pg1 1. Report on Sexually transmitted diseases & pregnancy 2. STD (epidemiology, most common std’s,diagnosis & management) STD in pregnancy should be treated because it may lead to miscarriages or premature labor. Post partal infection like endometritis , thrombophlebitis, sepsis. Amnionitis in pregnancy. Perinatal infection of the newborn starting from perinatal mortality or leading to handicapped baby & congenital malformations. Ante natal screening for STD in Latvia. A. gonorrhoea1st visit , then 3034th week. B. syphilis – 1st visit & then 30th week. C. trichomonas + gonorrhoea. D. bacterial vaginosis Gonorrhea Etiology –Neisseria gonorrhea ,grm ,kidney shaped diplococci. Male:female2:1. I.P37 days. Found mostly in places of columnar(glandular/cylindric) epithelium. In urethra, cervix, bartholini glands, anus, pharynx. Not usually found in vagina because vagina has squamous epithelium but may be found in vagina of children. Dominant age group 2029 yrs. Clinic 50% asymptomatic. Early symptoms vaginal discharge, frequency, urgency, disuria, rectal discomfort. In pregnancy discharge is not so specific b/c of physiological discharge in pregnancy. Vulva, vagina, urethra & bartholinian glands may be inflamed with itching & burning. Infection can spread to uterus but not in pregnancy b/c of product of conception. Urethra & bartholini glands should be squeezed out for discharge . anal inflammation is due to spread of vaginal discharge. Acute tonsillitis, pharyngitis occurs if oral sex. Spotting & post coital bloody discharge. Dg bacterioscopy, culture in Thayer Martin medium to confirm the dg. Dg in pregnancy screening on 1st visit & 34th week(30) . Smear taken from the cervix canal cylindrical epithelium. If discharge then do culture. Should be reevaluated after 1 week. Risk factors previous STD & clinical signs of STD. Complications premature labor↑ b/c of ↑ prostaglandins, septic puerperal infections , ophthalmia neonatorum( gonoblenoria ) conjuctival infection in neonates. Sulphosilnatrium injection after birth or drops into eyes used in some countries. Treatment at only time of pregnancy treated by venerologist. Gonococcal + must be checked for Chlamy. trachomatis. Treat the partner & check sensitivity of microbes. During pregnancy ofloxacin0.4g orally single dose. Ciprofloxacin 0.5g orally once, azithromycin 1g orally once ,if chlamidia +; if not pregnant penicillin with probenecid 1g P/O, ceftrioxone 125mg IM once & doxicycline 100mg 2x /d for 7 d (follow up culture should be made after 7 days of therapy, repeat culture made at monthly intervals following menses for 3 months if the reports are persistently – then the pt is declared cured.) Urogenital chlamidiosis Etiology chlamidia trachomatis. An obligatory intracellular gm m.o like neisseria. In men non gonococcal urethritis can also cause lymphogranuloma venerum.( rectal ulceration,rectal strictures, regional lymphadenopathy) M:F2:1. Clinicmostly no symptoms. Urethritis, painful voiding haematuria, mucopurulent cervicitisyellowish cervical discharge + polymorphoneutrophils, salphingitis can lead to infertility due to tubal obstruction or extra uterine pregnancy. Risk groupssexual contact with infected partner, new partner within 2 months, pregnant women <25 yrs of age, pregnant women has had STD or currently another STD. Common age group 20 29 yrs. Dg PCR, Elisa , blood analysis is not helpful. No screening in LV. Complications 314 days after delivery late peuperial endometritis , extra uterine pregnancy, infertility if salpingitis. Most common cause for adhesions in the tubes & with the hepar. Neonateophthalmia neonatorum developing 7 d after delivery conjunctiva sticky, swollen, erythema, purulent discharge can lead to blindness. Must use chlorotetracycline eye drops. Chlamidia pneumonia develops 34 weeks after delivery. Treatment pregnant azithromycin 1g P/O once, erythromycin 0.5 g 34d –7d, amoxycillin 0.5g 3x/d –7d, ofloxacin 0.5g once daily if connected with gonorrhea. If non pregnant woman doxacycline 100mg P/O 2x/d7d. Treat the partner.
