Professor Obstetrics and Gynecology at Aboubakr Mohamed Elnashar
Oct. 16, 2019

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  1. STD DURING PREGNANCY Prof. Aboubakr Elnashar Benha university Hospital, Egypt ABOUBAKR ELNASHAR
  2.  Bacterial 1. Gonococcal Infections 2. Syphilis  Viral: 1. Genital Herpes Simplex 2. Human Papillomavirus 3. HBV 4. HIV  Others 1. Chlamydial Infections 2. Trichomoniasis 3. Candida 4. Pediculosis Pubis 5. Scabies ABOUBAKR ELNASHAR
  3. RISK FACTORS FOR STIS 1. Multiple partners (two or more in the last year). 2. Recent partner change (in past 3mths). 3. Non-use of barrier protection. 4. STI in partner. 5. Other STI. 6. Younger age (particularly aged ≤ 25yrs). ABOUBAKR ELNASHAR
  4. HISTORY • Symptoms:  lumps, bumps, ulcers, rash  itching, IMB or PCB  Low abdominal pain, dyspareunia  sudden/distinct change in discharge. ABOUBAKR ELNASHAR
  5. • Past history of STIs/GUM clinic attendance/last HIV –ve test. • All sexual partners in past 12mths. • Risk factors for blood-borne viruses: • patient or partner from area of high HIV prevalence • IV drug use ABOUBAKR ELNASHAR
  6. TESTING FOR SEXUALLY TRANSMITTED INFECTIONS—INCUBATION PERIOD • Tests should be done at the time of presentation. • Incubation period  before tests for STIs become positive can give false negative after a single episode of sex.  for bacterial STIs this is 10–14 days  for HIV and syphilis it may be up to 3mths. ABOUBAKR ELNASHAR
  7. 1. GONORRHOEA Epidemiology • Neisseria gonorrhoeae: intracellular Gram –ve diplococcus. • Fourth most common STI in the UK. • > 35% of strains are resistant to ciprofloxacin 70% to tetracyclines. ABOUBAKR ELNASHAR
  9. Symptoms  Usually asymptomatic,  often diagnosed when screening on contact tracing  Can present with  vaginal discharge,  low abdominal pain,  IMB or PCB. ABOUBAKR ELNASHAR
  11. Diagnosis  Endocervical or vulvovaginal swab with NAAT.  Urethral, pharyngeal, and rectal swabs if contact with gonorrhoea.  If diagnosed on NAAT, culture for sensitivity testing should be taken from all sites prior to antibiotic treatment. ABOUBAKR ELNASHAR
  12. A nucleic acid test (NAT) or nucleic acid amplification test (NAAT)  a technique utilized to detect a particular nucleic acid, virus, or bacteria which acts as a pathogen in blood. tissue, urine, etc.  The NAT system differs from other tests in that it detects genetic materials rather than antigens or antibodies.  Detection of genetic materials allows 1. an early diagnosis of a disease because the detection of antigens requires time for antigens to appear in the bloodstream 2. Since the amount of a certain genetic material is usually very small, NAT includes an amplification step of the genetic material.  There are several ways of amplification including polymerase chain reaction (PCR), strand displacement assay (SDA), or transcription mediated assay (TMA).[ ABOUBAKR ELNASHAR
  13. Complications of gonococcus infection • PID (~10% of infections result in PID). • Bartholin’s or Skene’s abscess. • Disseminated gonorrhoea may cause: • fever • pustular rash • migratory polyarthralgia • septic arthritis. • Tubal infertility. • Risk of ectopic pregnancy. ABOUBAKR ELNASHAR
  14. Treatment • Ceftriaxone 500mg IM stat, plus azithromycin 1g PO stat. • Spectinomycin 2g IM, plus azithromycin 1g PO stat (if severe penicillin allergy). • Contact tracing and treatment of partners. • The same antibiotics are recommended for treating gonorrhoea in pregnancy. ABOUBAKR ELNASHAR
  15. Implications in pregnancy • Gonorrhoea associated with: • preterm rupture of membranes and premature delivery • chorioamnionitis. • The risks to the baby are of ophthalmia neonatarum (40–50%). ABOUBAKR ELNASHAR
  16. 2. SYPHILIS Epidemiology • Treponema pallidum —spirochaete. • Relatively rare STI in the UK; however, a 12-fold rise 1997–2007. • Doubling of congenital syphilis from 1999–2007. • Nearly 3000 cases were diagnosed in 2010 in the UK. ABOUBAKR ELNASHAR
  17. Symptoms Primary syphilis • 10–90 days postinfection. • Painless, genital ulcer (chancre)—may pass unnoticed on the cervix. • Inguinal lymphadenopathy. ABOUBAKR ELNASHAR
  18. Secondary syphilis • Occurs within the first 2yrs of infection. • Generalized polymorphic rash affecting palms and soles. • Generalized lymphadenopathy. • Genital condyloma lata. • Anterior uveitis. ABOUBAKR ELNASHAR
