Obstetrics and gynaecology infections 2

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Obstetric and gynecological infections
By
Ahmed Elbohoty MD, MRCOG
Assistant professor of obstetrics and gynecology
Ain Shams University
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STDS
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Anatomy
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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.3/27/20 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.
3/27/20 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 inacEvate
tumour suppressor
genes, which may
lead to carcinogenic
transformaEon of
cells
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• Most HPV infec.ons are asymptoma.c and self- limi.ng.
• However, persistent HPV infec.on 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.3/27/20 14

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Podophyllotoxin:
• home-based treatment
• paJent applies soluJon/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 irritaJon to surrounding skin
• licensed for use on external genitalia
• intercourse should be avoided following treatment as it may cause irritaJon to
partner.
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Trichlorace=c 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 infec7on about the risk of peripartum transmission of HPV
infec7on, poin7ng out that:
§ Infec7on with HPV types 6 and 11 can result in respiratory papillomatosis in infants and
children
§ The role of cesarean sec7on in reducing peripartum transmission of HPV is unknown
à SO, NOT RECOMMENDED
§ Recurrent respiratory papillomatosis is a rare but serious condi3on affec3ng four per 100 000 births as a
result of transmission of HPV to the neonate during delivery.
§ TCA has been used in pregnant pa7ents without adverse effects.
§ Podophyllin, podofilox, and fluorouracil should not be used in pregnant pa7ents because of
possible teratogenicity.
§ Imiquimod is not approved for use in pregnant women, although treatment with this agent
can be considered aQer informed consent has been obtained.
§ Surgical excision, cryotherapy, and electrocautery are appropriate treatment op7ons 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 poten7al complica7ons in infected children.
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Cervical cytology
•No changes are required to
screening intervals in women with
ano-genital warts
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Treatment Approach
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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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Pathogenesis of Chlamydia species
•Obligate Intracellular organism, small
non-motile
•Consists of both RNA and DNA ,
ribosomes, cell wall and divide by
binary fission
•But lack peptidoglycan and lack ability
to produce own ATP
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Pathogenesis of Chlamydia species
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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.3/27/20 31
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 contracepJon
• infecJon with another STI.
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The Na=onal 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 > women3/27/20 36

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Reiter's syndrome
• A small number of adults may present with arthriJc symptoms.
• It includes urethriJs, arthriJs and conjuncJviJs, can be triggered by chlamydial
infecJon, although it may be caused by other infecJons 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 Amplifica.on
Technique (NAAT): 95% sensi/ve
•The 'window period' for detec/ng
chlamydia on a NAAT test is
approximately 2 weeks.
• Therefore, when the test is taken, the pa1ent should be informed
that it will not accurately detect any chlamydia infec1on 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 a@end for
repeat tes1ng in a further 2 weeks.
•Tes/ng for other STI`s should be
carried out , ideally in GUM clinics
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Treatment
•Doxcycline I00 mg bd for seven
days or
•Azithromycin 1g-single dose
• 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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Rectal infection
• Preferred treatment : Doxycycline 100 mg bd for seven days
Alternative treatment . Azithromycin 1 g orally in a single dose
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Treatment op=ons for pregnant and breasLeeding
• azithromycin 1 g immediately (WHO recommends use in pregnancy
and BASHH reports that studies show efficacy and safety in pregnancy
however but the BNF cautions that manufacturers advise this should
only be used if there are no alternatives)
• 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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Lymphgranuloma venereum
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Neisseria gonorrhoeae
•A Gram-negative diplococcus that can infect
the mucous membranes of the
urethra, endocervix, rectum, pharynx and
conjunctiva
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N. gonorrhoeae-gram negative diplococci
52
Diplococci
Credit: Negusse Ocbamichael and Seattle STD/HIV Prevention Training Center
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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 sensiTve nucleic acid
amplificaTon tests (NAATs) detect up to
90% of infected individuals compared to
only 75% with the culture method
•The diagnosis can be confirmed by direct
culture
•Culturing N. gonorrhoea has the
advantage that anTbioTc sensiTviTes can
also be determined.
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Treatment of gonorrhoea
•The first line treatment of choice is determined by
antimicrobial sensitivity
•ceftriaxone 500mg IM as a single dose + Azithromycin 1 gm
•ALTERNATIVE REGIMENS
•Cefixime 400 mg oral as a single dose
•Ciprofloxacin
•Spectinomycin
•High dose Azythromycin
•Test of cure is not required unless symptoms persist, re-
infection is suspected, a resistant strain is identified or the
initial site of infection was pharyngeal, which is more
resistant to the standard treatment regimens
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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
30–40% of cases is polymicrobial
C. trachomatis is the commonest identified cause accounting for 14-35% of cases whilst
Gardnerella vaginalis, anaerobes (including Prevotella, Atopobium and Leptotrichia) and
other organisms commonly found in the vagina may also be implicated.
Neisseria gonorrhoeae only cause 3 % of PID in UK
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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Localised symptoms
lower abdominal pain which is typically bilateral (but can be unilateral)
abnormal vaginal or cervical discharge which is o8en purulent
deep dyspareunia
abnormal vaginal bleeding, including post coital bleeding, inter-menstrual bleeding
secondary dysmenorrhoea
Systemic symptoms
Fever
Anorexia
Malaise.
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Examina=on 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.
Although laparoscopic division of hepatic adhesions has been performed, there is
insufficient clinical trial evidence to make specific recommendations for additional
treatment beyond that for uncomplicated PID.
• 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.
• 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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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
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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.
• 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.
• 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 .
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Swab technique
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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.
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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
• CeYriaxone 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 ceYriaxone 500 mg immediately, followed by azithromycin 1 g per week for
2 weeks
Or
• Oral moxifloxacin 400 mg once daily for 14 days.
• Or
• intramuscular ceYriaxone 500 mg immediately, followed by azithromycin 1 g/week for 2
weeks
•
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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
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inpatient regimens
• ce#riaxone 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 Bmes daily plus
intravenous gentamicin,* followed by either oral clindamycin
450 mg four Bmes 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 Bmes 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
3/27/20 75
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.
3/27/20 76

