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Obstetric and gynecological infections
By
Ahmed Elbohoty MD, MRCOG
Assistant professor of obstetrics and gynecology
Ain Shams University
7/8/20 1
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HPV
DNA virus
Commonest sexually transmitted infection
The majority of HPV infections are asymptomatic and
spontaneously clear within two years.
Only 50–60% of women develop serum antibodies to
HPV after natural infection.7/8/20 5
•More than 120 HPV genotypes
have been identified.
•This association with cancer
risk is used to stratify persistent
HPV into high- and low-risk
types
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•They commonly infect the squamous epithelia or
mucosal cells with the potential to undergo
squamous maturation, including skin and the
mucosae of the anogenital and the upper respiratory
tract.
•Genital HPV is acquired through intimate skin to skin
contact, not just penetrative sexual intercourse and
has a lifetime risk of infection of up to 80% in
exposed individuals.
•The prevalence of HPV in women declines with age
but increases with increasing numbers of sexual
partners.
7/8/20 7
• the viral genome has a common structure with three main areas:
E (early) region
L (late) region
the genomic regulatory region.
.
two HPV proteins, E6
and E7, have been
found to inactivate
tumour suppressor
genes, which may
lead to carcinogenic
transformation of
cells
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• Most HPV infections are asymptomatic and self- limiting.
• However, persistent HPV infection occurs in 10–15% of
women and is associated with various forms of cancer.
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Types
•High-risk HPVs are known to be associated with cervical,
anogenital and head and neck cancers.
•E.g. 16, 18, 31, 33, 35, 39, 45
•They are responsible for causing high-grade squamous
intraepithelial lesions (HSIL) of the cervix.
•HPV types 16 and 18 are responsible for more than 70% of
cases of cervical cancers
•Low-risk HPVs cause genital warts and cervical low grade
lesions but are not implicated in the development of
cancers.
•E.g. HPV types 6 and 11
•Genital warts and low grade squamous intraepithelial
lesions (LSIL) of the cervix.
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Warts = Codyloma acuminatum
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Management
• Screen for other STIs
• Treatment is essentially cosmetic.
• Treating HPV-related genital warts may reduce infectivity but will not eliminate it.
• Significant psychological distress sometimes – reassure that HPV often clears
spontaneously
• Women with external anogenital warts should have a speculum examination to
check for vaginal / cervical lesions
• All treatments have significant failure and relapse rates.
• Treatment may involve discomfort and local skin reactions.
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A. Soft non-keratinised warts respond
well to
A. Podophyllin
B. Podophyllotoxin
C. trichloroacetic acid.
B. Keratinised lesions are better treated
with physical ablative methods such as
A. Cryotherapy
B. Excision
C. electrocautery
• Not treating the warts is also an option, and in approximately 30% of patients
the warts will resolve spontaneously.7/8/20 14
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Podophyllotoxin:
• home-based treatment
• patient applies solution/cream to warts twice daily for 3 days then has a 4-day
period of no treatment. This is repeated for four to five cycles (or less if warts
clear before then).
• can cause irritation to surrounding skin
• licensed for use on external genitalia
• intercourse should be avoided following treatment as it may cause irritation to
partner.
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Trichloracetic acid:
• must be applied by a clinician in a specialist clinic
• weekly application of 80-90% solution
• caustic agent that causes cellular necrosis – associated with an
intense burning and irritation for up to 10 minutes post application
• not recommended for large-volume warts
• can be used at most anatomical sites
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Imiquimod:
• home-based treatment
• Imiquimod cream is licensed for the treatment of external anogenital warts; it
may be used for both keratinised and non-keratinised lesions.
• patient applies cream before bed three times per week and washes off 6–10
hours after application
• can be used for up to 16 weeks
• can cause skin irritation
• is known to weaken latex condoms
• should not be applied prior to intercourse as can cause irritation to partner.
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Cryotherapy
• Cryotherapy with liquid nitrogen is a commonly used ablative
method.
• It needs to be carried out in a clinical setting with access to liquid
nitrogen and relevant safety equipment. Each lesion is 'frozen' with
the spray until a 'halo' forms. Treatment is repeated on a weekly
basis.
• Electrocautery or surgery are other options, depending on the size
and position of the warts.
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Intravaginal
•Cryotherapy, electrosurgery and trichloroacetic acid are
recommended treatments
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Pregnancy
§ Counsel pregnant women with HPV infection about the risk of peripartum transmission of HPV
infection, pointing out that:
§ Infection with HPV types 6 and 11 can result in respiratory papillomatosis in infants and
children
§ The role of cesarean section in reducing peripartum transmission of HPV is unknown
à SO, NOT RECOMMENDED
§ Recurrent respiratory papillomatosis is a rare but serious condition affecting four per 100 000 births as a
result of transmission of HPV to the neonate during delivery.
§ TCA has been used in pregnant patients without adverse effects.
§ Podophyllin, podofilox, and fluorouracil should not be used in pregnant patients because of
possible teratogenicity.
§ Imiquimod is not approved for use in pregnant women, although treatment with this agent
can be considered after informed consent has been obtained.
§ Surgical excision, cryotherapy, and electrocautery are appropriate treatment options during
pregnancy if treatment is necessary.
§ The goal of treatment in pregnant women primarily is to minimize neonatal exposure to the
virus by reducing the number of lesions present during delivery. à Anogenital warts and
laryngeal papillomatosis are potential complications in infected children.
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The vaccine
•(Cervarix®, GSK Biologicals), offering
protection against HPV types 16 and
18,
•Gardasil® (Merck), a quadrivalent
vaccine offering protection against
HPV types 6, 11, 16 and 18
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Gardasile
• From September 2014, a 2-dose schedule is recommended, as long as the first
dose is received before the age of 15 years.
• The first dose is given to females aged 11 to 14 years, and the second dose is
given 6–24 months after the first dose (for the purposes of planning the national
immunisation programme, it is appropriate to give the second dose 12 months
after the first—see Immunisation schedule).
• If the course is interrupted, it should be resumed (using the same vaccine) but
not repeated, even if more than 24 months have elapsed since the first dose or if
the girl is then aged 15 years or more.
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Chlamydia
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Chlamydiae cannot make their
own ATP.
The chlamydial cell wall lacks
classic peptidoglycan (due to
reduced muramic acid),
rendering β-lactam antibiotics
ineffective.
Types Presentation
A, B, C Chronic infection, cause blindness due to follicular conjunctivitis in Africa.
D, K Urethritis/PID, ectopic pregnancy, neonatal pneumonia (staccato cough) with eosinophilia, neonatal
conjunctivitis (1–2 weeks after birth).
L1, L2, and L3 Lymphogranuloma venereum—small, painless ulcers on genitals swollen, painful inguinal lymph nodes that
ulcerate (buboes). Treat with doxycycline.
Pathogenesis of Chlamydia species
•Obligate Intracellular organism, small non-motile
•Consists of both RNA and DNA , ribosomes, cell wall and
divide by binary fission
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•Chlamydia is the most common treatable
sexually transmitted disease in the UK
and the most common preventable cause
of infertility worldwide.
• It can be transmitted in vaginal or
seminal fluids through vaginal, anal or
oral intercourse. Prevalence of infection
in partners of those diagnosed with
chlamydia is up to 75%.
•It is caused by bacteria that infects
columnar and transitional epithelium.
•In UK GP surgeries, the prevalence of
chlamydial infection ranges between 5
and 10% in the under 25 age group.7/10/20 29
Risk factors for the acquisition of chlamydial
•young age (<25 years)
•a new sexual partner within the past year
•poor socioeconomic status
•the use of non-barrier contraception
•infection with another STI.
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The National Chlamydia Screening Programme
•The core elements of this NHS screening program for
sexually active men and women under the age of 25 years.
•The majority of patients diagnosed with chlamydial infection
are identified during routine NHS screening programmes,
investigation for other suspected STIs, or during specific
clinical episodes such as routine testing prior to induced
abortion or insertion of an intrauterine contraceptive device
or system.
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Symptoms / signs
•Asymptomatic in 70% in women and 50 %
in men
•Vaginal discharge
•Post coital or intermenstrual bleeding
•Dysuria (beware ‘sterile pyuria’ reported
on an MSU – it may be Chlamydia)
•Lower abdominal pain
•Deep dyspareunia
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Complications
•One third of women with untreated
chlamydia go on to develop pelvic
inflammatory disease
•1/5 women with an episode of PID will
become infertile
•Perihepatitis (Fitz-Hugh-Curtis
syndrome)
•Sexually Acquired Reactive Arthritis
‘SARA’ in men > women7/10/20 34
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Reiter's syndrome
•A small number of adults may
present with arthritic symptoms.
•It includes urethritis, arthritis and
conjunctivitis, can be triggered by
chlamydial infection, although it
may be caused by other infections
as well.
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Fitz–Hugh–Curtis syndrome
• Rarely, the development of right upper quadrant pain due to a perihepatitis
occurs in women.
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Rectal and pharyngeal infections
• In men or women who have receptive anal sex
and patients who present with proctitis and a
mucopurulent anal discharge, rectal chlamydial
infection has to be considered.
•Pharyngeal infection is generally asymptomatic
in both men and women.
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Pregnancy and the neonate
The incidence of chlamydial infection in pregnant women is 6%.
Untreated chlamydial infection in pregnancy is associated with increased risk of
miscarriage, premature delivery fetal growth restriction/low birthweight and
stillbirth.
Risk intra-partum pyrexia and late post partum endometritis
Risk post-abortal PID
Neonatal infections – exposed in birth canal during delivery
– 30 % exposed infants develop infection in eyes, lungs, nasopharynx, genitals
Time: eye infection(5-20 days) and pneumonia(4-12 weeks) (treated with
erythromycin)
Antibiotic treatment reduced chlamydia positivity in pregnant women by 90%.
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Ophthalmia Neonatorum
chlamydial infection should be considered in all infants who develop conjunctivitis within 30
days of birth
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Diagnosis
•Nucleic Acid Amplification
Technique (NAAT): 95% sensitive
•The 'window period' for detecting
chlamydia on a NAAT test is
approximately 2 weeks.
• Therefore, when the test is taken, the patient should be informed
that it will not accurately detect any chlamydia infection that has
been acquired within the last 2 weeks. If they have had any new
risk within the last 14 days they should be advised to attend for
repeat testing in a further 2 weeks.
•Testing for other STI`s should be
carried out , ideally in GUM clinics
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Testing
• For women, a vulvovaginal swab (VVS) is the specimen of choice.
• A NAAT swab is inserted approximately 5 cm into the vagina and rotated for
between 10 and 30 seconds. This can be self-collected or clinician-collected. If
clinician-collected, it should still be taken as a vulvovaginal swab, with the swab
inserted prior to speculum insertion. A VVS is more sensitive than an
endocervical swab or a 'first catch' urine in women. It is also acceptable to
women and allows self-sampling.