pg2 Trichomonas vaginalis Etiology Tr .v. A motile parasite which has 4 anterior flagella. Transmitted mainly by male partner who has organism in his urethra & prostata. Also by toilet articles from woman→w. Pathology worst just after menstruation or during pregnancy. There is vaginal inflammation & vaginal pH >5.(normal3.54.5) Clinic thin foamy greenish, foul smelling discharge. Pruritis vulvae. Vaginal exam painful inflamed vaginal walls with punctuate hemorrhagic spots. “Strawberry spots” in cervix & vagina. Dgdischarge on slide →saline→coverslip→microscopically can see motile trichomonas. Treatment immediately upon dg metrinodozole 500mg 2x/d orally 7 d. for both partners. Treat other std’s & treat the partner. No risk factors in pregnancy. Bacterial vaginosis normally in vagina is lactobacillus which keeps vaginal pH at 3.54.5. in anaerobic conditions lactobacillus ↓ & ↑ of gardnella,mycoplasma, bacteriodes mobilineus. ClinicpH: >4.5, fishy smell, creamy yellowish discharge w/o extensive evidence of inflammation. Clue cells vaginal epithelial cells surface stippled b/c of coccobacili m.o adherent that the borders are obscured. ( superficial epithelial cells). Treatment Metrinodozole500mg 2xd for 7 d or 2g once, locally dalacin 2% cream vaginally 1xd7d. in pregnancy metrinodozole alone 200mg 8hrs P/O for 7 d. If recurrent treating the partner may be helpful. There is an↑ risk of preterm labor, intraamniotic infection during pregnancy. [ Is bacterial vaginosis an std ? Yes→occurs after changing of partners, very rare if monogamist couple, Exam reveals different flora which are not endogenous. Even after treatment pt comes w recurrent attacks. ; No→no bacteria in male genital tract. 12% of b.v occur in women who are virgins. Similar m.o can be detected in rectum.(endogenous) ] Syphilis Etiology Triponema pallidum. Transmitted by sexual contact, transplacentally to the fetus and blood transfusion?, Male:female 1:1. Incubation 1090days. ~21days. Four main phases (1). Primary syphilisT.P invade through damaged skin or intact mucosa →organism reaches subcutaneous tissue where it multiplicates & in 1090 d dev a papule→ulcerates→forms a shallow punched out ulcer with well defined borders & a smooth shiny floor → chancre. Chancre is usually painless & found in cervix ,labia, vulva, penis, lips, anus, nipple or finger. Usually only one chancre is found. About 1week after appearance of chancre there is lymphadenopathy of regional lymph nodes. L.N are painless, mobile, rubbery in consistency. Dark field microscopy can be used to see motile T.P in this stage. (scrapings from edge of ulcer is taken). Serology – ve. (2). Secondary syphilis – 410 weeks after primary lesion. constitutional symptoms fever, sore throat, anorexia, malaise, arthralgia & headache. Bilateral symmetrical copper colored macular popular rash in trunk & limbs. ( palms & soles ). May also occur in face & scalp.( corona veneris) alopecia areata. Condyloma lata in moist areas (vulva, anus) –pink or grayishwhite raised plates. Mucus patches in lips tongue oral mucosa palate pharynx. Painless generalized lymphadenopathy. Serological test + ve. (3). Latent syphilis. history or serological evidence of previous infection. Absence of lesions. A) Early latent phase till 1 year after infection symptoms of secondary syphilis may reoccur during this stage (clinical relapses). B) Late latent phase→1 year after infection. D) Tertiary syphilis→ 420 yrs after primary syphilis. •Formation of gumma ( necrotic center surrounded by mononuclear, epithelial, giant, fibroblastic cells) in skin & bones. •Neurosyphilis asymptomatic neurosyphilis & symptomatic n.s . symptoms meningeal ,meningovascular , tabes dorsalis & generalized paralysis. •Cardiac syph aneurisma of aorta & aortic regurgitation.
Congenital syphilis A) Early within 2 years of birth begins as rhinitis (infectious). Followed by osteochondritis, ostitis, mucocutaneous rash (bullous,macular papular desquamating rash). Signs of TORCH hepatospleenomegaly, jaundice, anaemia, ly.pathy. B).Late (noninfectious) symptoms occur 2 years after birth. Mainly interstitial keratitis acute onset of photophobia, pain , circumcorneal injection, bilateral knee effusions. Characteristic stigmata hutchisons teeth, frontal loosing, saddle nose, poorly developed maxilla, anterior tibial loosing, linear scars in angle of mouth.