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Surgical Management
• laparoscopy may help early resolution of severe disease by dividing adhesions
and draining pelvic abscesses56 but ultrasound guided aspiration of pelvic fluid
collections is less invasive and may be equally effective57,58
• 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
3/27/20 77
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.3/27/20 78

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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%.
3/27/20 79
•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.
3/27/20 80

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Diagnosis
•The diagnosis is made when the clinical findings are
associated with raised inflammatory markers and
radiological findings demonstra^ng a mass.
•Fever and diarrhoea are more common in women with TOA
than in women with PID (90% versus 60%, respec^vely)
•Symptoms and signs of PID and/or a TOA include some or all
of the following:
• Adnexal tenderness (bilateral or unilateral)
• Cervical excita^on
• Pyrexia
• Abnormal cervical or vaginal discharge
• An adnexal mass on abdominal palpa^on/bimanual
examina^on or seen by imaging.3/27/20 81
Presenta5on
• 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.
3/28/20 82

42. 4/8/1441
42
• 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.
3/27/20 83
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.
3/27/20 84

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43
Ultrasound
• A TOA can be diagnosed by ultrasound, appearing as a complex solid/cysJc mass.
This can be unilateral or bilateral. A pyosalpinx may be seen as an elongated,
dilated, fluid-filled mass with parJal septae and thick walls. Incomplete septae
within the tubes is a sensiJve sign of tubal inflammaJon
• There may be a ‘cogwheel’ sign resulJng from thickened endosalpingeal folds
which is a sensiJve marker of a TOA
3/27/20 85
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.3/27/20 86

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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
3/27/20 87
Possible an+bio+c 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
3/27/20 88

45. 4/8/1441
45
3/27/20 89
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.
3/27/20 90

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46
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 aspiraJon 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 aspiraJon. There
were no complicaJons with aspiraJon alone and a 100% success rate. Catheter
placement was needed for larger, bilateral, mulJloculated abscesses with thick
viscous material.
• There were minor complicaJons in 10% of catheter placements including bladder
pain and infecJon, with an 80% success rate.
• Transvaginal aspira9on with an9bio9c cover should be the first line of
treatment of TOAs aner reporJng a high success of 93% (282 out of 302 women)
with no major complicaJons.
3/27/20 91
Timing of interven=on:
•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.
3/27/20 92

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47
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 pain3/28/20 93
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
3/27/20 94

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48
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.
3/27/20 95
Special cases
3/27/20 96

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49
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.
3/27/20 97
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.
3/27/20 98

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50
Complications
3/27/20 99
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.
3/27/20 100

