- Maternal infections during pregnancy may contribute significantly to fetal morbidity and mortality.
- Two of the most common groups of infections present during pregnancy are sexually transmitted infections and TORCH infections.
- Group B streptococcus
- Hepatitis B
- Human papillomavirus
- Bacterial vaginosis
- Human immunodeficiency virus (HIV)
- Other infections- hepatitis A, infectious hepatitis, hepatitis C, or syphilis
- Herpes simplex virus
- Infections in this category may be caused by various viruses. Other organisms such as bacteria, spirochetes, protozoa, or yeast also may cause maternal infections, which are harmful to the developing fetus. Even though the infection in the mother may be very mild, the effects on the fetus can be catastrophic.
- The infections organism may be acquired during sexual intercourse, through the use of contaminated articles, such as needles; from human body fluids (semen, saliva, blood, urine, cervical mucus, breast milk, and stool); by eating undercooked meat; or by contact with infected cat feces in the litter box, sand box, or garden soil.
- Most organisms cross the placenta and infect the fetus, causing birth anomalies. The fetus may also acquire the organism as it travels the birth canal during labor, causing illness after birth.
- These infections organisms are capable of crossing the placenta and adversely affecting the development of the fetus. Spontaneous abortion or fetal newborn abnormalities may occur.
- In some instances, the infection can also cause infertility or sterility in the mother.
Assessment Findings For Sexually Transmitted Diseases
1. Associated findings
- Previous history of sexually transmitted disease or pelvic inflammatory disease.
- Numerous sexual partners
- Use of intravenous drugs or partners who use intravenous drugs
2. Common clinical manifestations
- Preterm birth
- Systemic fetal infection
3. Laboratory and diagnostic study findings. Serologic and culture testing will reveal infection.
Assessment Findings For Torch Infections
1. Common clinical manifestations
- Influenza-type symptoms
- Lymphedema and lymphadenopathy
2. Laboratory and diagnostic study findings. Serologic and culture testing will reveal infection.
1. Carefully screen for infections during pregnancy and treat possible infections as ordered.
- At the first prenatal visit, the pregnant woman should have a rubella titer drawn. A titer of 1:8 provides evidence of immunity. If the titer is below 1:8, rubella vaccine is offered to the woman before discharge postpartum. Those women who require the vaccine should be cautioned not to become pregnant for at least 3 months afterward.
- Cytomegalovirus currently has no effective therapy. This is important to remember because the highest rate of maternal infections occurs between the ages of 15 and 35. Usually, the infection is symptomatic.
- Women who are presumed to be susceptible to varicella-zoster (chicken-pox) should have immune testing. Varicella-zoster immune globulin should be administered to those who are susceptible or who have been exposed. Varicella-zoster immune globulin should be administered to the exposed newborn within 72 hours of their birth.
- All pregnant women should be screened for HbsAg, the hepatitis B surface antigen. The hepatitis B immune globulin can prevent infection in both mother and newborn. An initial injection can be given to the newborn, followed by doses given at 1 month and 6 months of age. Adults receive three injections that are given over a 6- to 12-month period.
2. Provide client and family teaching regarding the diagnosis of infection to promote compliance with the treatment plan.
- Explain how maternal infections are acquired and transmitted to the developing fetus during pregnancy.
- Demonstrate proper handwashing technique, stressing that it is the single most successful means of preventing infection.
- Discuss hygienic and dietary measures that reduce the risk of infection.
- Explain the organism, test, treatment, and fetal effects of the specific infection to the client and family.
- Include the client in planning solutions for possible fetal effects.
- Discuss “safe sex” with the client and partner.
- Seek the couple’s input for development of a plan for follow-up care.
Nursing Care Plan
Risk For Maternal/Fetal Infection
Risk for Infection: At increased risk for being invaded by pathogenic organisms.
- Inadequate primary defenses (e.g., broken skin, stasis of body fluids).
- Inadequate secondary defenses (e.g., decreased hemoglobin, immunosuppression).
- Inadequate acquired immunity.
- Environmental exposure.
- Rupture of amniotic membranes.
Possibly evidenced by
- [Not applicable].
- Patient will verbalize understanding of individual causative/risk factors.
- Patient will review techniques and lifestyle changes to reduce risk of infection.
- Patient will initiate behaviors to limit the spread of infection, as appropriate, and reduce the risk of complications.