  19. Tertiary syphilis • P resents in up to 40% of people infected for at least 2yrs, but may take 40+yrs to develop. • Neurosyphilis: tabes dorsalis and dementia. • Cardiovascular syphilis: commonly affecting the aortic root. • Gummata: infl ammatory plaques or nodules. ABOUBAKR ELNASHAR
  20. Diagnosis • Specific treponemal enzyme immunoassay (EIA) for screening (IgG + IgM). • 1 ° lesion smear may show spirochaetes on dark field microscopy. • Quantitative cardiolipin (non-treponemal) tests, i.e. rapid plasma reagin (RPR)/VDRL are useful in assessing need for and response to treatment. ABOUBAKR ELNASHAR
  21. Treatment • Depends on penicillin allergy: • benzathine benzylpenicillin 2.4 MU single dose IM (used in pregnancy) • doxycycline 100mg bd PO for 14 days (contraindicated in pregnancy), • erythromycin 500mg qds PO for 14 days (used in pregnancy). • Treatment courses are longer in tertiary syphilis. • Contact tracing (potentially over several years). ABOUBAKR ELNASHAR
  22. Implications in pregnancy • Preterm delivery. • Stillbirth. • Congenital syphilis. • Miscarriage ABOUBAKR ELNASHAR
  23. 1. HERPES SIMPLEX Epidemiology • DNA virus—herpes simplex type 1 (orolabial/genital) and type 2 (genital only). • Third most common STI in England in 2010. ABOUBAKR ELNASHAR
  24. Symptoms  Primary HSV infection  usually the most severe  often results in: • Prodrome (tingling/itching of skin in affected area). • Flu-like illness +/– inguinal lymphadenopathy. • Vulvitis and pain (may cause urinary retention). • Small, characteristic vesicles on the vulva can be atypical with fissures, erosions, erythema of skin.ABOUBAKR ELNASHAR
  27.  Recurrent attacks  result from reactivation of latent virus in the sacral ganglia  normally shorter and less severe.  can be triggered by: • Stress. • Sexual intercourse. • Menstruation. ABOUBAKR ELNASHAR
  28. Complications of HSV infection (usually of primary infection) • Meningitis. • Sacral radiculopathy: urinary retention and constipation. • Transverse myelitis. • Disseminated infection. ABOUBAKR ELNASHAR
  29. Diagnosis • Usually from appearance of the typical rash. • PCR testing of vesicular fluid (most sensitive—gold standard). • Culture of vesicular fluid. • Serum antibody tests of no use for diagnosing primary herpes. ABOUBAKR ELNASHAR
  31. Maternal risks In pregnancy a primary attack may be severe. Complications include: • Meningitis. • Sacral radiculopathy: urinary retention and constipation. • Transverse myelitis. • Disseminated infection. ABOUBAKR ELNASHAR
  32. Fetal risks Primary infection miscarriage or preterm labour no related congenital defects. ABOUBAKR ELNASHAR
  33. Neonatal risks  Transmission rate from vaginal delivery  during primary maternal infection may be as high as 50%,  during recurrent attack (<5%) relatively uncommon  Neonatal herpes appears during first 2wks of life. • 25% limited to eyes and mouth only. • 75% widely disseminated, of which:  70% will die  many of the survivors will have long-term problems including mental retardation. ABOUBAKR ELNASHAR
  34. Treatment • No cure for genital herpes. • Symptomatic relief with • simple analgesia, • saline bathing, and • topical anaesthetic. • Oral aciclovir  200mg 5x day for 5 days or similar  double dose/length if immunosuppressed.  Topical aciclovir is not beneficial. ABOUBAKR ELNASHAR
  35.  Aciclovir  decrease severity and duration of the primary attack if given within 5 days of onset of symptoms.  If labour is within 6w of primary infection: CS provided the membranes have not been ruptured for >4h.  With active vesicles from a recurrent attack, the risk of surgery must be carefully weighed against the very small risk of neonatal infection. ABOUBAKR ELNASHAR
  36. • Condoms/abstinence whilst prodromal/symptomatic (unless history of HSV in both partners) may reduce transmission rates. • Suppressive antiviral treatment if >6 recurrences/year. ABOUBAKR ELNASHAR
  37. 2. HUMAN PAPILLOMAVIRUS Epidemiology • DNA virus, many subtypes. • Subtypes 6 and 11:genital warts (condylomata acuminata). • Subtypes 16 and 18: CIN and cervical neoplasia. • Commonest viral STI in England. • 25% of people presenting with warts have other concurrent STIs. ABOUBAKR ELNASHAR
  38. Symptoms  Majority asymptomatic.  Painless lumps anywhere in the genitoanal area.  Perianal warts are common in the absence of anal intercourse. ABOUBAKR ELNASHAR