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51
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.
3/27/20 101
Syphilis
•Causative agent: Treponema Pallidum
Treponema pallidum subspecies pallidum is a
spiral-shaped, Gram-negative, highly mobile
bacterium.
•Mode of transmission:
-sexual ( most common).
-close contact with open lesions( rare).
-direct blood transfusion.
-cong. Syphilis: Fetal infection is most likely
when the mother is in the primary or
secondary stages.
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3/27/20 103
3/27/20 104

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Syphilis: Clinical Presentation
• Primary / Infectious / Early Syphilis Stage:
• Primary Phase
§ Primary chancre
• Begins as papule and erodes into painless ulcer with a hard edge and clean base
• Usually in the genital area
• Appears 9-90 days after exposure
• Can be solitary or multiple (eg. kissing lesions)
• Heals with scarring in 3-6 weeks and 75% of patients show no further symptoms
1053/27/20
Syphilytic chancre
3/27/20 106

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54
Primary Chancre
107
Primary
Chancre
Credit: Centers for Disease Control and Prevention (CDC)
3/27/20
Syphilis: Clinical Presenta:on (con:nued)
• Primary / Infectious / Early Syphilis Stage:
• Secondary Phase
§ Occurs 6 weeks – 6 months after chancre
§ Lasts several weeks
§ Accompanied with fever, malaise, generalized lymphadenopathy, and
patchy alopecia
§ Maculo-papular rash usually on palms and soles
§ Condyloma lata on perianal or vulval areas
§ Possible mild hepatosplenomegaly
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3/27/20 109
Syphili:c Rash
110
Credit: Dr. Gavin Hart and CDC
Credit: Connie Celum and Walter Stamn
and Seattle STD/HIV Prevention Training Center
3/27/20

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Syphilis
3/27/20 111
Condyloma lata
3/27/20 112

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57
Condyloma lata
113
Credit: CDC
Condyloma
lata
3/27/20
SECONDARY SYPHILIS
Condyloma lata3/27/20 114

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Syphilis: Clinical Presentation (continued)
• Tertiary Stage:
§ Cardiovascular: Aortic valve disease, aneurysms
§ Neurological: Meningitis, encephalitis, tabes dorsalis, dementia
§ Gumma formation: Deep cutaneous granulomatous pockets
§ Orthopedic: Charcot’s joints, osteomyelitis
§ Renal: Membranous Glomerulonephritis
1153/27/20
Inves=ga=on
•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.
3/27/20 116

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59
(C) Investigations: by serological tests;
(I) Non- specific (non-treponemal ) tests:
Venereal disease research laboratory (VDRL).
Rapid plasma reagin (RPR), Treponempa
Palidum Hemaglutination test (TPHA)
They become negative with treatment and can
be used to monitor treatment.
(B) Specific (treponemal) tests:
Fluorescent treponemal antibody absorption
test (FTA - ABS).
Treponema pallidum immobilization test (TPI).
•They usually remain positive even after
adequate treatment3/27/20 117
False positives on the nontreponemal tests
• some viral infecJons such as varicella(chickenpox) and measles
• lymphoma
• tuberculosis
• malaria
• connecJve Jssue disease
3/27/20 118

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Implications of syphilis on the fetus and neonate
•Vercal transmission is can occur at any stage
of the pregnancy but is more common later in
pregnancy and in women with early syphilis.
3/27/20 119
Intrauterine problems
• Miscarriage
• preterm delivery
• Stillbirth
• congenital syphilis defects, including:
• 8 th nerve deafnes
• Hutchinson’s teeth
• saddle nose
3/27/20 120

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61
Figure 23.16
3/27/20 121
Neonatal
• Rhinitis
• a diffuse maculopapular, desquamative rash with extensive sloughing of the
epithelium, particularly on the palms and soles
• splenomegaly
• Anaemia
• thrombocytopenia and jaundice.
• If clinical signs are present at birth, 50% of infants will die in the neonatal period
3/27/20 122

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62
First-line treatment
•For early syphilis (early latent, primary or secondary)
•benzathine penicillin G 2.4 MU intramuscular injection
(single dose)
•For late latent, cardiovascular and gummatous syphilis:
•benzathine penicillin G 2.4 MU intramuscular injection
weekly for 3 weeks (three doses)
•For early syphilis in pregnancy:
•first and second trimester: benzathine penicillin G 2.4 MU
intramuscular injection (single dose)
•third trimester: benzathine penicillin G 2.4 MU
intramuscular injection on days 1 and 8 (two doses)
•For late latent, cardiovascular and gummatous syphilis in
pregnancy:
•benzathine penicillin G 2.4 MU I.M injection weekly on
days 1, 8 and 15 (three doses)3/27/20 123
Alternatives
•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
•or azithromycin (Zithromax), 2 g orally (single dose)
3/27/20 124