- Patient will achieve timely healing, free of complications.
|Obtain information regarding client’s past and present sexual partners and exposure to any STDs.||Multiple sexual partners or intercourse with bisexual men increases risk of exposure to STDs and HIV/AIDS.|
|Obtain information about client’s cultural background for risk factors.||In Africa, male-to-female ratio of HIV is 1:1 owing to cultural sexual practices, poor hygiene, and inadequate health care while recent arrivals from Asia, South America, and the Caribbean islands have increased the risk of exposure to Hepatitis B virus.|
|Review lifestyle and profession for the presence of associated risk factors.||Drug abusers and healthcare professionals are at risk for exposure to HIV/AIDS and HBV through contact with contaminated needles, body fluids, and blood products; tuberculosis through airborne droplets.|
|Assess for any specific signs and symptom, if present, notify healthcare provider:||Identifiable signs of infection assist in determining the mode of treatment. Some organisms have a predilection for the fetoplacental unit and the neonate, although the client may be asymptomatic; i.e., Mycoplasma and Ureaplasma organisms affect a significant number of pregnant women and have been cultured in aborted fetuses, even though the mothers have been free of symptoms.|
||May indicate herpes simplex virus type II (HSVII)/condyloma, which can be transmitted to the newborn at the time of delivery if a lesion is present at term or if viral shedding is occurring.|
||May be associated with Escherichia coli or GBS, or client may have asymptomatic bacteriuria.|
|Determine if the viral infection is either primary or recurrent.||Both herpes viruses (CMV and herpes simplex virus II [HSV-II]) recur in times of stress. Yet only primary CMV is problematic to the fetus, and only 50% of fetuses exposed are affected. Although recurrent HSV-II is associated with reduced viral shedding time, the newborn, if exposed to the virus at delivery, can be affected with either visible lesions or a disseminated type of the disease.|
|Determine status of maternal membranes. If they are ruptured, monitor blood cell count and fetal heart rate; or vaginal discharge having an odor)||Infectious organisms transmitted via the ascending route including Chlamydia, mycoplasmas, Ureaplasma urealyticum, develop bacteremia and pneumonia or possibly meningitis.|
|Obtain appropriate specimens and monitor laboratory/ diagnostic studies as indicated:|
||Approximately 40%–60% of patients with culture positive gonococcus have concomitant chlamydial infection, the most common STD associated with conjunctivitis and pneumonia of the newborn. Other than ophthalmia neonatorum, gonorrheal infection of the newborn is infrequent, but does increase rate of neonatal mortality associated with overwhelming infection.|
||Fever of nonspecific origin and history of abortions, neonatal meningitis, sepsis, congenital listeriosis, or postpartum maternal sepsis may indicate recurrent listerial infections requiring treatment. From 5%–30% of women have positive cultures for GBS, yet may be asymptomatic. Although antepartum treatment for GBS carriers is not recommended, intrapartum treatment with antibiotics is indicated for all women with positive cultures.|
||Asymptomatic bacteriuria (colony count greater than 100,000/mL) occurs in as many as 12% of prenatal clients and has been associated with acute and chronic pyelonephritis, preterm delivery, chorioamnionitis, postpartum maternal sepsis, and congenital defects. From 1%–5% UTIs are linked to GBS, which is the leading cause of neonatal meningitis|
||From 5%–15% of women of childbearing age are still susceptible to rubella, which has identifiable teratogenic effects on the fetus. If rubella is contracted in the first trimester, the fetus has no chance of escaping teratogenic effects. If rubella is contracted in the second trimester, the fetus has a 50% chance of being affected.|
||Hepatitis in the first and second trimesters rarely affects the fetus. Women who contract hepatitis in the third trimester have a 60% chance of transmitting it to offspring coming in contact with blood products at the time of delivery. Carrier status can be passed on to infants if they are not treated at birth. This can possibly result in cirrhosis and hepatocellular carcinoma.|
||Determines number of T4 helper cells to monitor progression of HIV.|
||AIDS destroys the immune system, causing a variety of problems, including Herpes simplex virus-II, cytomegalovirus, toxoplasmosis, candidiasis, Kaposi’s sarcoma, and pneumonia.|
|Assist as necessary with sputum collection and chest x-rays for client with respiratory symptoms.||Helps in identifying causative organism in bacterial pneumonia and active tuberculosis. Note: Tuberculosis is not exacerbated by pregnancy.|
|Administer antibiotics/medications as indicated:|
||Generally not recommended in treatment of HSV-II, unless primary infection disseminates.|
||Although controversial, these drugs are approved by the FDA and have been shown to reduce transmission to the fetus by 68% and to prolong life in HIV-positive clients. Research suggests ZVD administration in the second trimester can reduce maternal transmission of HIV to the neonate by over 60%.|
