prevalence, pattern and effect of STI on pregnancy and viceaversa

1. Sexually Transmitted Infections
in Pregnancy
PRESENTER : DR MAMTA RAI

2. ANATOMIC ALTERATIONS IN
PREGNANCY

3. ANATOMIC ALTERATIONS IN
PREGNANCY

4. ANATOMIC ALTERATIONS IN
PREGNANCY
Directly perfused
by maternal
blood
Obliteration
of cavity

5. ALTERATIONS IN CERVICOVAGINAL
MICROBIAL FLORA DURING PREGNANCY
• Number of bacterial species in vagina decreases
• Prevalence and quantity of lactobacilli increase
• Rate of carriage of Enterobacteriaceae, group B streptococci , and
other facultative bacteria remains unchanged
Changes in the vaginal pH, glycogen
content, and vascularity of lower genital tract

6. • Herpes simplex virus
• Human papillomavirus
infection
• Hepatitis B virus
• HIV
• Syphilis
• Gonoccocal infection
• LGV(Chlamydial)
• Donovanosis
• Bacterial vaginosis
• Chancroid
Bacterial
Classification Of STIs In Pregnancy
Viral
Fungal : Candidiasis
Protozoal : Trichomoniasis
Parasitic : Pubic lice &

7. PREVALENCE OF STI IN PREGNANCY

8. Indian Scenario
PREVALENCE OF STI IN PREGNANCY

9. BACTERIAL INFECTIONS

10. SYPHILIS IN PREGNANCY
Incidence : 0.36% (10 out of 2704
samples)

12. CLINICAL MANIFESTATIONS

13. EFFECT OF PREGNANCY ON SYPHILIS
• Primary chancre : Small size
• Cervical chancre more common
• Increased spirachaetemia
Pregnancy has no known effect on the clinical course of syphilis

14. EFFECT OF SYPHILIS ON PREGNANCY
Mother can transmit the infection transplacentally to fetus
or during passage through birth canal

15. EFFECT OF SYPHILIS ON PREGNANCY
Kassowitz’s Law
Colle’s Law
Profeta’s Law
Thumb Rules :

17. Factors influencing fetal outcome
• Gestational age
• Stage of maternal syphilis
• Maternal treatment
• Immunological response of fetus

18. SCREENING & DIAGNOSIS
Screening
Non Treponemal Test ( RPR/VDRL )
If positive
• To be done in all
pregnant women at
first visit
• Repeat at 28-32
weeks and again at
delivery for high
risk femalesConfirmatory Test
Treponemal Test ( FTA-ABS or MHA-TP
Treat

19. • Biological false positive reactions were detected in
0.59% of the general population, 0.72% of pregnant
women
• The rate of BFP reactors among pregnant women did
not differ significantly from the general population

20. TREATMENT
Indication of treatment :
1. Women with a positive treponemal test who do not
have clear documentation of previous adequate
treatment
2. Women with an epidemiologic history of recent
exposure to an individual with proven syphilis
regardless of serologic results.
3. If clinical or serologic relapse or reinfection occurs
4. If doubt exists about the adequacy of previous
therapy

21. TREATMENT
Penicillin – G
Only therapy with documented efficacy for syphilis during
pregnancy
Patients allergic to penicillin
Desensitization
Oral
Intraveno
us

22. • Penicillin skin testing with the major and minor
determinants of penicillin

24. GONOCOCCAL INFECTION IN
PREGNANCY

25. • Prevalence : 1-7 %
• Marker for concomitant chlamydial infection
(~40%)
• Infection mostly limited to the lower genital tract
• Rarely acute salpingitis

26. Effect of pregnancy on gonococcal
infection ?
• Increased oropharynageal and anal infections
• Disproportionate number of disseminated gonococcal
infection (~7-40%)
Effect of Gonococcal infection on
pregnancy ?
• Preterm delivery
• Premature Rupture of Membranes
• Chorioamnionitis
• Postpartum infections

28. Effect of gonococcal infection in newborn
?
Acute illness : Manifests 2-5 days after birth
Ophthalmia
neonatorum
Sepsis
Others

29. DIAGNOSIS
Gram stain (
Endocervical/pharyngeal/rectal)
Culture
Nucleic Acid Amplification Test
Insufficient and is not recommended alone; CDC 2015

30. TREATMENT
• Ceftriaxone 250 mg I/M + Azithromycin 1 gm
oral stat
Spectinomycin 2gm I/M Stat
If cephalosporin allergic
Prophylaxis : Erythromycin (0.5%) oint stat
Treatment : Ceftriaxone 25-50mg IV/IM Stat
• Evaluation for concomitant chlamydial infection
• Partner management
Do not use quinolones/tetracyclines in pregnant
females
Ophthalmia Neonatorum