• In men, a 'first catch' urine sample is the specimen of choice.
• “First catch” means that it is the first part of urine passed (i.e. not a midstream
sample) in order to sample any bacteria present in the urethra. It is more
acceptable to men than urethral sampling, and is as, or more, effective than
urethral swabs for detecting chlamydia. The urine is sent for NAAT testing.
• Rectal and pharyngeal NAAT swabs can be taken either by the patient or clinician.
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Treatment
•Doxcycline I00 mg bd for seven days or
•Azithromycin 1 g orally as a single dose, followed by 500mg
once daily for two days.
• there are significant rates of concommital rectal infection in men and women
with no history of anal sex, and 1 g of Azithromycin is an inadequate treatment
for rectal chlamydia.
• 3–15% of patients with chlamydia will also have mycoplasma genitalium. Giving a
single dose of 1 g Azithromycin to these patients may lead to increased cases of
Azithromycin-resistant mycoplasma.
• All current and recent sexual partners (60 days) of an infected person need to be
tested whether or not they have symptoms
Alternative regimens include:
•ofloxacin 200 mg twice daily or 400 mg once daily for 7 days
•erythromycin 500 mg twice daily for 10–14 days
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Treatment options for pregnant and breastfeeding
• Azithromycin 1 g orally as a single dose, followed by 500mg once daily
for two days.
• erythromycin 500 mg four times daily for 7 days or twice daily for 14
days
• amoxicillin 500 mg three times daily for 7 days.
• In pregnant women, a post-treatment test of cure is recommended
due to the risk of serious sequelae for mother and neonate if infection
is not treated. Management also includes counselling, a full STI screen,
contact tracing/treatment and advice on safe sex.
• As the treatment regimens with erythromycin and amoxycillin are less
effective than azythromycin and doxycycline, a post-treatment test of
cure is recommended. Management also includes counselling, a full STI
screen, contact tracing/treatment and advice on safe sex.
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Test of Cure
• A test of cure is not routinely recommended but should be performed in
pregnancy or if non-compliance or re-exposure is suspected.
• You should wait for 5 weeks following treatment (or 6 weeks with azithromycin)
as nucleic acid amplification tests can give false-positive results up to 5 weeks
following successful treatment because antigenic material can still be detected
even if the bacteria are dead.
• Evidence suggests that trained GP practice nurses doing partner notification and
telephone follow-ups are as effective as trained health advisers in a
genitourinary medicine clinic and have a comparable cost
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Counselling
• Contact tracing ('look back' policy in the NHS recommends four weeks
for symptomatic patients, and all sexual partners dating back six
months for asymptomatic patients, or to last sexual partner if longer
than six months).
• Two-thirds of sexual partners are likely to become infected following
sexual intercourse with an asymptomatic chlamydia positive partner
• A full STI screen (including hepatitis B, syphyllis and HIV)
• Treatment and contact tracing for sexual partners within the previous 6
months
• Advice on safe sex (condoms and avoiding sexual intercourse for 7 days
following commencement of treatment in both partners)
• Referral to genitourinary medicine clinic (level three STI provision) may
be considered in some instances if full STI screening or appropriate
counseling/contact tracing is not available in level one or two NHS
facilities.
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• Systemic disease caused by sub-type
of Chlamydia trachomatis (serovars
L1, L2 and L3)
• Class Symptoms and signs include
genital ulceration, lymphadenopathy
and a severe proctocolitis divided into
3 stages
• 1º: 3 to 30 day incubation period,
transient painless papule,
pustule or erosion
• 2º: regional dissemination
tender lymphadenopathy. Most
Pts recover at this stage
• 3º: local tissue destruction;
proctocolitis may mimic Crohn’s
disease
Lymphogranuloma venereum
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• It is a rare disease in UK
• Now seen in certain MSM in UK – dense
sexual networks centred around the gay
leather-bar scene
• Presents as proctitis
• Many Patients are HIV +ve and HepC +ve
• Take a rectal Chlamydia swab and/or
prompt referral to GUM if you suspect it
• Screen for other STIs
• treatment with doxycycline and
azythromycin..
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Neisseria gonorrhoeae
•the second most common bacterial STI. Young
people are most commonly infected, with
current rates highest in those aged 20–24 (men
390 per 100,000; women 223 per 100,000).
•A Gram-negative diplococcus that can infect
the mucous membranes of the
urethra, endocervix, rectum, pharynx and
conjunctiva
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Symptoms in Women
•Endocervical infection is often
asymptomatic (up to 50%)
•It may present as abnormal vaginal
discharge
• Rarely, it may cause intermenstrual bleeding or menorrhagia
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Investigation of gonorrhoea
•The more sensitive nucleic acid
amplification tests (NAATs) detect up to
90% of infected individuals compared to
only 75% with the culture method
•In any instances of suspected gonorrhoea
(from history/examination or contact of
partner with gonorrhoea), a culture
should be taken in addition to the NAAT
test, in order to confirm antibiotic
sensitivities.7/10/20 50
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Super Gonorrhea
• In 2018, the UK saw it's first case of
'super' gonorrhoea, in a man who had aquired
the infection in Asia. In January 2019, there were
2 cases of 'super' drug-resistant gonorrhoea in
the UK in heterosexual females, who had been on
holiday in a European party destination.
• All three cases have been successfully treated,
without the emergence of an outbreak. However,
in order to manage the very real threat of an
outbreak of multi-drug resistant gonorrhoea, the
Health Protection Agency (HPA) has set up a
special surveillance unit called GRASP
(Gonococcal Resistance to Antimicrobials
Surveillance Programme) to monitor the
situation.
• Public Health England has recommended that all
cases of suspected or confirmed gonorrhoea
should be referred to a specialist Sexual Health
Service to ensure correct testing, treatment and
partner notification.
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Treatment of gonorrhoea
• As per the new BASHH 2019 gonorrhoea:
• The first-line treatment where antimicrobial sensitivities are NOT known prior to
treatment:
• 1 g ceftriaxone IM as a single dose (safe in pregnancy) (dual therapy is no longer
recommended).
• If antimicrobial sensitivities are KNOWN and it is sensitive to ciprofloxacin, then:
• 500 mg ciprofloxacin PO as a single dose.
• Referral to a local genitourinary medicine clinic is recommended.
• In 2017, 36% of gonorrhoea cases were resistant to ciprofloxacin, and therefore
it is only recommended as a first-line treatment when results are already
available that confirm cipro sensitivity.
• If an alternative regimen is required (e.g. allergy/contraindication to
intramuscular injection or sensitivity results available and resistant to the above
treatments), this should be discussed with local genitourinary medicine
department/microbiology to assess local trends and resistance patterns.
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Contacts
• Partner notification
• All contacts should be tested with both a NAAT (to confirm if they
have gonorrhoea) and a culture (to determine sensitivities).
• If the index patient is a male with symptomatic urethral infection,
any contacts within the last 2 weeks should be notified for testing
and treatment
• For all other cases, all partners within the preceding 3
months should be notified.
• Treatment of contacts
• Epidemiological treatment is not required for all sexual contacts.
• For those who present within 14 days of exposure: treatment can
be given OR patient can choose to await test results to confirm they
have been infected prior to treatment.
• For those who present after 14 days of exposure: they should be
tested and await positive result and culture results.
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Test of cure
• Due to the emerging problem of antibiotic resistance, test of cure is
recommended in all cases.
• For patients with persistent symptoms or signs after treatment, culture
should be performed at least 72 hours after treatment
• For asymptomatic patients, a NAAT test should be performed 1 week
(for RNA NAATs) or 2 weeks (for DNA NAATs) post-treatment.
• Those with a positive test of cure may have been inadequately treated,
or may have been reinfected. Culture results will guide the appropriate
treatment.
• When patients attend for their test of cure it is a good opportunity to
check compliance with medication, ensure symptoms have resolved,
confirm that sexual partners have been contacted and provide further
health promotion advice.
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Pelvic inflammatory disease (PID)
• It is usually the result of
infection ascending from the
endocervix causing
endometritis, salpingitis,
parametritis, oophoritis, tubo-
ovarian abscess and/or pelvic
peritonitis.
•PID is a common cause
of morbidity and
accounts for one in
60 GP consultations by
women under the age
of 45 years
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Risk factors are:
• the most important risk factor is a previous history of
chlamydia, gonorrhea infection or PID
• the 16–24-year-old age group: five-times higher risk compared with
control group
• vaginal 'douching'
• smoking and low socioeconomic group
• recent intrauterine contraceptive device insertion: within 4 weeks
of insertion in woman at a low risk of sexually transmitted infection
• iatrogenic: hysterosalpingogram , intrauterine contraceptive device,
termination of pregnancy, surgical management of miscarriage,
embryo transfer
• the insertion of an intrauterine device (IUD) increases the risk of
developing PID but only for 4-6 weeks after insertion. This risk is
probably highest in women with pre-existing gonorrhoea or C.
trachomatis.
• high frequency of partner change
• lack of barrier contraception
• sex during menstruation or just afterward
• genetic factors may also play a role
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•Chlamydia infection is associated with a 10% risk of
PID.
•Combined oral contraceptive pill and the use of
barrier contraceptions are associated with reduced
PID incidence, possibly because of altered
presentation of the infection. Intrauterine devices
cause very little increase risk of PID, which is limited
to the first 3 weeks of insertion.
•Vaginal douching
•The practice of 'cleaning' the vagina by squirting
water or vinegar (known as douching) more than
three times in 1 month increases the risk of PID by
300% compared with not douching. It also
increases the risk of endometritis and ectopic
pregnancy.
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Causative agents
polymicrobial Neisseria gonorrhoeae and Chlamydia trachomatis cause around 25% of cases
of PID in the UK. Neisseria gonorrhoea (found in 14% of PID cases), Chlamydia
trachomatis (around 10% of cases) whilst Gardnerella vaginalis, anaerobes (including
Prevotella, Atopobium and Leptotrichia) and other organisms commonly found in the vagina
may also be implicated.
Mycoplasma genitalium has been associated with upper genital tract infection in women and
is a very likely cause of PID.
Pathogen negative PID is common
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Symptoms
•Systemic symptoms
•Fever
• Anorexia
•Malaise.
•Localised symptoms
• lower abdominal pain which is typically bilateral (but can be unilateral)
• abnormal vaginal or cervical discharge which is often purulent
• deep dyspareunia
• abnormal vaginal bleeding, including post coital bleeding, inter-menstrual bleeding
• secondary dysmenorrhoea
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Examination findings
• Pyrexia, tachycardia, hypotension
• Mucopurulent cervicitis
• Cervical inflammation or bleeding
• Cervical excitation (positive cervical motion test)
• Adnexal tenderness, usually bilateral
• Possible adnexal mass
• Abdominal distension
• Lower abdominal tenderness
• Rebound tenderness/guarding (peritonism)
• Right upper quadrant tenderness (associated with perihepatic inflammation).