||UTI, listeriosis, gonorrhea, syphilis, bacterial pneumonia, all respond to antimicrobial treatment. Note: Prenatal treatment of client who is carrier of GBS is not effective, because recolonization can occur before birth, with infant still at risk for neonatal sepsis or meningitis.|
||Controls active disease progression in toxoplasmosis, but have known teratogenic effects on fetus during the first and probably second trimesters.|
||Counteracts side effects of pyrimethamine.|
||Indicated for treatment of trichomonal infections after 20 weeks’ gestation. Treatment in the first 20 weeks’ is symptomatic; the trichomonal infection may be receptive to Mycelex vaginal suppositories. Note: Both partners must be treated to prevent reinfection.|
||Indicated for treatment of Candida albicans. Note:Diabetic client is prone to monilial infection, which may be extremely resistant to prenatal treatment.|
||Recommended for exposure to hepatitis A or B.|
||Treatment of choice for tuberculosis (or seroconversion to positive PPD in last 2 yr), with no known teratogenic effects. Streptomycin is avoided, owing to its association with vestibular and auditory defects, and pyrazinamide is also contraindicated. If time of seroconversion is unknown and chest x-ray is negative, treatment is begun after pregnancy; or if client is over age 35 with unknown or prolonged positive PPD, INH prophylaxis is not recommended in the absence of active disease because of risk of hepatotoxicity. Note: Pyridoxine (vitamin B6) is recommended for any pregnant woman receiving INH.|
|Prepare for/assist in transfer to tertiary care center as indicated.||Availability of staff and equipment ensures optimal care of high-risk client and fetus/newborn.|
|Prepare for termination of pregnancy or labor induction, as indicated.||Pregnancy may be terminated for such conditions as toxoplasmosis occurring prior to 20 wk gestation or rubella in the first trimester. Note: AZT in combination with cesarean birth decreases neonatal HIV infection rate, allowing pregnancy to be carried to term as appropriate, in presence of maternal HIV infection.|
Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.
May be related to
- Body response to an infective agent, properties of infection (e.g., skin/tissue irritation, development of lesions).
Possibly evidenced by
- Verbal reports, restlessness, withdrawal from social contact.
- Patient will identify/use individually appropriate comfort measures.
- Patient will demonstrate use of relaxation skills and diversional activities.
- Patient will report discomfort is relieved/controlled.
|Identify source, location, and extent of discomfort; note signs and symptoms of infectious process.||To determine the course of treatment and individual interventions.|
|Provide information about hygienic measures such as frequent bathing, use of cotton underwear, and application of cornstarch for client with vaginal discharge associated with STDs (chlamydial infection or gonorrhea).||Helps promote dryness and prevent skin breakdown.|
|Provide information regarding use of warm sitz baths, use of hair dryer on genital area, urinating through an empty toilet paper tube, and wearing loose-fitting jeans/pants and cotton underwear for client with HSV-II.||Prevents discomfort associated with urine coming in contact with lesions; Helps keep genital area dry/clean;|
|Encourage increasing oral fluid intake and voiding in warm sitz bath for client with Urinary tract infection.||Helps prevent stasis; warmth relaxes perineum and urinary meatus to facilitate voiding.|
|Encourage the use of humidified air, increased fluid intake, and use of semi-Fowler’s position during sleep for clients with respiratory infections, such as tuberculosis.||Helps liquefy secretions and facilitates respiratory functioning. Upright position allows diaphragm to descend, thereby facilitating lung expansion.|
|Encourage rest for client who has tuberculosis or flu-like symptoms associated with listeriosis, rubella, or toxoplasmosis.||Reduces metabolic rate; facilitates response of individual immune system to infection.|
|Administer medications as indicated:|
||Relieves discomfort associated with backache, neuralgia, cervical lymphadenopathy, and perineal lesions. Note: In toxic levels, acetaminophen can cause liver damage. Use of acetylsalicylic acid (ASA) can result in alteration of fetal clotting.|
||Reduce fever and chills. Note: In client with PROM, administration of analgesic that may have antipyretic properties (e.g., acetaminophen) should be avoided because it may mask temperature rise that would signal infection.|
||Eradicates organisms associated with UTI, bacterial pneumonia, STDs (gonorrhea, syphilis, chlamydial infection), and listeriosis. Relieves flu-like symptoms associated with listeriosis.|
||An experimental anti-AIDS drug that may help reduce discomforts associated with HSV-II, candidiasis, pneumonia, and Kaposi’s sarcoma.|
||Helps provide local anesthesia to herpetic lesions.|
Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
May be related to
- Lack of exposure to information and/or unfamiliarity with resources, misinterpretation.
