INVESTIGATIONS OF INFECTIVE SYMPTOMS IN PREGNANCY

Clinical presentation Possible diagnosis Investigations

Maculopapular rash Rubella IgM and IgG*
Parvovirus IgM and IgG*
Enterovirus Throat or faecal culture


Vesicular rash Varicella Rash IgM and IgG* if uncertain
Enterovirus Throat or faecal culture


Flu-like symptoms CMV IgM and IgG*
(fever, myalgia, malaise, LFTs, FBC
+/- lymphadenopathy) Toxoplasmosis IgM and IgG*
Listeriosis Blood and faecal culture
Other viral infections Serology or culture as required


*In parallel with previous
antenatal serum and 2-4 weeks later if required

PREPREGNANCY COUNSELLING.

GPs should encourage couples who are planning
to conceive to have counselling and
testing before conception.
Tests for infection should include:
• rubella IgG
• syphilis serology – TPHA or RPR
• hepatitis B serology – hepatitis B
surface antigen
• hepatitis C serology – hepatitis C antibody
• HIV
• varicella – IgG
• CMV IgG (in high-risk patients)
Women who have negative rubella serology
should be offered MMR vaccine and
retested for rubella seroconversion eight
weeks later. About 5% will need revaccination.
A very small number of women will
remain rubella seronegative despite two successive
MMR vaccinations.
It is unlikely that further vaccination will
lead to seroconversion. In these cases it is
best to counsel the woman to avoid rubella
contact in her subsequent pregnancy.
Women found negative to varicella IgG
should be offered varicella vaccine with two
doses, eight weeks apart. Pregnancy should
be delayed until eight weeks after vaccination
for rubella or varicella.
In those at high risk of CMV infection
(carers of young children), CMV IgG should
also be measured.
Seronegative women should be counselled
to practise thorough hygiene when in
contact with secretions of newborn infants
and toddlers.
A pre-pregnancy session will also allow
the GP to provide nutritional advice and
instructions on ways to minimise risks of
infection with toxoplasmosis, listeria and
other infections.

SIGNS OF A PERFORATED EYE

■ an irregular or peaked pupil
■ a shallow anterior chamber
compared to the other eye
■ absent or diminished red
reflex
■ a boggy haemorrhagic
swelling over the sclera
■ uveal tissue, which is dark,
lying external to the globe
Note: not all these signs need
be present.

EYE EXAMINATIO TOOLS

■ a vision chart
■ a light source with a cobalt
blue filter
■ a means of magnification such
as loupes (or a pair of +3.0
“chemist’s glasses”)
■ amethocaine drops to
anaesthetise the ocular surface
■ fluorescein drops to stain any
epithelial defects
■ cycloplegic drops to dilate the
pupil
■ an ophthalmoscope to visualise
the red reflex and/or posterior
segment of the eye
■ cotton buds to wipe up any
secretions and help evert the
upper lid.

Diagnosis of metabolic Syndrome

The size of the waistline is the key
to selecting patients to investigate.
People who are genetically predisposed
and who take in an excessive
amount of calories are most
likely to develop this condition.
The lean man with a pot belly, a
shape seen commonly in general
practice, could be considered the
most toxic shape of all.
Objective assessment of known
risk factors (cholesterol, fasting
lipids, blood glucose level, blood
pressure, smoking, obesity and
sedentariness) is also necessary.
Risk factors for metabolic syndrome
often cluster together and have
a multiplicative rather than an additive
effect. In women, it is the level
of fasting triglycerides, rather than
cholesterol, that predicts subsequent
cardiovascular disease and death.
Waist target parameters have
tightened over time and vary according
to genetic polymorphism (see
table below).
If BMI is >30kg/m2, central
obesity can be assumed and waist
circumference does not need to be
measured. Abnormal blood glucose
should be investigated with a
glucose tolerance test.
About a third of patients with diabetes
will be picked up by the
glucose tolerance test compared with
just focusing on the fasting glucose.
Obesity and central adiposity
seem to co-segregate, not only with
cardiovascular and diabetes risk, but
also with an increased risk of certain
types of malignancy, such as breast
and endometrial cancer.