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Treatment side effects and follow up
• Patients should be warned of the possibility of a Jarisch-Herxheimer
reaction.
• This is an acute febrile illness that develops approximately 4 hours
after antibiotic treatment and resolves within 24 hours.
• It is associated with rigors, headache, myalgia and general malaise.
• It is self-limiting and patients should be advised to rest and take
paracetamol.
• It occurs most commonly in secondary syphilis (75%) and primary
syphilis (50%).
• Follow-up serology is required at at least 3, 6, and 12 months post
treatment to ensure an adequate response.
• Treatment failure 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.
3/27/20 125
3/27/20 126

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64
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
3/27/20 127
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 inguinale3/27/20 128

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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.
3/27/20 129
MOLLUSCUM CONTAGIOSUM
- Umbilicated pearly papules
- Look for clues – “Central depression”
- May be filled with pus like material
- Rx: Liquid Nitrogen
3/27/20 130

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Vaginal discharge
3/27/20 131
3/27/20 132

67. 4/8/1441
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3/27/20 133
3/27/20 134

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68
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.
3/27/20 135
Clinical picture
•Not sexually transmiied but more likely to occur in the
sexually ac^ve hence the term ‘sexually associated’
•More common in black / smokers / vaginal douching /
bubble baths.
•Symptoms
•Offensive fishy-smelling watery discharge especially amer
intercorse
•Not usually associated with soreness or itching
•Signs
•Thin grey / white homogeneous discharge
•No inflamma^on in the vagina
•Raised vaginal pH: > 4.5 (normal is 3.5 to 4.5)3/27/20 136

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BV during pregnancy is associated with an
increased risk of:
• preterm prelabour rupture of membranes
• chorioamnioniJs
• amnioJc fluid colonisaJon
• low birthweight infants
• postpartum endometriJs.
3/27/20 137
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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3/27/20 139
Treatment:
•Metronidazole 400mg 1X2X7 or
•Metronidazole 2 gm stat (not in lactating
women)
3/27/20 140

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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
replicaJon.
• Three types of mycoplasmas have been isolated from female genital mucosal
surfaces:
• Mycoplasma genitalium
• Mycoplasma hominis
• Ureaplasma urealy4cum
• M. hominis and U. urealy1cum are commonly found in the genital mucosa of
sexually acJve women, and the level of colonisaJon increases with the number
of sexual partners.
• M. hominis and U. urealy1cum are also found in women with intra-amnioJc
infecJon, postpartum endometriosis and pelvic inflammatory disorders.
• Neonates can be colonised as they pass through the birth canal; however,
infecJon does not usually persist.
3/27/20 141
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.
3/27/20 142

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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
3/27/20 143
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 an^bio^cs)
3/27/20 144

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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
3/27/20 145
Candida albicans
3/27/20 146

74. 4/8/1441
74
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 (diferenhal diagnosis = herpes), satellite lesions,
excoriahon
• Discharge (typically curdy, but may be thin); generally no malodour
Note:
• Recurrent (> 4 symptomahc episodes / year)
• Non-albicans species (parhcularly persistent infechons)
• Abnormal host factors (immunosuppression, diabetes, increased
oestrogen levels)
3/27/20 147
Treatment:
•Itraconazole 500mg vaginal or
•Flucanazole 150mg PO (avoid during pregnancy)
3/27/20 148

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Trichomonas vaginalis
Flagellated protozoan, anaerobic, readily cultured on Diamond’s medium
Sexually transmitted
3/27/20 149
3/27/20 150

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STD
3/27/20 151
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.
Strawberry Cervix
152Credit: Claire E. Stevens and Seattle STD/HIV Prevention Training Center3/27/20

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Trichomonas vaginalis
• strawberry cervix and vagina only found in 5% of cases
3/27/20 153
Diagnosis
•The organism causes cervicis,
urethris, cyss and Bartholinis
•Diagnosed by microscopy of wet vaginal
smear or by culture
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Treatment:
• Metronidazole 400mg 1X2X7 or
• Metronidazole 2 gm stat (not in lactating women)
3/27/20 155
Viruses
3/27/20 156

