STD DURING PREGNANCY Prof. Aboubakr Elnashar Benha university Hospital, Egypt

1. STD
DURING PREGNANCY
Prof. Aboubakr Elnashar
Benha university Hospital, Egypt
ABOUBAKR ELNASHAR

2.  Bacterial
1. Gonococcal Infections
2. Syphilis
 Viral:
1. Genital Herpes Simplex
2. Human Papillomavirus
3. HBV
4. HIV
 Others
1. Chlamydial Infections
2. Trichomoniasis
3. Candida
4. Pediculosis Pubis
5. Scabies
ABOUBAKR ELNASHAR

3. RISK FACTORS FOR STIS
1. Multiple partners (two or more in the last year).
2. Recent partner change (in past 3mths).
3. Non-use of barrier protection.
4. STI in partner.
5. Other STI.
6. Younger age (particularly aged ≤ 25yrs).
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4. HISTORY
• Symptoms:
 lumps, bumps, ulcers, rash
 itching, IMB or PCB
 Low abdominal pain, dyspareunia
 sudden/distinct change in discharge.
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5. • Past history of
STIs/GUM clinic attendance/last HIV –ve test.
• All sexual partners in past 12mths.
• Risk factors for blood-borne viruses:
• patient or partner from area of high HIV prevalence
• IV drug use
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6. TESTING FOR SEXUALLY TRANSMITTED
INFECTIONS—INCUBATION PERIOD
• Tests should be done at the time of presentation.
• Incubation period
 before tests for STIs become positive can give
false negative after a single episode of sex.
 for bacterial STIs this is 10–14 days
 for HIV and syphilis it may be up to 3mths.
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7. 1. GONORRHOEA
Epidemiology
• Neisseria gonorrhoeae:
intracellular Gram –ve diplococcus.
• Fourth most common STI in the UK.
• > 35% of strains are resistant to ciprofloxacin
70% to tetracyclines.
ABOUBAKR ELNASHAR

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9. Symptoms
 Usually asymptomatic,
 often diagnosed when screening on contact tracing
 Can present with
 vaginal discharge,
 low abdominal pain,
 IMB or PCB.
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11. Diagnosis
 Endocervical or vulvovaginal
swab with NAAT.
 Urethral, pharyngeal, and
rectal swabs if contact with
gonorrhoea.
 If diagnosed on NAAT, culture
for sensitivity testing should be
taken from all sites prior to
antibiotic treatment.
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12. A nucleic acid test (NAT) or nucleic acid amplification
test (NAAT)
 a technique utilized to detect a particular nucleic acid, virus,
or bacteria which acts as a pathogen in blood. tissue, urine,
etc.
 The NAT system differs from other tests in that it detects
genetic materials rather than antigens or antibodies.
 Detection of genetic materials allows
1. an early diagnosis of a disease because the detection
of antigens requires time for antigens to appear in the
bloodstream
2. Since the amount of a certain genetic material is usually
very small, NAT includes an amplification step of the
genetic material.
 There are several ways of amplification
including polymerase chain reaction (PCR), strand
displacement assay (SDA), or transcription mediated
assay (TMA).[
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13. Complications of gonococcus infection
• PID (~10% of infections result in PID).
• Bartholin’s or Skene’s abscess.
• Disseminated gonorrhoea may cause:
• fever
• pustular rash
• migratory polyarthralgia
• septic arthritis.
• Tubal infertility.
• Risk of ectopic pregnancy.
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14. Treatment
• Ceftriaxone
500mg IM stat, plus azithromycin 1g PO stat.
• Spectinomycin 2g IM, plus
azithromycin 1g PO stat (if severe penicillin allergy).
• Contact tracing and treatment of partners.
• The same antibiotics are recommended for treating
gonorrhoea in pregnancy.
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15. Implications in pregnancy
• Gonorrhoea associated with:
• preterm rupture of membranes and premature
delivery
• chorioamnionitis.
• The risks to the baby are of ophthalmia neonatarum
(40–50%).
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16. 2. SYPHILIS
Epidemiology
• Treponema pallidum —spirochaete.
• Relatively rare STI in the UK; however, a 12-fold rise
1997–2007.
• Doubling of congenital syphilis from 1999–2007.
• Nearly 3000 cases were diagnosed in 2010 in the
UK.
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17. Symptoms
Primary syphilis
• 10–90 days postinfection.
• Painless, genital ulcer (chancre)—may pass
unnoticed on the cervix.
• Inguinal lymphadenopathy.
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18. Secondary syphilis
• Occurs within the first 2yrs of infection.
• Generalized polymorphic rash affecting palms
and soles.
• Generalized lymphadenopathy.
• Genital condyloma lata.
• Anterior uveitis.
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19. Tertiary syphilis
• P resents in up to 40% of people infected for at least
2yrs, but may take 40+yrs to develop.
• Neurosyphilis: tabes dorsalis and dementia.
• Cardiovascular syphilis: commonly affecting the
aortic root.
• Gummata: infl ammatory plaques or nodules.
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20. Diagnosis
• Specific treponemal enzyme immunoassay (EIA) for
screening (IgG + IgM).
• 1 ° lesion smear may show spirochaetes on dark
field microscopy.
• Quantitative cardiolipin (non-treponemal) tests, i.e.
rapid plasma reagin (RPR)/VDRL are useful in
assessing need for and response to treatment.
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21. Treatment
• Depends on penicillin allergy:
• benzathine benzylpenicillin 2.4 MU single dose IM
(used in pregnancy)
• doxycycline 100mg bd PO for 14 days
(contraindicated in pregnancy),
• erythromycin 500mg qds PO for 14 days (used in
pregnancy).
• Treatment courses are longer in tertiary syphilis.
• Contact tracing (potentially over several years).
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22. Implications in pregnancy
• Preterm delivery.
• Stillbirth.
• Congenital syphilis.
• Miscarriage
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23. 1. HERPES SIMPLEX
Epidemiology
• DNA virus—herpes simplex
type 1 (orolabial/genital) and
type 2 (genital only).
• Third most common STI in England in 2010.
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24. Symptoms
 Primary HSV infection
 usually the most severe
 often results in:
• Prodrome
(tingling/itching of skin in affected area).
• Flu-like illness +/– inguinal lymphadenopathy.
• Vulvitis and pain
(may cause urinary retention).
• Small, characteristic vesicles on the vulva
can be atypical with fissures, erosions, erythema of skin.ABOUBAKR ELNASHAR

