 140/90 orgt 30/115 from booking BP
  proteinuria gt0.3g/24h.
• Symptoms Headaches vomiting photophobia odd
  visual effects (flashing lights, stripes before
  the eyes, floaters or blackouts of vision)
  epigastric/ RUQ pain general malaise.
• Examination General appearance (drowsy,
  confused) anemia jaundice non-dependent edema
  sudden weight gain neurological examination
  reflexes, fundi, clonus CVS examination lung
  bases abdominal examination RUQ or epigastric
  tenderness, palpable liver obstetric
  examination fundal height appropriate for
  gestational age liquor volume presentation
  fetal movements fetal heart sounds and heart
  rate urinedipstick for proteinuria (as litle as
  1 is significant).

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• Criteria for admission of patients with PET
• BP gt has risen by gt30/2OmmHg over booking BP.
• IUGR.
• BP gt140/90 and symptomatic
• BPgt 160/100
• BP gt140/90 with proteinuria

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Prevention

• Low-dose aspirin is of benefit in women at risk
  of severe early pre-eclampsia i.e. those in whom
  it had occurred before.
• Aspirin makes no difference to any other group
  treated.
• Trials are in progress assessing .L-homocysteine
  in prevention of PET.
• Other trials using fish oil, calcium and dietary
  protein supplementation have all proved
  inconclusive.