• Gonococcal PID
• In approxiamtely 1% of GC cases, infection can spread haematogenously to a distant site,
resulting in disseminated gonococcal infection with manifestations ranging from tendon or
joint pain to meningitis or endocarditis.
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•A diagnosis of PID should be considered, and usually
empirical antibiotic treatment offered, in any
sexually active woman who has recent onset, lower
abdominal pain associated with local tenderness on
bimanual vaginal examination, in whom pregnancy
has been excluded and no other cause for the pain
has been identified.
•The risk of PID is highest in women aged under 25
not using barrier contraception and with a history of
a new sexual partner. The diagnosis of PID based
only on positive examination findings, in the absence
of lower abdominal pain, should only be made with
caution
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Complication
• women with immunosuppression secondary to HIV may have more
severe symptoms associated with PID but respond well to standard
antibiotic therapy.
• No change in treatment recommendations compared to HIV
uninfected patients is required
• The Fitz-Hugh Curtis syndrome comprises right upper quadrant pain
associated with perihepatitis which occurs in some women with PID,
especially by C. trachomatis. There is insufficient clinical trial evidence
to make specific recommendations for additional treatment beyond
that for uncomplicated PID.
• In women with mild to moderate PID the IUD may be left in situ but a
review should be performed after 48-72 hours and the IUD removed if
significant clinical improvement has not occurred.
• The decision to remove the IUD needs to be balanced against the risk
of pregnancy in those who have had otherwise unprotected
intercourse in the preceding 7 days. Emergency hormonal
contraception following removal of an IUD may be appropriate for
some women in this situation.
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A tubo-ovarian abscess
•A tubo-ovarian abscess should be suspected in patients who
are systemically unwell and/or have severe pelvic pain. The
palpation of an adnexal mass, or lack of response to therapy,
should prompt pelvic imaging with ultrasound, computed
tomography (CT) or magnetic resonance imaging (MRI).
•Tubo-ovarian abscess is an indication for hospital admission
for parenteral antimicrobial therapy, with appropriate
anaerobic cover, and to monitor for signs of rupture or
sepsis.
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The differential diagnosis of lower abdominal pain in a young
woman
• ectopic pregnancy – pregnancy should be excluded in all women suspected of
having PID
• acute appendicitis – nausea and vomiting occurs in most patients with
appendicitis but only 50% of those with PID. Cervical movement pain will occur
in about a quarter of women with appendicitis
• endometriosis – the relationship between symptoms and the menstrual cycle
may be helpful in establishing a diagnosis
• Complications of an ovarian cyst e.g. torsion or rupture – symptoms are often of
sudden onset
• urinary tract infection – often associated with dysuria and/or urinary frequency
• irritable bowel syndrome – disturbance in bowel habit and persistence of
symptoms over a prolonged time period are common. Acute bowel infection or
diverticular disease can also cause lower abdominal pain usually in association
with other gastrointestinal symptoms.
• functional pain (pain of unknown aetiology) – may be associated with
longstanding symptoms7/10/20 65
TESTS
• A pregnancy test
• Testing for gonorrhoea should be with an endocervical specimen (NAAT) and
tested via culture
• Testing for chlamydia endocervix using a NAAT.
• The absence of endocervical or vaginal pus cells on microscopy or wet-mounted
vaginal smear has a good negative predictive value (95%) for the diagnosis of
PID, but their presence is non-specific .
• A midstream specimen of urine should be checked to rule-out urinary tract
infection as a differential diagnosis.
• Markers for infections and its severeity:
• Raised white blood count count, erythrocyte sedimentation rate and C-reactive protein are
useful measures of the severity of PID.
• Electrolytes, liver function and coagulation are only indicated in cases of systemic
bacteraemia.
• A midstream specimen of urine should be checked to rule-out urinary tract infection as a
differential diagnosis.
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Swab technique
7/10/20 67
US
• Transvaginal ultrasound is useful and has a high sensitivity for ruling out other
pathology such as ovarian cysts, ovarian torsion and detecting hydrosalpinges.
• In the diagnosis of tubo-ovarian abscess, pelvic ultrasound has a sensitivity and
specificity of over 90% and laparoscopy is not necessarily needed to make the
diagnosis.
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Treatment
• It is likely that delaying treatment increases the risk of long term sequelae such
as ectopic pregnancy, infertility and pelvic pain. Because of this, and the lack of
definitive diagnostic criteria, a low threshold for empiric treatment of PID is
recommended
• Treatment must cover gonorrhoea- and chlamydia-associated organisms, as well
as anaerobic organisms
• Screening for STIs should be done in cases of suspected PID before starting
antibiotics. However, treatment should not be delayed
• Women with HIV should be given the same antibiotics as those not infected.
They should be managed with the help of the HIV physician.
7/10/20 69
General Advice
• Rest is advised for those with severe disease.
• Appropriate analgesia should be provided.
• Intravenous therapy is recommended for patients with
• more severe clinical disease e.g. pyrexia > 38C
• clinical signs of tubo-ovarian abscess
• signs of pelvic peritonitis.
• To avoid reinfection patients should be advised to avoid oral or genital
intercourse until they, and their partner(s), have completed their treatment
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Outpatient regimens
•Ceftriaxone 500 mg intramuscular single dose; then
doxycycline 100 mg twice daily + metronidazole 400 mg
twice daily for 14 days
Or
•Oral ofloxacin 400 mg twice daily plus oral metronidazole
400mg twice daily for 14 days
Or
•Intramuscular ceftriaxone 500 mg immediately, followed by
azithromycin 1 g per week for 2 weeks
Or
•Oral moxifloxacin 400 mg once daily for 14 days.
•
7/10/20 71
Quinolones
• not licensed for use in patients aged under 18.
• Ofloxacin and moxifloxacin should be avoided in patients who are at high risk of
gonococcal PID (e.g. when the patient’s partner has gonorrhoea, in clinically severe
disease, following sexual contact abroad) because of high levels of quinolone resistance.
• N. gonorrhoeae is, however, an uncommon cause of PID in the UK (< 3%) and in those not
at high risk of gonorrhoea quinolones can be used as first line empirical treatment, with
therapy being adjusted subsequently if testing reveals quinolone resistant N.
gonorrhoeae.
• Levofloxacin has the advantage of once daily dosing (500mg OD for 14 days). It may be
used as a more convenient alternative to ofloxacin
• Moxifloxacin for PID. There is a potential risk of serious liver reactions occurring with this
agent but they are uncommon.
• Of the three recommended PID treatment regimens, moxifloxacin provides the highest
microbiological activity against M. genitalium.
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Indications for admission
•a surgical emergency cannot be excluded
•lack of response to oral therapy
•clinically severe disease
•presence of a tubo-ovarian abscess
•intolerance to oral therapy
•pregnancy
7/10/20 73
inpatient regimens
• ceftriaxone 2 g by intravenous infusion daily plus intravenous
doxycycline 100 mg twice daily, followed by oral doxycycline 100
mg twice daily plus oral metronidazole 400 mg twice daily for a
total of 14 days
Or
• intravenous clindamycin 900 mg three times daily plus
intravenous gentamicin,* followed by either oral clindamycin
450 mg four times daily to complete 14 days OR oral doxycycline
100 mg twice daily plus oral metronidazole 400 mg twice daily to
complete 14 days.
Or
• intravenous ofloxacin 400 mg twice daily plus intravenous
metronidazole 500 mg three times daily for 14 days.
• Or
• i.v. ciprofloxacin 200mg BD plus i.v. (or oral) doxycycline 100mg
BD plus i.v. metronidazole 500mg TID for 14 days
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Special situations
• Treatment during pregnancy
Avoid tetracyclines in pregnancy or where there is a possibility of
pregnancy. This is owing to their teeth staining properties in the
second and third trimesters, as well as skeletal abnormalities in animal
studies in the first trimester. PID in pregnancy is rare in the absence of
septic miscarriage and the diagnosis should be made after careful
consideration.
• Treatment in young women
• Ofloxacin should be avoided in young women where possible, as bone
development is still occurring. Doxycycline can be safely used in
children over the age of 12 years.
7/10/20 75
Surgical Management
•laparoscopy may help early resolution of severe disease by
dividing adhesions and draining pelvic abscesses but
ultrasound guided aspiration of pelvic fluid collections is
less invasive and may be equally effective
•laparotomy may be required to assess and treat clinically
severe pelvic infection
•it is possible to perform adhesiolysis in cases of
perihepatitis but there is no evidence on whether this is
superior to only using antibiotic therapy
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Follow up
• Patients managed as outpatients should be followed-up at 72 hours. If
they do not show significant improvement, they will need hospital
referral for further investigations, parenteral antibiotic therapy and/or
surgical intervention.
• A further follow-up should be done at 2–4 weeks to:
• assess response to treatment
• reiterate the importance of screening for STIs
• advise on the need to use barrier contraception until treatment is
completed
• give advice on contraception (oral contraception is safe but delay
insertion of intrauterine devices until symptoms resolve)
• stress the need for contact tracing and the treatment of sexual
partners
• reassure that if compliance maintained with intake of medications,
then fertility is usually maintained. However, there is an increased
risk of ectopic pregnancy and chronic pelvic pain. Risk of infertility
increases following multiple episodes of PID.7/10/20 77
Tubo-ovarian abscess (TOA)
•It is a recognised and serious complication of untreated
pelvic inflammatory disease (PID).
•It most commonly affects women of reproductive age and
nearly 60% are nulliparous.
•TOA is defined as an inflammatory mass involving the tube
and/or ovary characterised by the presence of pus.
•The infection can occasionally involve other adjacent organs
such as the bowel and bladder.
•It carries a high morbidity and can be life threatening. When
associated with severe systemic sepsis, the mortality rate is
reported to be as high as 5–10%.
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•Around 15–35% of women being treated for
proven PID will be diagnosed with a TOA.
•A delay in treatment of PID is highly likely but
virulence of the causative pathogen might
make a TOA more likely.
•Women with co-existing endometriosis are
more likely to have more severe PID and TOA.
•The incidence of a TOA was 2.3% in women
with co-existing PID and endometriomas
compared with 0.2% in women without
endometriomas.
7/10/20 79
Diagnosis
•The diagnosis is made when the clinical findings are
associated with raised inflammatory markers and
radiological findings demonstrating a mass.
•Fever and diarrhoea are more common in women with TOA
than in women with PID (90% versus 60%, respectively)
•Symptoms and signs of PID and/or a TOA include some or all
of the following:
• Adnexal tenderness (bilateral or unilateral)
• Cervical excitation
• Pyrexia
• Abnormal cervical or vaginal discharge
• An adnexal mass on abdominal palpation/bimanual
examination or seen by imaging.7/10/20 80
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Presentation
• Elevated white cell count
• Elevated erythrocyte sedimentation rate
• Elevated C-reactive protein
• Neisseria gonorrhoeae and/or Chlamydia trachomatis test positive
• TOA had a higher white cell count on admission and a higher erythrocyte sedimentation rate
than those with PID without TOA; this might raise the suspicion of a TOA.
