107: Perinatal Infections and How to Keep Getting Better

Hello and welcome to episode 107 of the Physician Assistant Exam Review Podcast. This week we’re going to be covering prenatal transmission disorders and a few ideas to help you get better at studying and test taking. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review where we teach PA students how to dominate PA school and ultimately pass their PANCE and land their dream job. That’s really what my goal is for you. It’s to get you through PA school in the best possible fashion, to get you through your PANCE and then have you get out into the world and do the job that you can’t wait to do. That’s what we’re all about here.

That’s what we want. You know, sometimes we’ll gear things a little bit too much towards test taking perhaps, but my goal is always to get you to pass your PANCE and get you out into the world. And I think if we can get that done from that point, you can become a great provider over time. I don’t have any problem with that approach.

Now, I did want to address some things up here at the front, and I’ve recorded this introduction three or four times now because I haven’t quite been able to get it right. If you’re listening to this far in the future, maybe you don’t notice, but if you’re listening to it as I create these episodes, it’s been about a month and a half since I’ve put one out, which is unlike me. Usually, I get them out pretty regularly. Unfortunately, over the winter, we had some personal things happen. There were quite a few, but the most prominent was that my brother passed away the day after Christmas. And he was subsequently buried on January 17th. The last episode I put out was January 11th.

And quite honestly, I haven’t been able to bring myself to put out an episode since then. I’ve been struggling a lot to keep up with the work of the 33 Days program, of the Scholars newsletter, and everything else that I do here. And quite honestly, the podcast has slipped to the side. Partially because it’s one more thing to have to get done. Partially, it’s because I would have to get on here and share with you what’s been going on.

Now, I’ve shared it with the email list. Anybody who’s within the community, the physician assistant exam community who gets the daily emails, I’ve shared quite a bit about everything that’s been going on with my family there and how that’s been affecting things here. And the reason why I share this stuff, one is because I think, you know, it’s nice. You haven’t heard from me. If you just listen to the show, you haven’t heard from me in over a month. So I think it’s a good idea to share it with you. But the other thing I want to share with you is that I share it because I want you to realize is that things happen.

Things happen to everyone. You know, I get emails from people all the time that their pet passed away, their father passed away, that they’re getting kicked out of their apartment and have to move, that they’re getting married, that they’re getting divorced, that they’re having a baby. You know, so many things happen that screw up our plans. Hey, just for example, this isn’t quite as dire, obviously, but this morning, I’m working from home, working on Physician Assistant Exam Review, and every morning when I am home and not working at the hospital, I take my youngest to school. So as we were getting ready a few minutes before we needed to leave, I opened the drawer in the kitchen and my keys aren’t there. And I think, what the heck? My keys should be here.

I always put them here and what’s even stranger is my wallet is here and usually my wallet and my keys go together. I do that on purpose so that I know that I put them in there. So I look through the house. I looked through everything I had yesterday, you know, my pants I wore yesterday, and I can’t find them, and I can’t find them. And eventually, I call a friend to come pick up my son and bring him to school, and thankfully, I don’t have to drive into the hospital today, so I’m home, so it doesn’t completely ruin my day. But then I have to pick up my other son from baseball practice after school today, so I have to find him a ride. And the whole first hour or so of my day is screwed up, because I can’t find my keys.

Well, I come to find out later that my oldest son had taken something out of the car this morning and had gone to school with my keys in his pocket and our spare set my wife has. So I was out of luck. So the point isn’t that it was a big deal. It wasn’t. The point is that things happen and that screwed up the first hour or so on my day and quite honestly had me sort of angry, frustrated, and stressed out and it was difficult to sort of settle down and get to work. The point is all of these things happen. They happen to everyone.

They happen all the time. The point isn’t that they might happen. It’s that they’re going to happen. It’s how do you deal with them? How do you bounce back? How do you move on? How do you get things done despite the world happening?

And that’s what’s important. That’s the lessons to learn. That’s the things to pay attention to. It’s what do you do when things don’t go your way? Because we all do well when things go our way. We always talk about that with my son’s baseball teams. Everyone’s friendly when they’re winning.

It’s when they’re not winning that it’s hard. So I wanted to share that with you today to start off today’s show, just to make you aware of what’s been going on and how things have been going here. Again, things are improving. The sun is out. It’s springtime, which is magnificent for my emotional state. I do appreciate all the condolences I received from the community. It’s just amazing to hear people’s stories, and I do appreciate that.