  39. Dome shaped lesion on keratinized skin above clitoris ABOUBAKR ELNASHAR
  40. A filamentous genital wart is present in the urethra Cauliflower-like condyloma acuminata are seen on the perineum, adjacent posterior fourchette, and right lower labia majora. ABOUBAKR ELNASHAR
  41. Perianal condyloma acuminata are present, but their morphology is smoother. Keratinized flat warts are present in the junction between the introitus and the perineum. Keratin produces the strikingly white appearance. ABOUBAKR ELNASHAR
  43. Micropapillations are normal single- filament projections on the inner labia minora that can often be confused with genital warts. The single filament of each projection differentiates this normal finding from HPV induced genital warts. ABOUBAKR ELNASHAR
  44. Diagnosis  Usually identified by clinical appearance.  Non-wart HPV infection often diagnosed by  characteristic appearance on cervical cytology or  colposcopy (whitening on topical application of acetic acid). ABOUBAKR ELNASHAR
  46. Complications  HPV 16 and 18 associated with high-grade CIN and cervical neoplasia.  Smoking and immunosuppression both affect viral clearance thereby increasing the risk. ABOUBAKR ELNASHAR
  47. Treatment for genital warts  Removal of the visible wart.  High rate of recurrence due to the latent virus in the surrounding epithelial cells. 1. Clinic treatment • Cryotherapy. • Trichloroacetic acid. • Electrosurgery/scissors excision/curettage/laser. ABOUBAKR ELNASHAR
  48. 2. Home treatment  both contraindicated if pregnancy risk  Podophyllotoxin cream or solution:  this is self-applied  must be used for about 4–6wks. • Imiquimod cream: a self-applied immune response modifier. It may need to be used for up to 16wks. ABOUBAKR ELNASHAR
  49. Management of Sex Partners  Persons should inform current partner(s) about having genital warts because the types of HPV that cause warts can be passed on to partners.  Partners should receive counseling messages that partners might already have HPV despite no visible signs of warts, so HPV testing of sex partners of persons with genital warts is not recommended.  Partner(s) might benefit from a physical examination to detect genital warts and tests for other STDs.  No recommendations can be made regarding informing future sex partners about a diagnosis of genital warts because the duration of viral persistence after warts have resolved is unknown. ABOUBAKR ELNASHAR
  50. Implications in pregnancy  Genital warts tend to grow rapidly in pregnancy  usually regress after delivery.  Very rarely, babies exposed perinatally may develop laryngeal or genital warts.  Not an indication for CS.  CS is indicated for  women with anogenital warts if the pelvic outlet is obstructed or  vag delivery would result in excessive bleeding. ABOUBAKR ELNASHAR
  51. Routine vaccination  From 2008 the DH has recommended HPV vaccination for all girls aged 12–13.  Initially the selected vaccine was active against HPV 16 and 18  in 2012 was changed to include HPV 6 and 11 as well. ABOUBAKR ELNASHAR
  52. 3. HBV  Sexual transmision Primary mode of transmission in US by saliva, vaginal secretions, and semen.  Hepatitis B transmitted by direct contact with  blood  semen, vaginal fluids and other body fluids. So It is STD Fortunately there HBV vaccine (Bacq & Lee, UpToDate, 2015) ABOUBAKR ELNASHAR
  53.  Sex partners of HBsAg-positive persons CDC2015 use methods condoms to protect themselves from sexual exposure to infectious body fluids (e.g., semen and vaginal secretions) unless they have been demonstrated to be  immune after vaccination (anti-HBs >10 mIU/mL) or previously infected (anti-HBc positive). ABOUBAKR ELNASHAR
  54. 1. CHLAMYDIA Epidemiology • Chlamydia trachomatis: obligate intracellular parasite. • Commonest bacterial STI in the UK. • An important cause of tubal infertility. Symptoms  Dysuria  vaginal discharge, or  irregular bleeding (IMB or PCB)  70% of cases are asymptomatic. ABOUBAKR ELNASHAR
  55. Complications of Chlamydia infection • Pelvic inflammatory disease (10–40% of infections result in PID). • Perihepatitis (Fitz–Hugh–Curtis syndrome). • Reiter’s syndrome (more common in men): • arthritis • urethritis • conjunctivitis. • Tubal infertility. • Risk of ectopic pregnancy.ABOUBAKR ELNASHAR
  56. Diagnosis  Vulvovaginal (which can be self-taken) or  endocervical swab for nucleic acid amplification test (NAAT).  Requires specific medium. ABOUBAKR ELNASHAR