• The absence of a raised white cell count or pyrexia does not exclude TOA.
• A serum lactate and blood cultures are essential if the woman is systemically unwell (pyrexia,
tachycardia, increased respiratory rate).
• A screen for sexually transmitted disease such as N. gonorrhea and C. trachomatis is
important, although in the UK may only be positive in one-quarter of cases.
Immunodeficiency, for example, HIV, should also be considered.
• A pregnancy test should be performed in women of reproductive age.
7/10/20 81
• Challenges to diagnose a TOA:
• Differential diagnoses include
• an appendicular mass
• an endometrioma (or other ovarian cyst)
• an extrauterine pregnancy
• diverticulitis
• underlying malignancy.
• Adjacent structures such as the omentum and bowel can sometimes
contain the inflammatory process within the pelvis
• A TOA is characterised by clinical findings and radiological
abnormality. It is not necessary to perform a laparoscopy on all women
with suspected PID.
• A laparoscopy may be non-specific/inconclusive (endometritis or
salpingitis display subtle signs only at laparoscopy). If the woman is
clinically stable, she will usually respond to antibiotics.
• Women with PID are often treated in the primary care setting and
careful clinical evaluation and treatment may prevent hospital
admission.
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Imaging
•Ultrasound should still be considered as the first-line
imaging to guide diagnosis and treatment.
•CT and MRI may help to refine the diagnosis but
may cause delays in treatment.
7/10/20 83
Ultrasound
• A TOA can be diagnosed by ultrasound, appearing as a complex solid/cystic mass.
This can be unilateral or bilateral. A pyosalpinx may be seen as an elongated,
dilated, fluid-filled mass with partial septae and thick walls. Incomplete septae
within the tubes is a sensitive sign of tubal inflammation
• There may be a ‘cogwheel’ sign resulting from thickened endosalpingeal folds
which is a sensitive marker of a TOA
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Computed tomography (CT) imaging
•It is useful when there is a suspicion of gastrointestinal
pathology such as an appendix mass.2 When a TOA is
present, a common finding on CT is a thick-walled, fluid-
dense mass in the adnexa(e), often with internal septations.
There may be anterior displacement of the thickened
mesosalpinx.
•Internal gas bubbles are usually specific for bowel-associated
abscesses on CT and this sign is unusual with a TOA.
•There may also be rectosigmoid involvement. This is a result
of the posterior spread of inflammation (and consequent
fibrosis) from the nearby TOA. Pararectal fat may be
infiltrated.
•The ureter is the other most commonly involved structure
and there may be associated hydroureter/hydronephrosis.7/10/20 85
Magnetic resonance imaging (MRI)
•It has the advantage over CT of being a non-irradiating
mode of imaging.
•A TOA on MRI tends to have a low signal intensity on T1-
weighted imaging and a high signal intensity on T2-
weighted imaging.
•MRI has been found to have a higher sensitivity and
specificity than ultrasound for the diagnosis of TOA
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Possible antibiotic regimens for a tubo-ovarian abscess
•IV ofloxacin 400 mg twice-daily plus intravenous (IV)
metronidazole 500 mg three times a day
•IV clindamycin 900 mg three times a day plus IV gentamicin
•IV cefoxitin 2 g three times a day plus IV/PO doxycycline 100
mg twice-daily
•IV ciprofloxacin 200 mg twice-daily plus IV/PO doxycycline
100 mg twice-daily plus IV metronidazole 500 mg three
times a day
7/10/20 87
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Medical treatment
•Antibiotics can be effective in up to 70% of patients
but is associated with a high recurrence rate.
•Initially, intravenous broad-spectrum antibiotics that
cover the commonest causative pathogens are
required.
•Successful antibiotic therapy is based on the ability
to penetrate the abscess cavity, remain active within
the abscess environment and be active against the
commonest pathogens.
•Intravenous clindamycin, metronidazole and
cefoxitin have higher abscess cavity penetration and
have been shown to reduce abscess size.
7/10/20 89
Ultrasound/CT-guided drainage
• The success rate is reported between 83% and 100%
• 81% of women with a TOA managed by image-guided drainage avoided surgery
because they were treated with percutaneous drainage.
• TOAs can be drained by ultrasound- guided aspiration or drainage with catheter
placement.
• The transvaginal approach provides a direct route from the vagina into the pouch
of Douglas or adnexal regions where TOAs are usually found.
• Small, single abscesses with clear fluid usually needed only aspiration. There
were no complications with aspiration alone and a 100% success rate. Catheter
placement was needed for larger, bilateral, multiloculated abscesses with thick
viscous material.
• There were minor complications in 10% of catheter placements including bladder
pain and infection, with an 80% success rate.
• Transvaginal aspiration with antibiotic cover should be the first line of
treatment of TOAs after reporting a high success of 93% (282 out of 302 women)
with no major complications.
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Timing of intervention:
•The optimal duration of antibiotic therapy
before deciding to proceed with surgical or
image-guided drainage is variable. In clinical
practice, consideration is usually given to this
after 24 hours (and certainly after 48 hours) of
intravenous antibiotics if no clinical
improvement
•Rapid clinical deterioration may need prompt
surgical intervention in up to 25% of women.
7/10/20 91
Technical challenges
• Surgery for TOAs can be technically difficult; necrotic tissue is difficult
to handle as it is fragile, resulting in tissues collapsing and
haemorrhaging.
• There is also often oedema of tissues such as the peritoneum, making
visualisation of important structures such as the ureter(s) very
challenging.
• The bowel is commonly found to be adherent to structures in the
pelvis when there is a TOA, therefore increasing the risk of visceral
injury.
• Techniques include laparoscopic versus open surgery and drainage of
abscess versus radical excision.
• Potential long-term consequences of a TOA include infertility, an
increased risk of ectopic pregnancy and chronic pelvic pain7/10/20 92
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Surgical task
• Drainage of the pelvic abscess with copious irrigation of the abdominal cavity can be
considered if fertility is to be preserved.
• A large drain should be considered to allow any remaining pus or wash to be
expelled.
• If the woman has completed her family, consideration should be given to salpingo-
oophorectomy, thereby reducing the chance of recurrence and the consequent need
for potential further surgery.
• Resection may not be possible and can be associated with increased surgical risk.
• Unfortunately, removal of the adnexa may still be necessary, even in those women
wishing to maintain fertility, depending on the findings at laparoscopy or if a
drainage and washout has previously been performed and the woman has failed to
improve with this more conservative approach.
• If conservative surgery is felt to be appropriate in women wishing fertility
conservation then this should be considered.
• Although outcomes from pelvic clearance results are good, there is significant
morbidity in terms of surgical risks, infertility and premature menopause
7/10/20 93
Later on surgery
•Some women will need to be considered for elective
surgery later. This could be because of symptoms
such as chronic pain, a persistent adnexal mass or
repeated admissions/antibiotic courses for a TOA.
• The first 6 weeks after an acute episode of a TOA
should be avoided as inflammation and tissue quality
will be particularly poor at this time.
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Special cases
7/10/20 95
Pregnancy
• There are few reported cases of TOAs in pregnancy.
• TOAs can lead to adverse pregnancy outcomes including miscarriage, preterm
labour, chorioamnionitis, fetal or maternal death.
• Optimal treatment (and surgical approach if needed) in pregnancy depends on
the severity of the infection and the gestation of pregnancy.
• It is also important to consider in a pregnant woman with a suspected TOA that
an appendix abscess is much more common.
• MRI is safe in pregnancy and could help to establish the correct diagnosis.
• Early delivery of the baby or risking a potential miscarriage (by performing
surgery in pregnancy) may be necessary to benefit or even save the life of the
mother.
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Intrauterine devices
• Removal of an intrauterine device or intrauterine system should be considered
but it needs to be balanced against the risk of pregnancy in those who have had
intercourse in the preceding five days. Hormonal emergency contraception may
be appropriate for some women in this situation.
• There is a relationship with intrauterine devices and Actinomyces. Tubo-ovarian
actinomycosis is a chronic suppurative condition with Actinomyces israelii often
forming multiple abscesses, granulation tissue and fibrosis.
• On imaging, it frequently has a predominantly solid appearance with prominent
contrast enhancement in the solid portion.
• On MRI there is often direct inflammatory extension by solid and linear lesions.
• Actinomyces tends to respond well to penicillin.
7/10/20 97
Complications
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CPP
• The incidence of chronic pelvic pain has been shown to be 12% after one
episode, 30% after two episodes and 67% after three or more episodes of PID or
TOA.
• There were no statistical differences observed between those treated with
antibiotics and those managed surgically in terms of chronic pelvic pain.
7/10/20 99
Subfertility
• 32–63% of women achieved a pregnancy following laparoscopy and drainage of
abscess versus 4–15% in women treated with antibiotics alone.
• Laparoscopy and drainage of abscesses should be considered for all women with
TOAs who desire future fertility.
• In women presenting with subfertility who have a history of TOAs, consideration
should be given to assessment of fallopian tubes.
• Women with persistent hydrosalpinges and subfertility may be offered occlusion
of their fallopian tubes or bilateral salpingectomies in an attempt to optimise
outcomes with in vitro fertilisation.
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Syphilis
• Cases of syphilis in the UK rose by 162% between 2008 and 2018. 75% of all
diagnoses are in men who have sex with men. diagnoses in heterosexual men
rose by 63% and in women by 35%.
• 1.5 million pregnancies are affected by syphilis each year and up to 50% of those
untreated will incur an adverse outcome
• Causative agent: Treponema Pallidum
• Treponema pallidum subspecies pallidum is a spiral-shaped, Gram-negative,
highly mobile bacterium.
7/10/20 101
Transmission
•Mostly via sexual contact: one-third of those exposed to the
disease will become infected. Bacteria can also enter
extragenitally, for example via anal, rectal or oral routes.
•Transmission can also occur transplacentally during any stage
of pregnancy;in this instance, the risk of transmission is
dependent on the stage of maternal infection and duration
of fetal exposure
•close contact with open lesions( rare).
•direct blood transfusion.
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Primary syphilis
•Approximately 3 weeks following exposure to
infection (range 9–90 days), At the site at which the
bacteria entered the body, a single papule becomes
a chancre – a painless and indurated, nonpurulent
lesion
•If outside the genital tract, chancres can be multiple
and painful
•Chancres typically heal spontaneously over 3–8
weeks. Approximately 25% of patients will go on to
develop secondary syphilis if they do not receive
treatment.