But like I said, we’re going to move on here, and I just wanted to bring you in if you haven’t been on the email list and let you know what’s been going on. So we’re to go ahead and get started with today’s episode. Today we’re talking about prenatal transmission disorders, and we’re going to begin with priming questions. Just as a refresher, priming questions are a way to get your brain active, to get you involved in the material. This show is designed to cover information, right? But if you don’t think, if you just listen, it’s not that valuable. It’s actually a waste of time for you, despite what you may think.

So the priming questions are there to get your brain functioning, to get your brain primed into thinking about the topic and to get you looking for the answers. Even if you don’t know them, if you have no clue what we’re talking about, just paying attention and thinking will help to create anchors in your brain to the information as we come through it. Got it?

All right, good. This section is going to be a little bit short. It’s on congenital and prenatal issues. There’s only a couple of diseases here, and that will actually wrap up infectious disease for us.

So let’s go ahead and get started. What are three types of neonatal herpes simplex? Three types of neonatal herpes simplex. What is the treatment for newborn if a newborn contracts chickenpox? What is the treatment for a newborn who contracts chickenpox? And our last one for today, what is the treatment for Zika virus? What is the treatment for Zika virus?

All right, let’s begin with congenital varicella or chickenpox. So, the problem is if the mother contracts chicken pox during pregnancy, that’s where the problem comes into play here. If she gets it for the first time, rather. So, if it’s not the first time, maternal antibodies are transferred through the placenta to the fetus if she’s had either a vaccination or previous infection. But if she hasn’t and she gets and she comes down with the chicken pox then the chickenpox virus can be transmitted through the placenta to the fetus.

Now, there are two stages of problems here. Number one is if the fetus is from 0 to 28 weeks, I think is the number that they quote. From 0 to 28 weeks, you wind up with a fetus with what they call congenital varicella syndrome. Congenital varicella syndrome.

Now, the problem with congenital varicella syndrome is development of the fetus, right? So you can get anything from skin issues to brain damage and everything in between. So this can be a very, very serious and lead to some bad outcomes.

Now, if the child is infected near term or immediately after birth, meaning the mother contracts it, let’s say within a week, 10 days, two days before birth, these newborns are at an increased risk to get the chickenpox for sure, but then also at an increased risk to have a very severe case of the chickenpox, including things like pneumonia and those really bad cases.

Now, just like the rest of the things in this section, just because mom gets the chicken pox doesn’t mean she will 100% of the time pass it along. That’s not the way it works. There are, there’s obviously an increased risk for passing it along, but it’s not 100% in any of these. So as much as they seem devastating and entirely terrifying, there’s that caveat. Treatment. If the baby, if the mom contracts chickenpox right before delivery, then you’re going to give the baby varicella zoster immune globulin at birth, right? Or right after birth.

And this will decrease the chances of the severity of the infection. But really what we’d like to do is prevent this from being an issue at all. So what they recommend is pregnant women who come in contact with someone who has a shingles, the chickenpox, may also be given varicella zoster immune globulin in order to help prevent them from contracting it or having a bad case. And women seeking to become pregnant that have not had chickenpox or a vaccination are encouraged to get a vaccination at least 30 days prior to becoming pregnant. Neonatal herpes simplex. This is a little bit more complicated. This is a rare but a very serious disease.

Transmission from the mother to newborn is usually during delivery. And interestingly enough, the patient does not have to have symptoms to have active virus, right? So if you’ve never heard this before, we usually recommend that if a patient has active herpes infection, so if they have sores that are genital sores, you don’t want to do a vaginal birth. You’re going to do a cesarean delivery of that child to prevent neonatal herpes simplex. But it’s important to note, and as I said here, that the mom doesn’t have to be showing symptoms in order to have active disease that she can pass on.

Now, there are three variations of neonatal herpes simplex. The first two are kind of what they call localized disease. So they’re sort of local to wherever the infection is. So the first one is skin, eyes, and mouth herpes, or abbreviated SEM. This is external lesions with no internal organ involvement. Disseminated herpes, DIS, is internal lesions, particularly in the liver, so affecting the organs. And then lastly, you have CNS, which is central nervous system herpes.

This is an infection in the nervous system, which can lead to encephalitis. Obviously, each of these can be pretty nasty and have their own issues. Clinical presentation can be anything from skin vesicles to encephalopathy to neurological findings to hepatitis to disseminated intravascular coagulation to respiratory distress. Labs and studies you can do an HSV culture, PCR testing, or finally a Tzanck smear. Or a Tzanck test, rather. Sorry. Treatment.

So, we again, we really want to reduce the possibility of transmission. That’s the number one goal. So, taking antiviral medication during pregnancy, if we know a patient has active herpes, will help to reduce that. Avoiding sexual sexual activity during the third trimester will help to reduce that. Caesarean delivery, if there are active lesions or a high viral load, will help to reduce that transmission rate. Treatment of the infant is going to be acyclovir. Something that stood out to me is for patients with nervous system infections, acyclovir has continued for up to one year and that they find benefit from that.

