Immunisations and
Infections
Helen Toyne, GP
Toby Angstmann, O&G
Ashley Watson, Infectious Diseases
Case 1: Mrs A: Planning her first
pregnancy
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29 years of age
Never been pregnant
Works as primary school teacher
Thinks she had childhood immunisations, no
physical record
• No known history of varicella infection
• Several tattoos acquired in Bali 5 years
previously
Case 1 Mrs A: Routine care,
individualised care
• Syphillis, Rubella, Hep B Antigen, HIV, varicella
IgG, UMCS
• Other possibilities:
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Hep B sAntibody (if immune, no more tests!)
Hep C
chlamydia
Parvovirus B19 ?? Not routinely screened
Measles antibody – may be relevant in some people,
outbreak at present
– Bacterial vaginosis HVS – not antenatal, not first preg.
Parvovirus B19:
• Also known as fifth disease, slapped cheek
syndrome, erythema infectiousum
• 50% women immune pre-pregnancy
• If infected during pregnancy, less than 5%
have miscarriage/anaemia
• Serology availability and indications?
• When/ if to stay away from work (kids
infectious 48 hours before symptoms)
Toby’s video here
• Severe consequences possible
• 4 cases TCH past 12 months
Pre-pregnancy immunisations
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Influenza
MMR (live virus)
DTPa
Varicella (live virus)
• What about early pregnancy – fever??
Whooping cough outbreak from 2009
Influenza in the ACT – per CHO
• Influenza in neonates: ACT Data
• In 2012, there were 17 cases of influenza in
infants aged 12 months or less.
• Of those, 6 were aged 3 months or less, one
was aged 4 weeks
National FluCan data – pregnant
women
• Between 4 April to 12 October 2012,
– 39 pregnant women hospitalised with influenza,
accounting for
– 3.5% of all hospitalisations due to influenza.
– 2 were in ICU.
Case 2 - Antenatal
• Mrs H, 26 weeks pregnant, 2nd baby
• Immunised 3 year old son has mild varicella
illness
• She does not recall having chicken pox or
immunisation
– Which test
– How to get ZIG
• What if child 18months with vaccine
associated varicella?
Case 3 - Antenatal
• Mrs C, 36 weeks pregnant
• Copious white vaginal discharge, perineal itch
• History of recurrent candida
– Swab
– Treat ??
– Oral fluconazole??
– GBS – current practice
Case 4 Antenatal
• Mrs D
• 16 weeks pregnant
• Nasal congestion, coloured nasal discharge,
frontal headache, 5 days. Temp 37.9 aural
• 2 year old has streaming nose and moist
cough
• Mrs D desperate, can’t sleep, miserable +++
Options – limited guidelines
• “Safe” remedies: saline
• Unclassified but low risk remedies, eg topical
decongestants (xymetolazone)
• Nasal steroids –mometasone, fluticasone
lowest systemic bioavailability, listed as B3,
budesonide cat A
• Antibiotics – amoxycillin, erythromycin cat A
A, B, C, D, X – NOT hierarchical
• Human data are lacking or inadequate for
drugs in the B1, B2 and B3 categories
• Subcategorisation of the B category is based
on animal data
• The allocation of a B category does not imply
greater safety than a C category
• Medicines in category D are not absolutely
contraindicated during pregnancy
(e.g.anticonvulsants)
Case 5: Post partum
• Nikki, with 3 day old Arthur calls from home
• NVD, early discharge
• Increasing “period pain” feeling hot and cold,
moderate PV bleeding, light headed and tired
• Midwife already visited for the day
• Issues for GP:
– ?how urgent
– How to fit in to schedule
– Who to call and how if concerned
Cont.
• Nikki attends the surgery as an urgent “fit in.”
• Delivery record indicates placenta complete
• O/E temp 38.2, uterus 3cm above pubic bone,
mildly tender. BP normal, HR 85
– Empirical treatment
– Investigation – swab
– When to US?
– When to send back to hospital?
Summary - Immunisation
• Immunise prepregnancy where possible
• Live vaccines given in pregnancy are unlikely to
be harmful
• Influenza vaccine is routinely recommended for
all pregnant women
• dTpa is recommended pre-pregnancy, elsewhere
used during pregnancy.
– WATCH THIS SPACE
• Hep B
• Consider measles
Summary - screening
• New guidelines – HIV, hep B, syphillis, rubella,
bacteriuria, chlamydia in <25s, Hep C if high
risk, varicella if no history
• Effective interventions available for all except
Hep C
• Parvovirus - case by case
• GBS ???
Summary - infections
• Diagnosis and treatment of non pregnancy
related illness generally similar to non
pregnant
• Symptomatic treatments often safe and highly
significant to women
• Antibiotics category A first line if required
Referral pathways
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Pre-conception or early pregnancy
Antenatal
Post partum
Infectious diseases
THANK YOU