7/10/20 105
Secondary syphilis
• Systemic manifestations of syphilis often emerge 4–10 weeks after the
development of the primary chancre, including the following:
• General malaise/flu-like symptoms, such as loss of appetite and
lymphadenopathy
• A generalised mucocutaneous rash, which typically affects the mucous
membranes and can also occur on palms/soles
• Development of perianal condylomata lata – discoloured, warty, highly
infectious lesions (these can also be extra-genital): soft, flat, moist, pink
tan papules and nodules
• Other signs include meningitis, eye disease (e.g. uveitis and optic
neuropathy), hepatitis, glomerulonephritis and splenomegaly.
• 2ry syphilis resolves within 1–3 months, before entering a dormant/latent
phase.
• However, up to one-quarter of patients develop recurrence of their
secondary disease in the initial part of this latent period.
• If untreated, around 30% of these patients will progress to tertiary/late
syphilis, with its associated cardiovascular and neurological manifestations.7/10/20 106
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Investigation
•Diagnosis may be made on serological
testing (for screening), by detecting
treponemes on dark ground microscop
from a sample taken from
•a chancre
•mucous patch
•aspiration of a lymph node),
•or by PCR testing from a lesion.
7/10/20 109
Investigations
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Non- specific (non-treponemal ) tests:
• They include rapid plasma reagin and Venereal Disease Research
Laboratory carbon antigen tests.
• These assays react with immunoglobulin M and G antibodies and can
demonstrate disease activity through their titre levels.
• These titres should reduce over time and will subsequently become
negative/undetectable once treatment is completed.
• These tests can also give rise to false positives for syphilis as they will
show a raised antibody response to other endemic treponemal
conditions, such as yaws, or in other systemic inflammatory conditions,
such as endocarditis. Notably, this method can give false positives
because of pregnancy itself.
• Only 40% of the women who screened positive required antibiotic
treatment for the condition
7/10/20 111
Next step
•If the first syphilis serology screen returns as
reactive/positive: a second sample should be sent to test
for an alternative treponemal antibody to confirm the
disease. In addition, a test should also be rapid plasma
reagin performed prior to treatment to establish baseline
titre levels at their highest point.
•If test results are negative and a suspicion of syphilis
remains: repeat serology should be sent at 6 and 12 weeks
after the date of the last sexual contact, to allow for the
incubation period of the disease.
•Although spirochetes are seen in the circulation relatively
quickly after they breach the mucocutaneous defences,
antibody levels often do not rise for many weeks.
•False negatives are also commonly seen in HIV-positive
patients7/10/20 112
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Confirmation
•Send a 10-ml clotted blood sample (gold or red-topped
bottle) to obtain a full syphilis screen. (Treponemal
serological tests used for screening will vary according to
local hospital/laboratory practices – please consult your
local guidelines. Enzyme immunoassays and Treponema
pallidum particle agglutination assays are the tests most
commonly cited in Public Health England serology guidance).
•Swab any active lesions identified on the genitals or
elsewhere with a ‘flock’ swab (flock/virology swabs are
usually sent in red/green-topped tubes). Send these for
syphilis PCR and also to test for herpes simplex as a
differential diagnosis.
•Use this opportunity to screen for other STIs, including
chlamydia, hepatitis B/C and HIV, if the patient consents.
7/10/20 113
Specific (treponemal) tests:
Fluorescent treponemal antibody absorption test (FTA - ABS).
Treponema pallidum immobilization test (TPI).
They usually remain positive even after adequate treatment
7/10/20 114
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Repeat testing
•For who are at high risk of syphilis exposure, including those
who engage in unprotected vaginal, anal or oral intercourse
with homosexual men
•Commercial sex workers; those who inject drugs; those with
a sexual partner linked to countries in which there is a high
disease prevalence (e.g. African countries); and those with
multiple sexual partners or a partner with a diagnosed STI.
•Typically be offered every 3 months and be guided by
patients’ sexual histories and practices.
7/10/20 115
Syphylis in pregnancy
• From as early as 14 weeks of gestation, spirochete bacteria can cross
the placenta and cause fetal infection. This risk increases as the
pregnancy progresses towards term.
• Fetal loss of 30–40% of fetuses infected during the pregnancy. Fetal
loss is often caused by infection of the placenta, or compromised
blood flow to the fetus.
• Of the fetuses that survive, around one-third will be born with signs of
congenital syphilis.
• The stage of syphilis in the mother also influences the risk of
transmission to the fetus: it can be as high as 100% in primary syphilis,
whereas the risk is much lower in early and late latent syphilis, with
transmission rates of 40% and 10%, respectively
7/10/20 116
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Fetal ultrasonic features
• Fetal infection is initially characterised by placental involvement and hepatic
dysfunction.
• It can result in fetal growth restriction, hepatomegaly, thrombocytopenia,
anaemia and ascites, with a subsequent risk of preterm birth, stillbirth and
neonatal death.
• Signs recognised on ultrasound are often general hallmarks of in utero infection
and, as such, are fairly nonspecific. In more severe cases this may manifest as
distorted fetal long bones or fetal hydrops.
• Around 6–10% of cases of fetal hydrops are associated with congenital infections.
• Although the mechanism can vary, fetal hydrops caused by Treponema infection
typically occurs as a result of disseminated damage to capillaries and endothelial
cells, which results in fluid shift.
• The common fetal ultrasound features are,
• Ascites
• Hepatosplenomegaly
• Intrahepatic calcifications
• Placentomegaly.
7/10/20 117
Congenital syphylis
• England is deemed to have met the criteria set by the WHO for elimination of
mother-to-child transmission of syphilis (<50 cases of congenital syphilis per 100 000
(0.5 per 1000) live births). Across Europe it is 1.1 per 100 000 live births
• Early disease manifests in the first 2 years of life, whereas late congenital syphilis is
apparent after the age of 2 years.
• Around two-thirds of babies with congenital syphilis are asymptomatic at birth and,
of these, two-thirds will demonstrate signs and symptoms from 3–8 weeks of age.
Most present before 12 weeks of age.
• Congenital syphilis is a multisystem infection that can result in neonatal death and
long-term disability. Babies born with congenital syphilis are 10% more likely to die in
the first year of life.
• Signs seen in early disease include skin rashes, stigmata of meningitis and jaundice.
Hepatosplenomegaly is a common finding, alongside deranged liver function, with a
notably raised alkaline phosphatase level.
• Blood tests may also show severe anaemia, monocytosis and thrombocytopenia. X-
rays may demonstrate periostitis, which leads to the development of bone deformity.
‘Bloody snuffles’, caused by syphilitic rhinitis, create a pink coloured nasal discharge
characteristic of the disease.
7/10/20
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Late disease
• It typically presents with bony deformities secondary to chronic
inflammation.
• Hutchinson’s Triad: eighth cranial nerve deafness, interstitial keratitis
and ‘Hutchinson’s Teeth’ (notched incisors).
• Syphilitic rhinitis leads to the characteristic saddle nose and anterior
bowing of the mid-tibia creates the classic ‘sabre shins’.
• The impact of late congenital disease can be devastating, with one-
third to one-quarter of children presenting over the age of 2 years
having asymptomatic neurosyphilis.
7/10/20 119
Management
•It should include antimicrobial therapy, counselling, partner
notification and safer sex advice.
•Women should be treated as soon as the diagnosis is
established, preferably in early gestation.
•The treatment of maternal syphilis at least 30 days before
delivery is possibly the most important factor influencing the
risk of congenital infection and perinatal mortality
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Antibiotics
• Stat dose of intramuscular benzathine penicillin G (2.4 million units).
• A second dose is recommended when treating early syphilis in the
third trimester because there are lower serum levels of the drug and a
risk of treatment failure.
• For patients who report possible sensitivity to penicillin and who can
tolerate cephalosporins, the alternative is ceftriaxone 500 mg
intramuscularly, daily, for 10 days
• If a patient is not penicillin-allergic but unable to tolerate an
intramuscular regime, the alternative is amoxicillin 500 mg and
probenecid 500 mg, both orally, four times per day, for 14 days
• Erythromycin and azithromycin, have now been removed from the
BASHH guideline.
• For late latent, cardiovascular and gummatous syphilis:
• benzathine penicillin G 2.4 MU intramuscular injection weekly for 3
weeks (three doses)
• 7/10/20 121
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in nonpregnant patients with penicillin
allergy
•:
•doxycycline (Vibramycin), 100 mg orally twice daily for 2
weeks or tetracycline, 500 mg orally four times daily for 2
weeks.
•ceftriaxone (Rocephin), 1 g once daily IM/IV for 10 days
7/10/20 123
Jarisch–Herxheimer reaction
• It complicates up to 45% of syphilis treatments in pregnancy. It is associated with
large numbers of Treponema palladium being killed, which in turn releases excessive
cytokines, initiating an acute inflammatory reaction.
• Symptoms: typically occur within the first 24 hours of treatment and include fever,
rigours and a skin rash, case reports of uterine contractions
• The reaction is particularly common during the management of early syphilis,
occurring in 50% of cases of primary disease and as many as 90% of cases of
secondary syphilis. In comparison, latent disease has a reaction rate of only 25%.
• Symptoms of the Jarisch–Herxheimer reaction are highly variable and generally self-
limiting; therefore, there is no recommended treatment regime, aside from fluids,
supportive care and symptom control. Opioids, paracetamol and hydrocortisone
have been trialled 1–2 hours before and after administration of antibiotics to prevent
or reduce the severity of the reaction; however, the results were not sufficiently
beneficial to be universally recommended.
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Treatment failure
• It is defined as recurrent or persistent symptoms or a sustained fourfold
increase in nontreponemal test titers despite appropriate treatment.
§ Patients with treatment failure should be tested for HIV infection and
evaluated for neurosyphilis with a cerebrospinal fluid (CSF) examination.
§ Follow-up serology is required at at least 3, 6, and 12 months post
treatment to ensure an adequate response.
§
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Granuloma inguinale (also known as donovanosis)
•is a bacterial disease caused by Klebsiella
granulomatis
•Begin as single or multiple nodules (bumps) that
erode through the skin.
•Beefy red soft and bleed easily and leeds to sinus
formation and can be ulcerative genital lesions.
•90% in genital region (groin ulceration, serpiginous
ulceration of the groin)
•Enlarge by autoinoculation
•It is endemic in many less developed regions.
• appear 8-80 days after exposure usually 2-3 weeks
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PML containing Donovan bodies
Donovan bodies are rod-shaped, oval organisms that can be seen in
the cytoplasm of mononuclear phagocytes or histiocytes in tissue samples
from patients with granuloma inguinale7/10/20 127
Treatment
•Recommended regimen is doxycycline 100 mg orally twice a
day
•Alternatively with azithromycin 1 g orally once per week
•or ciprofloxacin 750 mg orally twice a day
•or erythromycin base 500 mg orally four times a day
•or trimethoprim-sulfamethoxazole one double-strength
(160 mg/800 mg) tablet orally twice a day.
•All antibiotic regimens should last for at least 3 weeks and
until all lesions have completely healed.