And then obviously with the infected infant, we’re going to be talking about supportive care as necessary. I told you all the nasty things that can come along with this disease. So each of those, you’re not necessarily treating the viral infection aside from the acyclovir, but you’re going to need to be treating all those other things that are going to be going on, right? So that’s going to be, you’re just going to have to branch out that tree and depending on what’s happening. We have two more we’re going to cover today, human papillomavirus and Zika virus. HPV is really pretty quick. HPV can be transmitted to the newborn during delivery.

It’s believed these cases are rare, although HPV is capable of hiding for years without symptoms. So from what I came across, what they were saying is that they believe that transmission to the infant is during vaginal delivery, right? And there has been evidence that cesarean deliveries have a decreased rate of transmission over vaginal deliveries. But there are question marks about how the virus is transferred to the fetus. That’s just one way that’s kind of bearing out a little bit. The problem though is HPV is so good at hiding and remaining dormant for decades even, that there’s a little bit of concern here that we’re missing something, right? So it can be within the body without showing any symptoms for years and years and years.

Now the risk of perinatal HPV transmission is higher if the mother has active genital warts or an HPV-related cervical lesion at the time of delivery. So just like our herpes situation. If a newborn is exposed to HPV during delivery, they may develop warts in the throat or genital area, although this is rare. Again, it’s a rare transmission. In extremely rare cases, perinatal HPV infection can lead to respiratory papillomatosis, which is a rare condition in which warts grow in the airways and can cause breathing difficulties. And that brings us to the end of HPV. There’s not a whole lot to talk about as far as that transmission.

We want to keep it low, but there’s not a lot to do once we have the problem, right?

All right, Zika virus is our last one for today. Zika is an interesting one for a couple of reasons. It’s a mosquito-borne virus. And this is what I came across that was kind of interesting to me, is as far as adults are concerned, it’s really a non-issue. Only about one in five adults experience symptoms when they’re infected. It really is maybe a little headache, maybe a little, you know, the symptoms are headache, conjunctivitis, fever, skin rash, muscle, and joint pain. But a lot of people won’t even know that they have it.

Some people have some minor symptoms. Though most people will go about their day. But that’s the adults, right? So why is this such a problem? Why is this an issue? Why do we learn about it? Well, the issue becomes that it’s believed that a mother who becomes infected with Zika virus, there has been an uptick in the number of children born with microcephaly.

And in fact, it was a 20-fold increase in Brazil. I forget the dates when this started, that spiked the reaction across the globe that we needed to start looking in this. I mean, again, not 20%, I think I said 20%, 20 times increase in the cases of microcephaly, of babies being born with microcephaly and eye and brain disorders that go along with it that they track back to Zika infections in the pregnant mom. So that’s why it’s an issue. And again, part of that is also a problem because adults don’t know that they have it, right? So it can spread. And the reason why it can spread is it’s a little bit the, how can I explain this and not go too far down a rabbit hole that doesn’t matter for your exam?

What happens is this mosquito infects the humans, right? So the mosquito is the vector, it carries the virus, it gives it to the humans. But this virus has the ability to live and replicate within humans. So then when the mosquito bites, when a different mosquito bites the infected human, it will now pick up that virus and pass it along, right? So that’s the problem. So it can go unnoticed and it can travel from person to person through the vector of the mosquito. And again, people may not even know that this is going on.

So something that’s important in when you’re working on a patient who may, who your concern may have Zika is that the symptoms in the history of travel should sway your suspicions, right? Because this is particular areas of the world have increased risk of contracting the Zika virus. And all clinical cases must be reported to the CDC. Transmission is primarily through mosquitoes, but they have found that it can be transmitted through sexual transmission, through blood transfusion, intrauterine transmission, that’s what we’re talking about here, and then breast milk transmission. So two ways we can give it from mom to baby. Clinical presentation in adults, headaches, conjunctivitis, fever, skin rash, muscle, and joint pain. Clinical presentation in neonates, again, we’re talking about that microcephaly and other eye and brain disorders.

Labs and studies, we’re going to do serological testing and then reverse transcriptase, polymerase chain reaction testing.

Now, as far as treatment goes, there is no treatment and no vaccination for the Zika virus. We don’t have anything. So it’s largely supportive care, right? So when we’re talking about an adult, no big deal. They usually have a little bit of fever, a little muscle pain. They get better. We use acetaminophen or aspirin or something for pain control and for fever prevention.