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27.  Recurrent attacks
 result from reactivation of latent virus in the
sacral ganglia
 normally shorter and less severe.
 can be triggered by:
• Stress.
• Sexual intercourse.
• Menstruation.
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28. Complications of HSV infection (usually of primary
infection)
• Meningitis.
• Sacral radiculopathy:
urinary retention and constipation.
• Transverse myelitis.
• Disseminated infection.
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29. Diagnosis
• Usually from appearance of the typical rash.
• PCR testing of vesicular fluid
(most sensitive—gold standard).
• Culture of vesicular fluid.
• Serum antibody tests
of no use for diagnosing primary herpes.
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31. Maternal risks
In pregnancy a primary attack may be severe.
Complications include:
• Meningitis.
• Sacral radiculopathy:
urinary retention and constipation.
• Transverse myelitis.
• Disseminated infection.
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32. Fetal risks
Primary infection
miscarriage or preterm labour
no related congenital defects.
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33. Neonatal risks
 Transmission rate from vaginal delivery
 during primary maternal infection may be as
high as 50%,
 during recurrent attack (<5%) relatively uncommon
 Neonatal herpes appears during first 2wks of life.
• 25% limited to eyes and mouth only.
• 75% widely disseminated, of which:
 70% will die
 many of the survivors will have long-term
problems including mental retardation.
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34. Treatment
• No cure for genital herpes.
• Symptomatic relief with
• simple analgesia,
• saline bathing, and
• topical anaesthetic.
• Oral aciclovir
 200mg 5x day for 5 days or similar
 double dose/length if immunosuppressed.
 Topical aciclovir is not beneficial.
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35.  Aciclovir
 decrease severity and duration of the primary
attack if given within 5 days of onset of symptoms.
 If labour is within 6w of primary infection:
CS
provided the membranes have not been ruptured for
>4h.
 With active vesicles from a recurrent attack, the risk
of surgery must be carefully weighed against the very
small risk of neonatal infection.
ABOUBAKR ELNASHAR

36. • Condoms/abstinence
whilst prodromal/symptomatic
(unless history of HSV in both partners)
may reduce transmission rates.
• Suppressive antiviral treatment
if >6 recurrences/year.
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37. 2. HUMAN PAPILLOMAVIRUS
Epidemiology
• DNA virus, many subtypes.
• Subtypes 6 and 11:genital warts (condylomata
acuminata).
• Subtypes 16 and 18: CIN and cervical neoplasia.
• Commonest viral STI in England.
• 25% of people presenting with warts have other
concurrent STIs.
ABOUBAKR ELNASHAR