pg3 Risk factors – Women < 25 years ( most common age 2029), Unstable relationship, history of STD or PID, new partner 20 d before delivery. Risk factors for new born mother serologically +, mother did not receive treatment or no record , M received tr during pregnancy, end of pregnancy, received optional medicine not penicillin. Diagnosis 1. Screening 1st visit VDRL + TPH , repeat at 34th ( 30th) week. , if intercourse with infected person VDRL +TPH +FTAABS( fluorescent T antibody absorption ). (Wassermann reaction done sometimes, but due to false –ve results seldomly used.) Neonatal screening VDRL, TPHA, Tri pallidum immobilization reaction, FTAABS & IgM antibodies. Treatment Benzyl penicillin G 2.4 million units IM. Doxycycline 100 mg 2x14d. Tetracycline( not in pregnancy) 500mg 4x14d. congenital syphilis tr Tr of pregnant woman 1618 week of gestation. Prevents congenital syphilis. Tr after that arrest fetal infection. Benzathine penicillin G 50, 000 units/ kg IM as a single injection for asymptomatic infants w/o neurosyphilis. Procaine penicillin G 50,000 units /kg IM 1014 d. for symptomatic infants or those with n.s. Follow up 1,3,6,12 months after Tr of early syphilis & serological tests. Herpes simplex –genital infectionHSV type 2, HSV type1. Rarely in pregnancy. Clinics symptoms of the 1st attack usually appear <7d after sex contact. Initially red inflammatory area appears commonly on the clitoris, labia, vestibuli, perineal skin, thighs, vaginal wall & cervix. Extremely painful vesicles which breaks to form small ulcers→ scabs. Virus shed from the lesion until healing is complete. Micturination is very painful, retention of urine may occur. Initial attack fever, malaise, inguinal ly.nodes. In some pt virus remains dormant but in others recurrent attacks occur.& may last for about 710 days. During pregnancy→a) primary attack of genital herpes during early pregnancy→ abortions ,IUD, congenital malformations, microcephaly, microophthalmia. A 1ry attack during last weeks of pregnancy→ transplacental spread of V to fetus may cause damage to CNS. ( increase mortality of neonate). Babies who survive→ neurological sequence. If evidence of recurrent active lesions in vagina, vulva in the last weeks of pregnancy or at onset of labor→ wise to carry out Csection. Diagnosis clinics, viral cultures, in the smearinclusion bodies, antibodies in serum. Treatment Saline bath may ↓local pain , Acyclovir 200mg P/O every 4 Hrs5d. (does not prevent recurrence). Neonates given acyclovir IV. Both partners should be treated. Woman should have anal cervical smear. HIVIt’s a retrovirus. Transmissionisolated from semen, plasma, tears, saliva, CSF, urine, breast milk, cervical mucus, but only semen, blood & cervical secretions transmits. Modes sexual intercourse homo, bi, hetreo, blood products, contaminated needles, breast feeding, vertical transmission transplacental during delivery or breast milk. Clinics following exposure to HIV infection pt develops antibodies to HIV in 812 weeks → stage of seroconversion→ clinically flu like syndrome w fever, skin rash, arthralgia, diarrhea, for 23 weeks. After initial exposure pt remains asymptomatic for yrs(710yrs). During this pt s immunity ↓. With ↑ immunodeficiency→ pt becomes susceptible for 2ry infections. Some may have ly.pathy during this period. Commonly as 2ry infections→ atypical TBC, pneumocystic carini pneumonia, systemic candiditis,
meningitis, encephalitis, myolopathy. High grade lymphoid neoplasmas, karposhi sarcomas, non Hodgkin’s lymphoma. Diagnosisan absolute CD4 cell count <200 / mm3 – cutoff point when 2ry infections can occur. ELISA test confirmed by western blot method. Treatment transmission prevented – Zidovudine(ZDV) or Azidothymidine(AZT) admin after birth1st 6weeks. ZDV 150500mg /d/ divided doses. AZT100 mg5 days P/O. Delivery CSection preferable. 3638 weeks. IV AZT 2mg/kg. Vaginal delivery staff should use gloves, apron, face protection. Artificial rupture of memb – application electrodes on fetal scalp, scalp sampling. New born early cord clamping & early bathing may↓ the risk of transmission. Neonatologist should be present. W.H.O rules & regulations should be followed. Virus culture & PCR method till 2 months of age. Antibody test cannot be done b/c it can be females antibody. Baby of an infected female will carry the antibody for 69 months or a yr may be. (congenital anomalies, IUGR, Preterm delivery)
1. Report on Sexually transmitted diseases & pregnancy 2. STD (epidemiology, most common std’s,diagnosis & management) Report prepared by 1. Dr. Sajid Mahmood, MD (EU), Accident & Emergency Department, NHS Royal infirmary Liverpool United Kingdom. 2. Dr. Adnan Akram, MD (EU), Department of Infectious Diseases. University Hospital Riga Latvia. 3. Dr. Aftab Ahmed, MD (EU), Infection Control Department, Kaunas Medical University Clinic. Lithuania. Contact: publications [at] infekcijas.eu