I. Definition. Infection with Neisseria gonorrhoeae (a Gram-negative diplococcus) is a reproductive tract infection that is an important infection in pregnancy because of transmission to the fetus or neonate.
II. Incidence. The prevalence of gonococcus infection among pregnant women is ~1–8 in 1000. If routine ophthalmic prophylaxis was not used, it is estimated that a third of newborn infants born to infected mothers would become infected.
III. Pathophysiology.N. gonorrhoeae primarily affects the endocervical canal of the mother. The infant may become infected during passage through an infected cervical canal or by contact with contaminated amniotic fluid if rupture of membranes has occurred.
IV. Clinical presentations
A. Ophthalmia neonatorum. The most common clinical manifestation is gonococcal ophthalmia neonatorum. This occurs in 1–2% of cases of positive maternal gonococcal infection despite appropriate eye prophylaxis. For a description of this disease, see Chapter 47.
B. Gonococcal arthritis. The onset of gonococcal arthritis can be at any time from 1–4 weeks after delivery. It is secondary to gonococcemia. The source of bacteremia has been attributed to infection of the mouth, nares, and umbilicus. The most common sites are the knees and ankles, but any joint may be affected. The infant may present with mild or moderate symptoms. Drainage of affected joint and antibiotics are necessary.
C. Amniotic infection syndrome occurs when there is premature rupture of membranes, with inflammation of the placenta and umbilical cord. The infant may have clinical evidence of sepsis. This infection is associated with a high infant mortality rate.
D. Sepsis and meningitis.
E. Scalp abscess is usually secondary to intrauterine fetal monitoring.
A. Mother. Endocervical scrapings should be obtained for culture.
2. Culture. Material may be obtained by swabbing the eye or nasopharynx or the orogastric or anorectal areas. Blood should be obtained for culture. Cultures for concomitant infection with Chlamydia trachomatis should also be done. Gonococcal cultures from nonsterile sites (eg, the pharynx, rectum, and vagina) should be done using selective media.
3. Spinal fluid studies. Cell count, protein, culture, Gram stain, and others should be ordered.
VI. Management. Isolation precautions for all infectious diseases, including maternal and neonatal precautions, breast-feeding, and visiting issues, can be found in Appendix F.
A. Hospitalization. Infants with clinical evidence of ophthalmia neonatorum, scalp abscess, or disseminated infection should be hospitalized. Complete sepsis evaluation including lumbar puncture should be performed. Tests for concomitant C. trachomatis, congenital syphilis, and HIV infection should be performed. Results of the maternal tests for hepatitis B surface antigen should be confirmed.
B. Antibiotic therapy
1. Maternal infection. Most infants born to mothers with gonococcal infection do not experience infection; however, because there have been some reported cases, it is recommended that full-term infants receive a single injection of ceftriaxone (125 mg intravenously [IV] or intramuscularly [IM]) and that premature infants receive 25–50 mg/kg (maximum, 125 mg).
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