38. Symptoms
 Majority asymptomatic.
 Painless lumps anywhere in the genitoanal area.
 Perianal warts are common in the absence of anal
intercourse.
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39. Dome shaped lesion on
keratinized skin above clitoris
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40. A filamentous genital
wart is present in the
urethra
Cauliflower-like
condyloma acuminata
are seen on the
perineum, adjacent
posterior fourchette,
and right lower labia
majora. ABOUBAKR ELNASHAR

41. Perianal condyloma
acuminata are present, but
their morphology is smoother.
Keratinized flat warts are
present in the junction
between the introitus and
the perineum. Keratin
produces the strikingly white
appearance.
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43. Micropapillations are normal single-
filament projections on the inner
labia minora that can often be
confused with genital warts. The
single filament of each projection
differentiates this normal finding
from HPV induced genital warts.
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44. Diagnosis
 Usually identified by clinical appearance.
 Non-wart HPV infection often diagnosed by
 characteristic appearance on cervical cytology
or
 colposcopy (whitening on topical application of
acetic acid).
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46. Complications
 HPV 16 and 18 associated with high-grade CIN
and cervical neoplasia.
 Smoking and immunosuppression both affect viral
clearance thereby increasing the risk.
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47. Treatment for genital warts
 Removal of the visible wart.
 High rate of recurrence due to the latent virus in
the surrounding epithelial cells.
1. Clinic treatment
• Cryotherapy.
• Trichloroacetic acid.
• Electrosurgery/scissors excision/curettage/laser.
ABOUBAKR ELNASHAR

48. 2. Home treatment
 both contraindicated if pregnancy risk
 Podophyllotoxin cream or solution:
 this is self-applied
 must be used for about 4–6wks.
• Imiquimod cream:
a self-applied immune response modifier.
It may need to be used for up to 16wks.
ABOUBAKR ELNASHAR

49. Management of Sex Partners
 Persons should inform current partner(s) about
having genital warts because the types of HPV that
cause warts can be passed on to partners.
 Partners should receive counseling messages that
partners might already have HPV despite no visible
signs of warts, so HPV testing of sex partners of
persons with genital warts is not recommended.
 Partner(s) might benefit from a physical examination
to detect genital warts and tests for other STDs.
 No recommendations can be made regarding
informing future sex partners about a diagnosis of
genital warts because the duration of viral persistence
after warts have resolved is unknown.
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50. Implications in pregnancy
 Genital warts tend to grow rapidly in pregnancy
 usually regress after delivery.
 Very rarely, babies exposed perinatally may
develop laryngeal or genital warts.
 Not an indication for CS.
 CS is indicated for
 women with anogenital warts if the pelvic outlet
is obstructed or
 vag delivery would result in excessive bleeding.
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51. Routine vaccination
 From 2008 the DH has recommended HPV
vaccination for all girls aged 12–13.
 Initially the selected vaccine was active against
HPV 16 and 18
 in 2012 was changed to include HPV 6 and 11 as
well.
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52. 3. HBV
 Sexual transmision
Primary mode of transmission in US
by saliva, vaginal secretions, and semen.
 Hepatitis B transmitted by direct contact with
 blood
 semen, vaginal fluids and other body fluids.
So It is STD
Fortunately there HBV vaccine
(Bacq & Lee, UpToDate, 2015)
ABOUBAKR ELNASHAR

53.  Sex partners of HBsAg-positive persons
CDC2015
use methods condoms to protect themselves from
sexual exposure to infectious body fluids (e.g., semen
and vaginal secretions)
unless they have been demonstrated to be
 immune after vaccination (anti-HBs >10 mIU/mL)
or
previously infected (anti-HBc positive).
ABOUBAKR
ELNASHAR

54. 1. CHLAMYDIA
Epidemiology
• Chlamydia trachomatis: obligate intracellular parasite.
• Commonest bacterial STI in the UK.
• An important cause of tubal infertility.
Symptoms
 Dysuria
 vaginal discharge, or
 irregular bleeding (IMB or PCB)
 70% of cases are asymptomatic.
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55. Complications of Chlamydia infection
• Pelvic inflammatory disease
(10–40% of infections result in PID).
• Perihepatitis (Fitz–Hugh–Curtis syndrome).
• Reiter’s syndrome (more common in men):
• arthritis
• urethritis
• conjunctivitis.
• Tubal infertility.
• Risk of ectopic pregnancy.ABOUBAKR ELNASHAR