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3/27/20 157
During pregnancy
• an increased risk of maternal morbidity
• a high risk of foetal loss and prematurity
• perinatal infecJon in the infant, which may be associated with a high mortality
and the risk of subacute sclerosing panencephaliJs
• There is no evidence to support an associaJon between measles in pregnancy
and congenital effects.
3/27/20 158

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3/27/20 159
3/27/20 160

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Mumps Virus
• Paramyxovirus
• RNA virus
• One antigenic type
• Rapidly inactivated by chemical agents, heat, and ultraviolet light
3/27/20 161
Mumps Pathogenesis
• 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
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Mumps Clinical Features
•Incubation period 14-18 days
•Nonspecific prodrome of myalgia, malaise,
headache, low-grade fever
•Parotitis in 30%-40%
•Up to 20% of infections asymptomatic
3/27/20 163
3/27/20 164

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CNS involvement
Orchitis
Pancreatitis
Deafness
Death
15% of clinical cases
20%-50% in post-
pubertal males
2%-5%
1/20,000
Average 1 per year
(1980 – 1999)
Mumps Complications
3/27/20 165
Mumps Epidemiology
• Reservoir Human
Asymptomatic infections may transmit
• Transmission Respiratory drop nuclei
• Temporal pattern Peak in late winter and spring
• Communicability Three days before to four days after onset of
active disease
3/27/20 166

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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)
3/28/20 167
•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.
3/28/20 168

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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.
3/28/20 169
Transmission
•Most cases: human to human transmission.
•Respiratory, fomite or faecal methods.
•No evidence concerning transmission through
placenta, genital fluids or breast feeding to the
baby.
•Transmission is most likely to be as a neonatal
transmission.
•There is an estimated incubation period of 0-
14 days (mean 5-6 days)
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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.
3/27/20 171
Presentation
• Asymptomatic individuals or those with very minor symptoms
• The large majority: experience only mild or moderate cold/flu like
symptoms.
• Other relevant symptoms: Cough, fever and shortness of breath
• More severe symptoms: such as pneumonia and marked hypoxia are
widely described with COVID-19 in
• older people
• the immunosuppressed and those with long-term conditions such
as diabetes, cancer and chronic lung disease.
• At present there is one reported case of a woman with COVID-19 who
required mechanical ventilation at 30 weeks’ gestation, following
which she had an emergency caesarean section and made a good
recovery.
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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
3/27/20 173
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.
3/27/20 175
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. 1763/27/20

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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
3/27/20 177
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 aJendees
3/27/20 179
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: mulJ-disciplinary team approach including an infecJous diseases
or medical specialist with consultant obstetrician, consultant anaestheJst,
midwife-in-charge, consultant neonatologist and neonatal nurse in charge
• ConfirmaJon of the onset of labour, as per standard care
• Maternal observa9ons: temperature, respiratory rate and oxygen saturaJons
(Aim to keep oxygen saturaJon >94%, JtraJng oxygen therapy accordingly)
• Fetal monitoring: ConJnuous 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 elecJve instrumental birth in a
symptomaJc woman who is becoming exhausted or hypoxic
• 3rd stage: Delayed cord clamping is sJll recommended following birth, provided
there are no other contraindicaJons.The baby can be cleaned and dried as
normal, while the cord is sJll intact.
3/27/20 181
Mode of birth and intrapartum analgesis
•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 PPE3/27/20 183
Elective caesarean birth
• Obstetric management should be according to usual pracace.
• Anaestheac management for symptomaac 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 intubaaon checklist must be used
• Rapid sequence inducaon as per usual pracace ensuring aght seal during pre-
oxygenaaon so as to avoid aerosolisaaon
• Videolaryngoscopy by most experienced anaestheast available
• In case of difficult intubaaon, plan B/C is to use a supragloec airway, plan C is
to use FONA scalpel-bougie-tube
• The anaestheast performing intubaaon should therefore consider wearing a
second pair of gloves for the procedure, and remove once the ET tube is
secured
• Determine posiaon of tube without using auscultaaon – 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.
3/27/20 185
Breastfeeding:
• All babies born to COVID-19 posihve mothers should have appropriate
close monitoring and early involvement of neonatal care, where
necessary. They will need neonatal follow-up and ongoing surveillance
aler discharge.
• The risks and benefits of breasmeeding, including the risk of holding
the baby in close proximity to the mother, should be discussed with
her.
• For women wishing to breasmeed, precauhons should be taken to
limit viral spread to the baby:
• Hand washing before touching the baby, breast pump or bonles
• Avoiding coughing or sneezing on the baby while feeding at the
breast
• Considering wearing a face mask while breasmeeding, if available
• Following recommendahons for pump cleaning aler each use
• Considering asking someone who is well to feed expressed milk to
the baby
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Potential needed interventions:
•Radiographic inves^ga^ons 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
radioac^ve exposure should be made, as per usual
protocols.
•There is no evidence to suggest that steroids for fetal lung
matura^on, 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 administra^on.
3/27/20 187
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 fer^lity treatment cycles should be started at the
moment.
•no new ovula^on induc^on, IUI, fresh IVF or Frozen Embryo
Transfer (FET) cycles can be started un^l further no^ce.
•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.
3/28/20 189
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
3/27/20 191
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
3/27/20 192