Possibly evidenced by
- Verbalization of problem.
- Inaccurate follow-through of instructions.
- Development of preventable complications/continuation of infectious process.
- Patient will verbalize understanding of the importance of providing necessary information for data collection.
- Patient will identify appropriate preventive practices.
- Patient will adopt behaviors/lifestyle changes as indicated.
- Patient will follow-through with individual treatment regimen.
- Patient will list signs and symptoms that necessitate evaluation/intervention.
|Identify signs/symptoms of infection. Discuss importance of prompt reporting to healthcare provider.||Maternal infection may not be serious, but can have serious implications for the fetus. Timely intervention may prevent complications and enhance likelihood of a positive outcome.|
|Identify risk factors associated with client’s lifestyle.||Injection drug users are susceptible to percutaneous transmission of HSV-II, HBV, HIV/AIDS, and other STDs. Involvement with multiple sex partners also increases risk of being infected.|
|Provide information concerning identified risks associated with client’s employment or profession. Stress the use of gloves and the importance of handwashing esp. when client must handle blood products,saliva, or urine.||Dialysis workers and healthcare professionals who handle body fluids or blood products are at high-risk for exposure to HSV-II, HIV, and HBV, and need to use universal precautions.|
|Discuss mode of transmission of specific infections, as appropriate.||Provides information to assist the client in making decisions relative to lifestyle/behavioral changes; reinforces need for partner to be treated.|
|Discuss importance of avoiding contact with persons known to have infections, such as upper respiratory infections, tuberculosis, rubella (if not immune), and hepatitis. Stress the need for immunization for rubella after delivery as indicated.||Preventing exposure helps reduce the risk of acquiring infection. From 5%–15% of women of childbearing age are still susceptible to rubella, which is spread by droplets. Immunization after delivery results in immunity during subsequent pregnancies|
|Provide information about possible effects of infection on client/fetus.||Infection affects approximately 15% of all pregnancies. For some infections, such as rubella, the outcome may be fairly predictable, if the gestational age at which the fetus was exposed is known. For other maternal infections, such as those caused by Ureaplasma, Mycoplasma, or Listeria organisms, it is more difficult to predict the fetal/neonatal outcome, especially because the client may be asymptomatic. Most infections do not pose serious problems to the mother, but can have varying effects on the fetus. Two thirds of these exposed infants are infected in utero, with resultant effects on the liver and brain. Ascending tract infections have a greater chance of resulting in neonatal bacteremia and pneumonia.|
|Recommend wearing gloves while gardening, avoiding contact with cat litter boxes while pregnant, and cooking meats to appropriate internal temperatures.||Helps prevent toxoplasmosis, most commonly acquired in the United States through contact with cat feces. Some French and Japanese meat dishes are eaten raw or undercooked, thereby increasing the risk of acquiring toxoplasmosis.|
|Encourage client to drink 6–8 glasses of fluid per day and to void regularly. Discuss results of urine test.||May help prevent UTI associated with stasis. Client with asymptomatic bacteriuria (colony count greater than 100,000/ml) may be at risk for premature delivery, congenital defects in offspring, or anemia.|
|Review hygiene measures, including wiping vulva from front to back after urinating and washing hands frequently (including after animal contact.)||Helps prevent rectal E. coli contaminants from reaching the vagina and reduces contamination with other viruses/bacteria that may be transmitted by poor hygiene practices. Listerial infection is thought to be transmitted via animal contact.|
|Suggest client void following intercourse.||May prevent/reduce risk of UTI and transmission of STD, especially CMV, and nongonococcal urethritis.|
|Suggest alternative means of sexual gratification for client with active HSV-II, HIV/AIDS, or HBV.||Fondling or masturbation for sexual gratification helps prevent spread of infection to sexual partner.|
|Discuss necessary treatments that may have serious fetal implications, such as sulfadiazine and pyrimethamine (used to treat toxoplasmosis), or oral sulfonamides (used to treat UTI during the latter weeks of gestation).||These medications have known teratogenic effects on newborn. When toxoplasmosis is present, the fetus can be damaged by either the disease or the treatment. Neonatal hyperbilirubinemia and kernicterus may occur with the use of oral sulfonamides.|