56. Diagnosis
 Vulvovaginal (which can be self-taken) or
 endocervical swab for nucleic acid amplification
test (NAAT).
 Requires specific medium.
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58. Treatment
• Azithromycin 1g single dose
doxycycline 100 mg bd for 7 days—not in pregnancy
both have similar efficacy of >95%.
• Contact tracing and treatment of partners.
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60. Implications in pregnancy
 Association with preterm rupture of membranes
and premature delivery.
 The risks to the baby are of:
• Neonatal conjunctivitis
(30% within the first 2wks).
• Neonatal pneumonia
(15% within the first 4mths).
 Treat pregnant woman with
 erythromycin 500mg bd for 10–14 days
 73–95% effective
ABOUBAKR ELNASHAR

61. 2. Trichomonas
Epidemiology
• Trichomonas vaginalis —
flagellated protozoan.
• Found in
vaginal,
urethral
para-urethral glands.
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62. Symptoms
 Asymptomatic in 10–50%
 may present with:
• Frothy, greenish, offensive smelling vaginal
discharge.
• Vulval itching and soreness.
• Dysuria.
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64. Diagnosis
 Cervix
 may have a ‘strawberry’ appearance from
punctate haemorrhages (2%).
 wet smear:
Direct observation of the organism by normal
saline
 acridine orange stained slide from the posterior
vaginal fornix
(sensitivity 40–70% cases).
 Culture media
diagnose up to 80% cases.
 NAATs
sensitivities and specificities approaching 100%
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66. Saline wet mount of vaginal secretions in trichomonal vaginitis,
showing two T. vaginalis (arrows), leukocytes and a normal
vaginal epithelial cell
McGraw-Hill
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68. Pap smear: 70% sensitive in showing TV.
Wet mount: TV
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69. Purulent Vaginal Discharge in Trichomo
Vaginitis
McGraw-Hill
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73. Complications
may enhance HIV transmission.
Treatment
• Metronidazole: 2g orally in a single dose.
• Metronidazole: 400–500mg bd for 5–7 days.
• Partner:
 Contact tracing and treatment
 advised to abstain from intercourse until they
and their sex partners have been adequately
treated and any symptoms have resolved.
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74. Implications in pregnancy
• Trichomonas is associated with:
• preterm delivery
• low birth weight.
• Trichomonas may be acquired perinatally, occurring
in 5% of babies born to infected mothers.
ABOUBAKR ELNASHAR

75. 3. Candidiasis (thrush)
Epidemiology
• Yeast-like fungus
90% Candida albicans,
remainder other species, e.g. C. glabrata
 75% of women will experience at least one
episode
 10–20% are asymptomatic chronic carriers
(increasing to 40% during pregnancy).
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76. • Predisposing factors
those that alter the vaginal micro-flora and include:
• immunosuppression
• antibiotics
• pregnancy
• diabetes mellitus
• anaemia.
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77. Symptoms
 May be asymptomatic
 usually presents with:
• Vulval itching and
soreness.
• Thick, curd-like, white
vaginal discharge.
• Dysuria.
• Superficial
dyspareunia.
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79. Diagnosis
• Characteristic appearance of:
• vulval and vaginal erythema
• vulval fissuring
• typical white plaques adherent to the vaginal wall.
• Culture from HVS or LVS.
• Microscopic detection of spores and pseudohyphae
on wet slides.
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83. Complications
Unlikely to cause any significant complications unless
the woman is severely immunocompromised.
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84. Treatment
• As so many women are chronic carriers, candidiasis
should only be treated if it is symptomatic.
• Clotrimazole 500mg pessary +/– clotrimazole cream; or
• Fluconazole 150mg (single dose)
contraindicated in pregnancy.
 Other simple measures may help to decrease
recurrent attacks, e.g.:
• Wearing cotton underwear.
• Avoiding chemical irritants, e.g. soap&bath salts.
ABOUBAKR ELNASHAR

85.  Uncomplicated VVC is not usually acquired through
sexual intercourse; thus, data do not support
treatment of sex partners.
 A minority of male sex partners have balanitis,
characterized by erythematous areas on the glans of
the penis in conjunction with pruritus or irritation.
These men benefit from treatment with topical
antifungal agents to relieve symptoms.
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86. Implications in pregnancy
• It is very common in pregnancy with no apparent
adverse effects.
• Topical imidazoles are not systemically absorbed
and are therefore safe at all gestations.
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87. You can get this lecture and 444 lectures
from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://www.facebook.com/groups/2277
44884091351/
2.Slide share web site
3. elnashar53@hotmail.com
4. My clinic, 3 Althawra St. Almansura
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