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MOLLUSCUM CONTAGIOSUM
- caused by a pox virus
- spread by physical contact, sexual
contact or through fomites
- incubation period 3-12 weeks
- they are small (2–5 mm), smooth, pearly,
dome-shaped papules with central
umbilication, and typically a patient will
have between one and 30 lesions, which
may cluster and may koebnerise.
Molluscum can affect any part of the
body
- Umbilicated pearly papules
- Look for clues – “Central depression”
- May be filled with pus like material
- Rx: Liquid Nitrogen
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Vaginal discharge
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Bacterial vaginosis
•Commonest cause of abnormal vaginal discharge in
women of childbearing age
•Trigger overgrowth of mixed (mostly anaerobic) bacteria
replaces ‘normal’ vaginal lactobacilli
• An alkaline pH (> 4.5) favors the growth of the mixed
anaerobes
•Gardnerella vaginalis is a commensal organism in 30–
40% of asymptomatic women.
•Other organisms associated with BV include Prevotella
species, Mycoplasma hominis and Mobiluncus species.
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not classified as an STI.
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Clinical picture
•Not sexually transmitted but more likely to occur in the
sexually active hence the term ‘sexually associated’
•More common in black / smokers / vaginal douching /
bubble baths.
•Symptoms
•Offensive fishy-smelling watery discharge especially after
intercorse
•Not usually associated with soreness or itching
•Signs
•Thin grey / white homogeneous discharge
•No inflammation in the vagina
•Raised vaginal pH: > 4.5 (normal is 3.5 to 4.5)7/10/20 135
BV during pregnancy is associated with an
increased risk of:
• preterm prelabour rupture of membranes
• chorioamnionitis
• amniotic fluid colonisation
• low birthweight infants
• postpartum endometritis.
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There are two ways to diagnose BV
• the Ison / Hay criteria:The microscopic appearance of a Gram-stained
smear of vaginal discharge,
• Grade 1: lactobacilli predominate (this is normal)
• Grade 2: some lactobacilli but other organisms present
(intermediate)
• Grade 3: few / absent lactobacilli – lots of other organisms (this is
BV)
• 2. Amsel’s criteria: 3 out of 4 make the diagnosis...
• Thin white homogenous discharge
• pH of vaginal fluid > 4.5 (normal is 3.5 to 4.5 )
• Release of fishy odour on adding alkali (10% KOH) to drop of
discharge on a microscope slide
• ‘Clue cells’ (vaginal epithelial cells covered in bacteria) seen on
microscopy
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Treatment:
•Regimens includes oral metronidazole (400 mg BD
for 5–7 days, OR 2 g stat dose) or topical
preparations, such as metronidazole 0.75% gel PV
once daily for 5 days, or clindamycin 2% cream PV for
7 days. Alternatively, Tinidazole or Clindamycin can
be used.
•Recurrent or persistent BV can be difficult to
eradicate; treatment with longer-term topical
metronidazole for up to six months (or with a
combination of metronidazole and acigel) can be
tried, but effectiveness is variable.
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M. hominis and U. urealyticum
• Mycoplamsas are small membrane-bound (i.e., they lack a cell wall) free-living
prokaryotes. They are the smallest organisms capable of independent
replication.
• Three types of mycoplasmas have been isolated from female genital mucosal
surfaces:
• Mycoplasma genitalium
• Mycoplasma hominis
• Ureaplasma urealyticum
• M. hominis and U. urealyticum are commonly found in the genital mucosa of
sexually active women, and the level of colonisation increases with the number
of sexual partners.
• M. hominis and U. urealyticum are also found in women with intra-amniotic
infection, postpartum endometriosis and pelvic inflammatory disorders.
• Neonates can be colonised as they pass through the birth canal; however,
infection does not usually persist.
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Diagnosis
•There is little point in testing for mycoplasmas
and ureaplasmas in culture, due to the high
level of colonisation in the general population.
In addition, these microorganisms are rarely
isolated from pure cultures.
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Management of mycoplasma
• M. hominis is susceptible to tetracyclins. (Use clindamycin for
tetracycline-resistant mycoplasmas.)
• U. urealyticum is susceptible to tetracyclins and erythromycins.
• Encourage the use of barrier contraception to prevent infection
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Vulvo-vaginal candidiasis
Cause
•92% cases: Candida albicans
•8% non-albicans sp eg: C glabrata, Saccharomyces
cerevesiae, C.Krusei
Can arise spontaneously or 2º to disturbance of vaginal flora
(e.g. recent antibiotics)
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Candida albicans
• Commensal organism in the mouth, gut or vagina
• Yeast-like fungus, grows by budding and may produce long non-
branching filaments called pseudohyphae. Candida is a polymorphic
yeast, i.e., yeast cells, hyphae and pseudohyphae are produced
• Can stain positive by Gram staining
• Culture - Sabouraud's medium
• Vaginal infection associated with a pH at the low end of normal (3-4)
• Sensitive to polyene antibiotics (nystatin / amphotericin B)
• Sensitive to imidazole derivatives - clotrimazole, econazole,
floconazole, miconazole
• Rarely isolated from the vagina in pre-pubertal or post-menopausal
women
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Candida albicans
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CP
• Symptoms (not all may be present)
• Vulval / vaginal itch / soreness, external dysuria, external
dyspareunia (beware other causes of these Sx, such as dermatoses,
herpes, Trichomonas)
• Vaginal discharge
• Signs (not all may be present)
• Erythema, fissures (diferential diagnosis = herpes), satellite lesions,
excoriation
• Discharge (typically curdy, but may be thin); generally no malodour
Note:
• Recurrent (> 4 symptomatic episodes / year) It will occur in <5% of healthy
women. Candida must be confirmed by culture or microscopy on at least two of
the occasions.
• Non-albicans species (particularly persistent infections)
• Abnormal host factors (immunosuppression, diabetes, increased
oestrogen levels)7/10/20 146
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Treatment:
•Itraconazole 500mg vaginal or
•Flucanazole 150mg PO (avoid during pregnancy)
• Longer courses of topical treatment are recommended for pregnant women
7/10/20 147
For women with recurrent vulvovaginitis
• ≥4 episodes/year
• Suppressive maintenance therapy
• fluconazole 150 mg every 72 hours for three doses, then
maintenance fluconazole 150 mg once per week for six months.
• Women with recurrent infection should try to eliminate or reduce
risk factors for infection.
7/10/20 ELBOHOTY 148
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Trichomonas vaginalis
Trichomonas vaginalis is a flagellated
protozoan. It can be found in the
vagina, urethra, paraurethral glands,
sub preputial sac and penile lesions.
Urethral infection is present in 90% of
cases (though it is the sole site of
infection in only 5% of cases)
It is spread during sexual intercourse
Up to 50% of infected women are
asymptomatic
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STD
7/10/20 150
It can be isolated from the
vagina and urethra in infected
women and the urethra in
infected men. It is not
transmitted through anal or
oral sex.
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Trichomonas vaginalis
•The most common symptoms are vaginal discharge, vulval
itching, dysuria or an offensive odour
•Vaginal discharge is present in 70% of cases – classical
frothy, yellow discharge occurs in approximately 20–30% of
cases, but discharge may be thick or thin, profuse or
scanty, or of varying colours
•There may be vulvitis and vaginitis, which may present as
dyspareunia
•The so-called 'strawberry cervix' with its characteristic
vascular pattern is only present in 2 to 5 % of cases,
although this may be more visible at colposcopy
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Diagnosis
•NAAT testing has high sensitivity for trichomonas and is the
current gold standard for testing, but is not available in all
centres
•Diagnosis can also be made by direct observation of the
organism on a wet smear, in centres where near-patient
microscopy is available, or by culture. Specialised culture
media are required and will be diagnostic in 95% of cases
•Trichomonads may occasionally be seen on cervical smears,
though not all laboratories will report them because of a
significant false-positive rate. It is prudent to confirm the
diagnosis by NAAT testing, direct observation or culture.
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Treatment:
• Metronidazole 400mg 1X2X7 or
• Metronidazole 2 gm stat (not in lactating women)
• During treatment and for at least 48 hours afterwards, alcohol should
not be taken because of the antabuse effect with metronidazole.
• A test of cure is recommended if the patient remains asymptomatic.
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Viruses
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Measles
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A paramyxovirus that causes measles. Usual
presentation involves prodromal fever with cough,
coryza, and conjunctivitis, then eventually Koplik spots
(bright red spots with blue-white center on buccal
mucosa), followed 1–2 days later by a maculopapular
rash that starts at the head/neck and spreads
downward.
Lymphadenitis
Possible sequelae:
•SSPE (subacute sclerosing panencephalitis, occurring
years later)
•Encephalitis (1:2000)
•Giant cell pneumonia (rare except in
•immunosuppressed)
During pregnancy
• an increased risk of maternal morbidity
• a high risk of foetal loss and prematurity
• perinatal infection in the infant, which may be associated with a high mortality
and the risk of subacute sclerosing panencephalitis
• There is no evidence to support an association between measles in pregnancy
and congenital effects.
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7/10/20 157
Paramyxovirus
RNA virus
One antigenic type
Rapidly inactivated by chemical agents, heat, and
ultraviolet light.
Respiratory transmission of virus
Replication in nasopharynx and regional lymph
nodes
Viremia 12-25 days after exposure with spread to
tissues
Multiple tissues infected during viremia
Mumps Clinical Features
• Incubation period 14-18 days
• Communicability Three days before to four days after onset of
active disease
• Nonspecific prodrome of myalgia, malaise, headache, low-grade fever
• Parotitis in 30%-40%
• Up to 20% of infections asymptomatic
• CNS involvement: 15%
• Oophritis: 5% in post- pubertal females
• Orchitis: 20%-50% in post- pubertal males
• Pancreatitis: 2%-5%
• Deafness: 1/20,000
• Mumps infection in pregnant women increases spontaneous fetal loss,
and fetal death. No association has been found between mumps and
congenital anomalies.
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Coronaviruses (CoV)
•They are a large family of viruses that cause
illness ranging from the
•The common cold (HCoV 229E, NL63, OC43
and HKU1)
•Severe Acute Respiratory Syndrome (SARS-
CoV).
•Middle East Respiratory Syndrome (MERS-
CoV)
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•Coronaviruses are zoonotic, meaning they are
transmitted between animals and people.
•Detailed investigations found that
•SARS-CoV was transmitted from civet cats to
humans and
•MERS-CoV from dromedary camels to humans.
•Several known coronaviruses are circulating in
animals that have not yet infected humans.
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Novel coronavirus (SARS-
COV-2)(COVID-19)
• It is a new strain of coronavirus causing COVID-19, first identified in
Wuhan City, China.
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Transmission
•Most cases: human to human transmission.
•Respiratory, fomite or faecal methods.