|Discuss possible effects of infection on type and timing of delivery.||Operative delivery may be indicated in the case of certain infections, such as HSV-II if client has active herpes with intact membranes or if membranes are ruptured for more than 4–6 hr. If client or fetus has developed an ascending tract infection following PROM, fetus may need to be delivered prior to term to prevent maternal/fetal sepsis.|
|Discuss implications of PROM for client and fetus/neonate.||Membrane rupture more than 18 hr before delivery increases the risk of ascending tract infection, with resultant chorioamnionitis and maternal/neonatal sepsis. Common causative organisms in ascending tract infections include GBS, Chlamydiae, and Haemophilus influenzae.|
|Review available options in cases of known teratogenic effects.||Fetus is more susceptible to effects of rubella early in gestation. HBV poses more risks for the fetus in the third trimester. Teratogenic effects of toxoplasmosis include growth retardation, CNS calcification, microcephaly, hydrocephaly, and chorioretinitis. In cases of rubella infection or toxoplasmosis, client/couple may elect to terminate the pregnancy, depending on stage of gestation in which exposure occurs.|
|Discuss implications of specific disease process/ treatment as appropriate:|
||Client may have asymptomatic bacteriuria with large colony counts (greater than 100,000/ml), and culture may be positive for GBS, Ureaplasma organisms, or Mycoplasma organisms, placing client at risk for sepsis during and following delivery, and placing the newborn at risk for early- or late-onset infection.|
||Occurring in 5%–30% of pregnant women, GBS is the leading cause of neonatal meningitis and is associated with neonatal sepsis, and with chorioamnionitis if it occurs at37 weeks’ gestation and is accompanied by PROM. Treating client with antibiotics (penicillin) prior to 38 weeks’ gestation is ineffective because the bacteria will probably recolonize before delivery. Antibiotics given after 38 weeks’ gestation effectively treat the client, but not the fetus. However, intrapartal treatment for clients with positive GBS culture (between 35 and 37 wk) or prophylaxis for at-risk clients may be useful in preventing GBS disease in the neonate.|
||It is uncertain how the fetus/infant contracts listeriosis; however, the infection can result in abortion if it is contracted between 17 and 28 weeks’ gestation, or cause newborn problems such as meningitis, mental retardation, or hydrocephalus if it is contracted after 28 weeks’ gestation.|
||Transmission by sexual contact requires that both partners be treated, that condoms be used, and that orogenital sex is avoided until post-treatment cultures are negative at two consecutive follow-up visits.|
||Chlamydia transmitted to the fetus through the ascending route can cause conjunctivitis or pneumonia in the first 3–4 mo after birth.|
||Spread occurs through sexual contact during viral shedding, which lasts 21 days in active primary infections and 12 days in recurrent infections. A stressor such as pregnancy may cause viral shedding.|
||Incubation periods for HIV range from 6 mo to 5 or more yr. Because of its immunosuppressive properties, HIV/AIDS results in opportunistic infections, which include pneumonia, meningitis, and encephalitis, caused by CMV, herpes viruses, Toxoplasma, Histoplasma, Candida, or Pneumocystis carinii.|
||Administration of penicillin effectively treats the fetus/newborn. The spirochete does not cross the placenta until 16–18 weeks’ gestation. Primary and secondary stages of untreated syphilis may lead to stillbirth; tertiary stage results in congenital syphilis of the newborn.|
|Primary CMV infection during pregnancy;||Although CMV can recur in times of stress, only primary CMV can potentially cause cytomegalic inclusion disease in 50% of the offspring of affected mothers.|
||Exposure to hepatitis A or B may result in fetal anomalies, preterm birth, intrauterine fetal death, or fetal/neonatal hepatitis. Chronic HBV carrier states can result in cirrhosis and hepatocellular cancer.|
|Supplemental pyridoxine (vitamin B6).||Helps prevent peripheral neuropathy when INH is used to treat active tubercolsis.|
|Provide information, specific to infection, regarding possible long-term effects and incubation period.||For example, longitudinal studies of children at age 3.5–7 yr show that effects of CMV are ongoing, resulting in learning disabilities, motor deficits, deafness, and lower than normal IQs.|
|Discuss newborn care and the need for follow-up in infants born to mothers in active or carrier state of HBV.||Bathing the newborn immediately after delivery and administering HBIG and hepatitis B vaccine will prevent the newborn from contracting the virus. Follow-up immunizations of the newborn with hepatitis B vaccine at 1 and 6 mo are then necessary.|
|Identify self-help groups and sources of community supports.||May help client in gathering information and resolving issues.|