So the real issue is not how do we treat adults, because adults are going to do pretty well with this. The real question is how do we keep pregnant women from contracting this virus and thereby passing along to their children and having them born with developmental issues. So prevention is going to be our biggest thing here in what we’re talking about. So the CDC puts out travel alerts for different areas. If you have someone who’s pregnant and they’re traveling, they should definitely be checking those sites for updated information as far as travel restrictions. Avoiding mosquito bites, right? So all the things we talk about, whether we’re, we talk about going out into the wild, right?

All the things we can do to avoid mosquito bites. So long sleeves, mosquito netting, if you’re in certain areas, those sorts of things. And then the CDC also recommends serological testing of all pregnant women upon returning from travel from areas known to have elevated Zika regardless of symptoms. So, we’re talking about testing every pregnant woman who comes back so we can get out in front of the problem.

All right. Awesome. Well, that will bring us to the end of infectious disease. Like I said, I’m not haven’t decided yet where we’re going to go from here. I have to go back through and see what we’ve covered. We haven’t covered in season two here as we’re going through the material again and see what else might be a good way to go from here. Anyway, let’s move along to our study tip.

And our study tip for today is going to be a little more vague maybe than usual. Our study tip for today, although the last episode looking back was a little, may have been a little esoteric as well, but our study tip for today is to always be testing. Always be looking for new ways to do things. Always be trying out new ideas. I run into a lot of students who do what they’re doing and they’re working very hard, but they’re not getting the results they want. So the natural thing to do is to do what you’re doing, but more of it and do it harder. And I get that.

I totally understand that. But a lot of times it’s a mistake.

Now, I’m not opposed to hard work. I think hard work is extremely important. And believe me, I push it all the time, right? But sometimes it’s not the answer. Sometimes it’s finding a better way. You know, the example I like to use is of the person digging a ditch who’s struggling to dig and can’t get the work done they want to get done. And then somebody comes in with a backhoe and gets everything done in 30 minutes where they could have not gotten done in a week, right?

There’s two different ways to do that work. So, when you’re studying, test different methods for studying. Test different ideas. Some people really like flash cards. Some people hate flash cards. Some people like to make lists. Some people hate lists.

Some people like to draw things out on whiteboards. Some people hate that. Some people like to do work early in the morning. Some people like to do work late at night. Some people like to have music running. Some people need it quiet. You know, some people like to work in a coffee shop.

Some people don’t. When you’re taking a test, some people like to, I’m trying to come up with some ideas here. I’m drawing a little bit of a blank. What do people like to do about tests? Nobody likes anything. Some people will study right up to the minute before the test. Some people will wander off and get their brain in order before their exam and not worry about what they could learn in that little period of time.

Some people will race through exams as fast as they can. Some people will grind through and read every question twice. Try different methods. Try different ideas. If you don’t like the results you’re getting, and then you’ve worked harder and they’re not changing, and then you’ve worked harder and they’re not changing, perhaps there’s something else that needs to move. You know, I just spoke with someone recently. We were talking about flashcards, and they said they hate doing flashcards because they take so much time.

The problem is they work, and they weren’t getting the results they wanted. So they said, you know what? I’m going to have to go back and do this. And that sucks. I get it. You don’t want to have to do that. But if you’re not getting the results you want, you’ve got to mix it up.

You have to change something. You have to learn something new, a new way to study, a new way to take tests, a new way to process the information. There are thousands of different ways, right? The mental model you’re currently using is only one way to do things. One takeaway from today is to understand that everyone has different ways of doing things. You see people who are done faster than you on exams. Doesn’t mean they’re smart.

They have a different way of reading them than you do. A different way of moving through test questions. Maybe ask them if they understand what they’re doing and see if you can’t learn something from them. So always be testing.

All right, let’s finish up with our priming questions for today. Did you catch these on the way through? What are the three types of neonatal herpes simplex? SEM, DIS, and CNS. What is the treatment for a newborn who contracts chickenpox? That’s one you should be able to hold on to. What is the treatment for a newborn who contracts chickenpox?

Varicella zoster immune globulin, VZIG. What is the treatment for Zika virus? That you should be able to nail too, right? We don’t have one. There is no treatment for Zika virus. It’s only symptomatic treatment, you know, some Tylenol or something, supportive care.

All right. Fantastic. It was great to be back behind the mic. Great to be here with you again. Thank you so much for being part of the community. I do really, really appreciate each and every one of you. Getting to work with you guys is what brings me out and makes me really enjoy what I’m doing here.

So thank you for that. I do appreciate it. And I am happy to be back behind the microphone. So thank you again and take care. And hopefully I will see you again as we launch the next section, the next topic session for the Physician Assistant Exam Review. Can’t wait. See you then.

Thank you.