•Emerging evidence now suggests that vertical
transmission is probable, although the
proportion of pregnancies affected and the
significance to the neonate has yet to be
determined. Two reports have published
evidence of IgM for SARS-COV-2 in neonatal
serum at birth
•There is an estimated incubation period of 0-
14 days (mean 5-6 days)
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Risk factors
•There was also evidence that pregnant women
admitted to hospital with COVID-19 were more likely
to be of black, Asian or other minority ethnicity
(BAME; OR 4.49, 95% CI 3.37–6.00), suggesting that
pregnant women from BAME groups are at
particularly increased risk.
•pregnant women in later stages of pregnancy could
potentially become more seriously unwell.
7/10/20 163
Pregnant women
•They do not appear to be more susceptible to
the consequences of infection with COVID-19
than the general population.
•In other types of coronavirus infection (SARS,
MERS), the risks to the mother appear to
increase in particular during the last trimester
of pregnancy.
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Birth Outcome of pregnant women who were
hospitalised with COVID-19
•the median gestational age at birth was 38 weeks
(IQR 36–39 weeks)
•27% had preterm births
• 47% of these were iatrogenic for maternal compromise
• 15% were iatrogenic for fetal compromise
•10% of term babies required admission to the
neonatal unit
7/10/20 165
Presentation
• Asymptomatic individuals or those with very minor symptoms
• The large majority: experience only mild or moderate cold/flu like
symptoms up to mild pneumonia. 81%
• Severe (dyspnea, hypoxia, or >50% lung involvement on imaging) 14%
• Critical (respiratory failure, shock, or multiorgan system dysfunction)
5%
• are widely described in
• older people
• the immunosuppressed and those with long-term conditions such as
diabetes, cancer and chronic lung disease.
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Effect on the fetus
•No data suggesting an increased risk of miscarriage
or early pregnancy loss
•Iatrogenic delivery was predominantly for maternal
indications related to the viral infection.
•Until now no reported FGR however Two thirds of
pregnancies with SARS were affected by FGR
•Intrapartum fetal distress is more common
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Travel
•Advice about travel safety that is regularly updated in line
with the evolving situation.
•Ensure adequate insurance arrangements prior to travel with
coverage for birth and care of a newborn baby if they give
birth while abroad.
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Pregnant women who may have been exposed or are
experiencing symptoms suggestive of COVID-19
•Women returning from areas of the world which indicate a
possible increased risk for coronavirus transmission or who
have been in contact with a known case of COVID-19 should
phone NHS 111 or, if in Scotland, NHS 24 (on 111) or their
GP.
•Diagnostic swabs will be arranged if indicated, following
advice from local Health Protection.
•Women with symptoms suggestive of COVID-19 should be
advised to self-isolate until advised otherwise.
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Viral testing
• Diagnosis of COVID-19 requires detection of SARS-CoV-2 RNA by reverse
transcription polymerase chain reaction (RT-PCR). Detection of SARS-CoV-2 viral
RNA is better in nasopharynx samples compared to throat samples.
• Lower respiratory samples may have better yield than upper respiratory samples.
• SARS-CoV-2 RNA has also been detected in stool and blood.
• Detection of SARS-CoV-2 RNA in blood may be a marker of severe illness.
• Viral RNA shedding may persist over longer periods among older persons and
those who had severe illness requiring hospitalization. (median range of viral
shedding among hospitalized patients 12–20 days).
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Laboratory Findings
• Lymphopenia is the most common lab finding in COVID-19 and is
found in as many as 83% of hospitalized patients.
• Lymphopenia, neutrophilia, elevated serum alanine aminotransferase
and aspartate aminotransferase levels, elevated lactate
dehydrogenase, high CRP, and high ferritin levels may be associated
with greater illness severity.
• Elevated D-dimer and lymphopenia have been associated with
mortality.
• Procalcitonin is typically normal on admission, but may increase
among those admitted to the ICU.
• Patients with critical illness had high plasma levels of inflammatory
makers, suggesting potential immune dysregulation.
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Radiographic Findings
•Chest radiographs of patients with COVID-19
typically demonstrate bilateral air-space
consolidation, though patients may have
unremarkable chest radiographs early in the disease.
•Chest CT images from patients with COVID-19
typically demonstrate bilateral, peripheral ground
glass opacities.
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Laboratory abnormalities associated coagulopathy
include:
•Mild thrombocytopenia
•Increased D-dimer levels
•Increased fibrin degradation products
•Prolonged prothrombin time
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Thrombotic complications
•Microvascular thrombosis of the toes
•Clotting of catheters
•Myocardial injury with ST-segment elevation
•Large vessel strokes
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For women who are advised to self-isolate, the guidance
currently recommends to:
• Stay at home and not allow visitors
• Ventilate the rooms where they are by opening a window
• Separate themselves from other members of their household as far as
possible, using their own towels, crockery and utensils and eating at
different times
• Use friends, family or delivery services to run errands, but advise them
to leave items outside
• Pregnant women who are due to attend routine maternity
appointments in the UK should contact their maternity care provider,
to inform them that they are currently in self-isolation for
possible/confirmed COVID-19, and request advice on attendance.
• Routine appointments (growth scans, OGTT, antenatal community or
secondary care appointments) should be delayed until after the
recommended period of isolation.
• Pregnant women are advised not to attend maternity triage units or A&E unless
in need of urgent obstetric or medical care after calling the maternity triage unit.
• Arrange to travel by private transport and alert the maternity triage reception
once on the premises, prior to entering the hospital. 1757/10/20
Continuing the pregnancy after confirmed infection
•Further antenatal care should be arranged 14 days
after the period of acute illness ends.
•Referral to antenatal ultrasound services for fetal
growth surveillance is recommended, 14 days
following resolution of acute illness.
•Although there isn’t yet evidence that fetal growth
restriction (FGR) is a risk of COVID-19, two thirds of
pregnancies with SARS were affected by FGR and a
placental abruption occurred in a MERS case, so
ultrasound follow-up seems prudent
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Staff and facility
• Staff providing care should take personal protective equipment (PPE)
• The face mask should not be removed until the woman is isolated in a
suitable room.
• All staff (including maternity, neonatal and domestic) should have been
trained in the use of PPE so that 24 hour emergency theatre use is
available and possible delays reduced
• Women should immediately be escorted to an isolation room, suitable
for the majority of care during their hospital visit or stay
• Rooms should have negative pressure in comparison to the
surrounding area, if available
• Only essential staff should enter the room and visitors should be kept
to a minimum
• Remove non-essential items from the clinic/scan room prior to
consultation
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Assess COVID-19 risk in maternity unit attendees
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Management
•There are no drugs or other therapeutics presently approved
by the U.S. Food and Drug Administration (FDA) to prevent
or treat COVID-19.
•Current clinical management includes infection prevention
and control measures and supportive care, including
supplemental oxygen and mechanical ventilatory support
when indicated.
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Place of birth:
•Women with mild COVID-19 symptoms can be encouraged
to remain at home (self-isolating) in early (latent phase)
labour as per standard practice.
•If birth at home or in a midwifery-led unit is planned, there
is potentially increased risk of fetal compromise in women
infected with COVID-19
•An obstetric unit for birth, where the baby can be monitored
using continuous electronic fetal monitoring.
•The use of birthing pools in hospital should be avoided
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Intrapartum care for women with suspected/confirmed
COVID-19:
• Assessment: multi-disciplinary team approach including an infectious diseases
or medical specialist with consultant obstetrician, consultant anaesthetist,
midwife-in-charge, consultant neonatologist and neonatal nurse in charge
• Confirmation of the onset of labour, as per standard care
• Maternal observations: temperature, respiratory rate and oxygen saturations
(Aim to keep oxygen saturation >94%, titrating oxygen therapy accordingly)
• Fetal monitoring: Continuous electronic fetal monitoring in labour is currently
recommended for all women with COVID-19 as there is more risk for intrapartum
fetal compromise.
• 2nd Stage: An individualised decision should be made regarding shortening the
length of the second stage of labour with elective instrumental birth in a
symptomatic woman who is becoming exhausted or hypoxic
• 3rd stage: Delayed cord clamping is still recommended following birth, provided
there are no other contraindications.
• The baby can be cleaned and dried as normal, while the cord is still intact.
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Mode of birth and intrapartum analgesia
•Mode of birth: should not be influenced by the presence of
COVID-19, unless the woman’s respiratory condition
demands urgent delivery.
•Epidural analgesia: should therefore be recommended early
in labour, to women with suspected/confirmed COVID-19
•Entonox should be used with a single-patient microbiological
filter. This is standard issue throughout maternity units in
the UK.
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Obstetric theatre
•Elective procedures should be scheduled at the end
of the operating list
•Non-elective procedures should be carried out in a
second obstetric theatre, where available, allowing
time for a full post-operative theatre clean
•For Category 1 CS: donning protective personal
equipment is time consuming. This may impact on
the decision to delivery interval but it must be done.
•The number of staff in the operating theatre should
be kept to a minimum, all of whom must wear
appropriate PPE7/10/20 183
Elective caesarean birth
• Obstetric management should be according to usual practice.
• Anaesthetic management for symptomatic women should be to:
• Provide epidural or spinal anaesthesia as required and to avoid general
anaesthesia unless absolutely necessary
• If general anaesthesia is needed, either for pre-existent reasons the advice is as
follows:
• an intubation checklist must be used
• Rapid sequence induction as per usual practice ensuring tight seal during pre-
oxygenation so as to avoid aerosolisation
• Videolaryngoscopy by most experienced anaesthetist available
• In case of difficult intubation, plan B/C is to use a supraglottic airway, plan C is
to use FONA scalpel-bougie-tube
• The anaesthetist performing intubation should therefore consider wearing a
second pair of gloves for the procedure, and remove once the ET tube is
secured
• Determine position of tube without using auscultation – chest wall expansion
R=L, end Tidal CO2
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Additional considerations for women with
moderate/severe symptoms
•A multi-disciplinary discussion planning meeting
•Most appropriate location of care (e.g. intensive care unit,
isolation room in infectious disease ward or other suitable
isolation room) and lead specialty.
•Given the association of COVID-19 with acute respiratory
distress syndrome, women with moderate-severe symptoms
of COVID-19 should be monitored using hourly fluid input-
output charts, and efforts targeted towards achieving
neutral fluid balance in labour, in order to avoid the risk of
fluid overload.
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Breastfeeding:
• All babies born to COVID-19 positive mothers should have appropriate
close monitoring and early involvement of neonatal care, where
necessary. They will need neonatal follow-up and ongoing surveillance
after discharge.
• The risks and benefits of breastfeeding, including the risk of holding
the baby in close proximity to the mother, should be discussed with
her.