31. Chlamydial infection in pregnancy

32. Prevalence of chlamydia trachomatis infection in
pregnant patients
Public Health Rep.1991;106(5):490–493.
Prevalence : 2 to 37 %
Prevalence of CT infection of the cervix of prenatal clinic
women : ~8%
Prevalence Of Chlamydia Trachomatis Infection In
Parturient Women In Northern Spain. Springerplus.2016;5:566.
Overall age adjusted prevalence : 1%
• < 25 years - 6.4 %
• 25–29 years – 2%
• 0.5 % in older women

33. Effect of Chlamydia on Pregnancy
Effect of Pregnancy on Chlamydial Infection
Increased viral shedding

34. • Vertical transmission of infection to neonate
• Post partum endometritis, salpingitis or pelvic
inflammatory disease
• Obstetric complications
Consequences of Untreated Infections

35. DIAGNOSIS
• Specimen : Urine sample / Swab (
vaginal/endocervical )
• Nucleic Acid Amplification Tests : Most sensitive
• Others : culture , Direct Immunofluorescence, EIA

36. TREATMENT
Recommended Regimen
Azithromycin 1gm stat
Alternative Regimens
Amoxicillin 500mg TDS X 7 days
Erythromycin base 500mg QID X 7days or 250mg QID X
14 days
Erythromycin ethylsuccinate 800mg QID X 7 days or
400mg QID X 14 days

37. • Test of cure ( preferably NAAT) : 3-4 weeks after
completion of therapy
• Retest 3 months after treatment

38. • Prevalence : Same as in non-pregnant females
• Routine screening not recommended
• Pregnancy has no effect on natural course of
bacterial vaginosis
BACTERIAL VAGINOSIS

39. Effect of Bacterial Vaginosis on Pregnancy

40. Treatment indicated in symptomatic patients
only
Treatment regimen :
• Metronidazole 500mg BD X 7 days or
• Metronidazole 250mg TDS X 7days or
• Clindamycin 300mg BD X 7 days

41. VIRAL INFECTIONS

42. HERPES SIMPLEX VIRUS

43. Effect of HSV infection on pregnancy ?
• Transmission : Mostly intrapartum
• In Utero transmission : in ~5%
• ~75-90% of infants with neonatal HSV :
Asymptomatic infected mothers with no prior
history of genital HSV

44. • Antibodies to HSV-2 : detected in ~ 20 percent of
pregnant women
• ~5 percent : history of symptomatic infection

45. Risk of transmission from infected mother to
child ?
• If infection acquired near delivery : High risk (30-
50%)
• History of recurrent herpes preconception/
during first half of pregnancy : Low (<1%)

47. TREATMENT
• Acyclovir : safe in pregnancy and lactation
• Valacyclovir and Famciclovir : Insufficient
data
Regimen for Suppressive Therapy
Acyclovir 400mg TDS or Valacyclovir 500mg BD

48. HUMAN PAPILLOMAVIRUS

49. • HPV DNA detection during pregnancy : 5.2 – 65%
• On comparing with non-pregnant (age adjusted)
: Increased detection in pregnant females
• Clinical manifestation of HPV infection : Warts
• HPV infection manifesting as symptomatic warts :
More common during pregnancy

50. • Pregnant women showed decreased viral
clearance rates during first and second trimester
while there was a trend for increased clearance
during third trimester and post partum period
compared to non pregnant women

51. CONCERNS IN PREGNANCY
• Enlarge during
pregnancy
• Podophyllin –
contraindicated
• Perinatal exposure
The Internet Journal of Gynecology and Obstetrics. 2009 Volume 13

52. RISK OF PERINATAL TRANSMISSION
• Variable in different populations
• Range : 3.7 to 72%

53. • 19.7% of infants born to hpv positive mothers and
16.9% of those born to hpv negative mothers tested
HPV positive
• Strong and statistically significant association
between mother's and child's HPV status at the 6week
postpartum visit

55. • No randomised clinical trials for effectiveness of
various treatment modalities in pregnancy
• Drugs contraindicated : Cytotoxics (
podophyllin/podophyllotoxin)
• Effective treatment : Cryotherapy, RFA, TCA
TREATMENT

56. Prevalence :
• Acute HBV infection :1–2 per 1000 pregnancies
• Chronic infection : 5–15 per 1000 pregnancies
HEPATITIS B VIRUS
Pregnancy has no effect on clinical presentation or course
of acute/ chronic Hepatitis B infection

57. • Elevated Transaminase levels : Acute HBV (over
1000 μm(ml)
• Confirmation : HBsAg and anti-HBc IgM antibody in
the serum
DIAGNOSIS
In chronic cases :
• HBsAg is positive
• Anti-HBc IgM is negative and IgG is positive

58. • Both passive and active immunization against
hepatitis B : Safe in pregnancy
• If a nonimmune pregnant woman has been exposed
to HBV : HBIG followed by vaccine
• Interferon : Not recommended
TREATMENT