  58. Treatment • Azithromycin 1g single dose doxycycline 100 mg bd for 7 days—not in pregnancy both have similar efficacy of >95%. • Contact tracing and treatment of partners. ABOUBAKR ELNASHAR
  60. Implications in pregnancy  Association with preterm rupture of membranes and premature delivery.  The risks to the baby are of: • Neonatal conjunctivitis (30% within the first 2wks). • Neonatal pneumonia (15% within the first 4mths).  Treat pregnant woman with  erythromycin 500mg bd for 10–14 days  73–95% effective ABOUBAKR ELNASHAR
  61. 2. Trichomonas Epidemiology • Trichomonas vaginalis — flagellated protozoan. • Found in vaginal, urethral para-urethral glands. ABOUBAKR ELNASHAR
  62. Symptoms  Asymptomatic in 10–50%  may present with: • Frothy, greenish, offensive smelling vaginal discharge. • Vulval itching and soreness. • Dysuria. ABOUBAKR ELNASHAR
  64. Diagnosis  Cervix  may have a ‘strawberry’ appearance from punctate haemorrhages (2%).  wet smear: Direct observation of the organism by normal saline  acridine orange stained slide from the posterior vaginal fornix (sensitivity 40–70% cases).  Culture media diagnose up to 80% cases.  NAATs sensitivities and specificities approaching 100% ABOUBAKR ELNASHAR
  66. Saline wet mount of vaginal secretions in trichomonal vaginitis, showing two T. vaginalis (arrows), leukocytes and a normal vaginal epithelial cell McGraw-Hill ABOUBAKR ELNASHAR
  68. Pap smear: 70% sensitive in showing TV. Wet mount: TV ABOUBAKR ELNASHAR
  69. Purulent Vaginal Discharge in Trichomo Vaginitis McGraw-Hill ABOUBAKR ELNASHAR
  73. Complications may enhance HIV transmission. Treatment • Metronidazole: 2g orally in a single dose. • Metronidazole: 400–500mg bd for 5–7 days. • Partner:  Contact tracing and treatment  advised to abstain from intercourse until they and their sex partners have been adequately treated and any symptoms have resolved. ABOUBAKR ELNASHAR
  74. Implications in pregnancy • Trichomonas is associated with: • preterm delivery • low birth weight. • Trichomonas may be acquired perinatally, occurring in 5% of babies born to infected mothers. ABOUBAKR ELNASHAR
  75. 3. Candidiasis (thrush) Epidemiology • Yeast-like fungus 90% Candida albicans, remainder other species, e.g. C. glabrata  75% of women will experience at least one episode  10–20% are asymptomatic chronic carriers (increasing to 40% during pregnancy). ABOUBAKR ELNASHAR
  76. • Predisposing factors those that alter the vaginal micro-flora and include: • immunosuppression • antibiotics • pregnancy • diabetes mellitus • anaemia. ABOUBAKR ELNASHAR
  77. Symptoms  May be asymptomatic  usually presents with: • Vulval itching and soreness. • Thick, curd-like, white vaginal discharge. • Dysuria. • Superficial dyspareunia. ABOUBAKR ELNASHAR
  79. Diagnosis • Characteristic appearance of: • vulval and vaginal erythema • vulval fissuring • typical white plaques adherent to the vaginal wall. • Culture from HVS or LVS. • Microscopic detection of spores and pseudohyphae on wet slides. ABOUBAKR ELNASHAR
  83. Complications Unlikely to cause any significant complications unless the woman is severely immunocompromised. ABOUBAKR ELNASHAR
  84. Treatment • As so many women are chronic carriers, candidiasis should only be treated if it is symptomatic. • Clotrimazole 500mg pessary +/– clotrimazole cream; or • Fluconazole 150mg (single dose) contraindicated in pregnancy.  Other simple measures may help to decrease recurrent attacks, e.g.: • Wearing cotton underwear. • Avoiding chemical irritants, e.g. soap&bath salts. ABOUBAKR ELNASHAR
  85.  Uncomplicated VVC is not usually acquired through sexual intercourse; thus, data do not support treatment of sex partners.  A minority of male sex partners have balanitis, characterized by erythematous areas on the glans of the penis in conjunction with pruritus or irritation. These men benefit from treatment with topical antifungal agents to relieve symptoms. ABOUBAKR ELNASHAR
  86. Implications in pregnancy • It is very common in pregnancy with no apparent adverse effects. • Topical imidazoles are not systemically absorbed and are therefore safe at all gestations. ABOUBAKR ELNASHAR
  87. You can get this lecture and 444 lectures from: 1.My scientific page on Face book: Aboubakr Elnashar Lectures. 44884091351/ 2.Slide share web site 3. 4. My clinic, 3 Althawra St. Almansura ABOUBAKR ELNASHAR