• For women wishing to breastfeed, precautions should be taken to
limit viral spread to the baby:
• Hand washing before touching the baby, breast pump or bottles
• Avoiding coughing or sneezing on the baby while feeding at the
breast
• Considering wearing a face mask while breastfeeding, if available
• Following recommendations for pump cleaning after each use
• Considering asking someone who is well to feed expressed milk to
the baby
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Potential needed interventions:
•Radiographic investigations should be performed as for the
non-pregnant adult; this includes chest X-ray and CT of the
chest. Reasonable efforts to protect the fetus from
radioactive exposure should be made, as per usual
protocols.
•There is no evidence to suggest that steroids for fetal lung
maturation, when they would usually be offered, cause any
harm in the context of COVID-19. Steroids should therefore
be given where indicated. As is always the case, urgent
delivery should not be delayed for their administration.
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Pregnant healthcare professionals at the time of
corona pandemic
• Pregnant women of any gestation should be offered the choice of
whether to work in direct patient-facing roles during the coronavirus
pandemic.
• Women who are less than 28 weeks pregnant should practise social
distancing but can choose to continue working in a patient-facing
role, provided the necessary precautions are taken.
• Women who are more than 28 weeks pregnant, or have underlying
health conditions, should avoid direct patient contact and it is
recommended that they stay at home.
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Women who are preparing for infertility
treatment:
•In view of the unknown effects of Covid-19 on embryos and
pregnancy, and in the midst of a public health emergency, no
new fertility treatment cycles should be started at the
moment.
•no new ovulation induction, IUI, fresh IVF or Frozen Embryo
Transfer (FET) cycles can be started until further notice.
•For who are under treatment: ASRM and ESHRE advice we strongly
suggest that, in a fresh IVF cycle, all embryos are frozen rather than transferred
fresh.
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Viral Hepatitis
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Hepatitis CHepatitis BHepatitis A
RNADNARNAVirus type
30-60 nm42 nm27 nmVirus size
4-20 weeks6 weeks to 6 months15–45 days (average
28 days).
Incubation
period
50-65%10%NoPersistent
infection
Parentral
Sexual
Parentral or body fluid
Sexual
Fecal – oral
MSM
Transmission
5%Up to 90 % in + Hepatitis
e Antigen
Less than 10% if –ve
Not observedVertical
transmission to
fetus
Anti Hepatitis C Ab
& PCR
Infection: HBs Ag
High infectivity:HBe Ag
& PCR
Previous infection or
immune:Anti HBs IgG
AB
Anti Hepatitis A IgM
types
Serologic
diagnosis
50 – 85%5 – 10%NoneCarrier state
Asymptomatic to sever
relapsing
Asymptomatic to
fulminant
Asymptomatic to
fulminant
Acute clinical
forms
Chronic persistent hepatitis
Chronic active hepatitis
Cirrhosis
Chronic persistent
hepatitis
Chronic active hepatitis
Cirrhosis
NoneChronic clinical
forms
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acute hepatitis A:
• Hepatitis A is a picorna (RNA) virus.
• It is particularly common in areas of the world where sanitation is poor
(developing countries), where it mainly affects children. In the developed world,
it is less common
• Transmission
• Faeco-oral (via food, water, close personal contact).
• Outbreaks have been reported in MSM, linked to oro-anal or digital-rectal contact,
multiple sexual partners, anonymous partners, sex in public places and group sex.
• Patients are infectious for approximately two weeks before and one week after
the period of jaundice by the non-parenteral routes but virus can be found in
blood and stool until after the serum aminotransferase levels have peaked.
• In HIV-positive patients, HAV viraemia may continue for over 90 day
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CP
•The prodromal illness: flu-like symptoms
(malaise, myalgia, fatigue), often with right
upper abdominal pain. This phase lasts for 3–
10 days and is followed by
•. The icteric illness: jaundice (mixed hepatic
and cholestatic) associated with anorexia,
nausea and fatigue which usually lasts for 1–3
weeks. It can persist for 12 or more weeks in a
minority of patients who have cholestatic
symptoms (itching and deep jaundice).
•Fever is rare in this phase.7/10/20 193
Complications
• ALF complicates approximately 0.4% of cases, although 15% of patients with
acute infection may require hospital care, of whom a quarter will have severe
hepatitis (prothrombin time P.T. >3 s prolonged or bilirubin >170
mmoles/l).26,27 ALF due to hepatitis A is more common in patients already
infected with chronic hepatitis B or C, although studies differ widely in
measured rates.26,28
• Chronic infection (>6 months) has only been reported in a small number of
case-reports.
• The overall mortality is <0.1%, although rises to 40% in those with ALF.
Patients with ALF should be considered for liver transplantation.26,27
• Pregnancy – The infection does not have any teratogenic effects, but there is
an increased rate of miscarriage and premature labour, proportional to the
severity of the illness.
• There have been case reports of possible vertical transmission
• The risk from breast feeding is uncertain. Therefore, the balance of risks
between infection and stopping breast feeding should be considered on an
individual basis
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Serology
•Confirmed by a positive serum Hepatitis A virus – specific
IgM (HAV-IgM) which usually remains positive for 45–60
days, although can be positive for six months or more.
•HAV-IgG does not distinguish between current or past
infection and may remain positive for life
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contact of a patient with acute hepatitis A
•Screen for evidence of HAV infection or immunity
•HNIG 250–500 mg intramuscularly should also be considered
in addition to the vaccine for patients at higher risk of
complications (concurrent chronic hepatitis B or C, chronic
liver disease, HIVþ or age >50-year old)
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HBV is a double-stranded DNA virus in the Hepadnaviridae family that primarily
affects the liver.
The virus consists of an outer lipid envelope, and a protein core that encapsulates a
small partially double stranded genome and HBV DNA polymerase.
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• The average incubation period is 90 days from time of
exposure to the onset of symptoms, but may vary
from 6 weeks to 6 months
• In infected persons HBV is found in highest
concentrations in the blood, and lower concentrations
in saliva, semen, vaginal secretions, and wound
exudates.
• Acutely infected individuals develop clinically
apparent hepatitis with loss of appetite, nausea,
vomiting, fever, abdominal pain and jaundice.
• Some may have dark urine and gray stool.
• About one half of acute HBV infections in adults are
symptomatic .
• About 1% cases result in acute liver failure and death
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Chronic infection
•Chronic infection (>6 months) occurs in 5–10% of
symptomatic cases, but the rate is higher in
immunocompromised patients with HIV infection, chronic
renal failure or those receiving immunosuppressive drugs.
•Profound immunosuppression, for example in advanced HIV
infection or in patients taking immunosuppressive treatment
can also reactivate hepatitis B
•Almost all (>90%) of infants born to infectious (HBeAg +ve)
mothers will become chronic carriers unless immunised
immediately at birth
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Approximately 25% of the regular sexual
contacts of infected individuals will
themselves become seropositive.
In patients with acute hepatitis B vertical
transmission occurs in up to 10% of
neonates when infection occurs in the first
trimester and in 80 -90% of neonates when
acute infection occurs in the third trimester.
In women who are seropositive for both
HBsAg and HBeAg vertical transmission is
approximately 90%.
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Pregnancy and breast feeding
• In the absence of intervention, vertical transmission occurs in 90% of
pregnancies where the mother is hepatitis B e-antigen positive and in
about 10% of surface antigen positive, e antigen-negative mothers.
• Most (>90%) infected infants become chronic carriers.
• Infants born to infectious mothers are vaccinated from birth.
• Hepatitis B specific Immunoglobulin 200 IU IM is also given in certain
situations where the mother is highly infectious. This reduces vertical
transmission by 90%.
• Consider tenofovir monotherapy for pregnant women with HBV DNA
>107 IU/ml in the third trimester to reduce the risk of transmission of
HBV to the baby
• Hepatitis B activity may increase immediately following pregnancy but
is seldom associated with clinical consequences.
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Screening
•Hepatitis B testing in asymptomatic patients should be
recommended in MSM, sex workers (of either sex), people
who inject drugs (PWID), HIV-positive patients, sexual
assault victims, people from countries where hepatitis B is
endemic (outside of Western Europe, North America and
Australasia), needle stick victims and sexual partners of
positive.
•The screening tests of choice are anti-HB core anti- body
and/or the hepatitis B surface antigen (HBsAg) test with
further serology to assess the stage of infection and
infectivity as appropriate.
•Measure anti-HBs in those who have been vaccinated
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asymptomatic patient is not immune to hepatitis B?
•In at-risk patients, consider vaccination with the
monovalent hepatitis B vaccine or the combined
hepatitis A and B vaccine if non-immune to both.
The ultra-rapid vaccination schedule (0, 1, 3 weeks) leads to
an anti-HBs antibody response in only 80% of recipients 4–
12 weeks after the third dose.
•This rises to 95% just prior to the 12-month booster dose.
Consider offering booster vaccinations of up to three further
doses to the 20% without detectable antibodies 4–12 weeks
after the primary course.
•Protection provided by monovalent vaccination is believed
to persist for >20 years once immunity has been confirmed
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•Hepatitis B should be notified to the public health
authorities
•Patients should be advised to avoid unprotected sexual
intercourse, including oro-anal and oro-genital contact until
they have become non- infectious (HBsAg negative) or their
partners have been successfully vaccinated
•Partner notification should be performed and documented
and the outcome documented at subsequent follow-up.
Contact tracing to include any sexual contact (penetrative
vaginal or anal sex or oro/anal sex) or needle sharing
partners during the period in which the index case is thought
to have been infectious.
•The infectious period is from two weeks before the onset of
jaundice until the patient becomes surface antigen negative
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•Arrange referral to a hepatologist or other suitable
specialist for disease monitoring, liver cancer
screening and possible therapy
•Arrange screening for hepatitis C, hepatitis D and
hepatitis A immunity (Vaccinate against hepatitis A if
non-immune)
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Post exposure prophylaxis
• Specific hepatitis B immunoglobulin 500 IU intra- muscularly (HBIG)
may be administered to a non- immune contact after a single
unprotected sexual exposure or parenteral exposure/needlestick injury
if the donor is known to be infectious. This works best within 12 h,
ideally should be given within 48 h and is of no use after more than
seven days
• An accelerated course of hepatitis B vaccine (at 0, 1, 3 weeks or 0, 1, 2
months with a booster at 12 months in either course) should be
offered to all non-immune sexual and household contacts, including to
those given HBIG. Vaccination theoretically will provide some
protection from disease when started up to six weeks after exposure
• Contacts who have previously been vaccinated and achieved immunity
can have a single booster dose, with no HBIG
• Avoid sexual contact, especially unprotected penetrative sex, until
vaccination as been successful (anti-HBs titres >10I.U./l.)
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Hepatitis C
• Hepatitis C is a RNA virus in the flaviviridae family. It is endemic worldwide with
an estimated 185 million individuals infected and with prevalence rates varying
from 1% in Europe to as high as 4% in North Africa/
• Recent national estimates suggest approximately 215,000 individuals are
chronically infected with HCV in the UK. Most (90%) is due to infection with
genotypes 1 and 3
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Testing
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