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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.3/27/20 193
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
3/27/20 195
contact of a pa5ent with acute hepa55s 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.
3/27/20 197
• 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.
• HBV can remain viable for >7 days on environmental
surfaces at room temperature.
• 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 death3/27/20 198

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3/27/20 199
Chronic infec=on
•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 þve)
mothers will become chronic carriers unless immunised
immediately at birth
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3/27/20 201
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%.
3/27/20 202

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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.
3/27/20 203
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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
3/27/20 205
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
3/27/20 206

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•Hepa^^s B should be no^fied to the public health
authori^es
•Pa^ents should be advised to avoid unprotected sexual
intercourse, including oro-anal and oro-genital contact un^l
they have become non- infec^ous (HBsAg nega^ve) or their
partners have been successfully vaccinated
•Partner no^fica^on should be performed and documented
and the outcome documented at subsequent follow-up.
Contact tracing to include any sexual contact (penetra^ve
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 infec^ous.
•The infec^ous period is from two weeks before the onset of
jaundice un^l the pa^ent becomes surface an^gen nega^ve
3/27/20 207
•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.)
3/27/20 209
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
3/27/20 211
STD
• The hepatitis C virus can be transmitted through seminal and vaginal
fluids but the risk of sexual transmission is low.
• <1% per year of relationship or about 2% of spouses in long-term
relationships.
• Rates of infection increase if the index patient is also infected with HIV.
3/27/20 212

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Pregnancy and breast feeding
• At present there is no clearly demonstrated intervention to reduce HCV transmission
from mother-to- child)
• Treatment of HCV in pregnancy is not recommended (Ribavirin is teratogenic).
• Performing an elective caesarean section has not been shown to prevent or reduce the
incidence of vertical transmission of HCV.
• Risk of vertical transmission of HCV increases with prolonged rupture of membranes
during labour for 6 hours or longer, use of internal fetal monitoring, invasive procedures,
and if the mother has a higher HCV viral load during labour or birth.
• The neonate should be bathed to remove maternal body fluids prior to IM injections. E.g.
vit K1.
• Breastfeeding is not contra-indicated for women with HCV infection. However, if the
nipples are damaged, cracked or bleeding it is recommended the milk is expressed and
discarded until the nipples are healed.
• It is recommended that a child at risk of perinatal transmission for HCV should be tested
for HCV antibodies at 18 months of age. Testing prior to this time is limited due to passive
transfer of maternal antibodies.
• Diagnosis of vertical transmission of HCV be required prior to 18 months of age (e.g.
parental request) then testing of infant serum HCV RNA can be obtained when the infant
is between than 2 and 6 months of age.
• A sample is collected on two occasions at least 3 - 4 months apart to confirm diagnosis
3/27/20 213
Herpes viruses
3/27/20 214

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Fetal infections
3/27/20 215
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Genital Herpes
Genital Herpes
§A recurrent, lifelong disease with no cure
• DNA virus
• Type I & type II ovaralaping
• Incubation period 3-7 days
• Primary infection: genital vesicles which progress into painful ulcers that
eventually crust over.
Dysuria, urinary retention, bilateral inguinal lymphadenopathy, systemic illness
may occur. Aseptic meningitis / encephalitis are rare complications
• Virus remains dormant in dorsal root ganglia, causing recurrent infection.
Genital infection can be acquired from oro-genital contact.
3/27/20 218

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3/27/20 219
Clinical Features
§ Prodrome: lasts 2-24 hrs à characterized by localized or regional pain,
tingling, and burning à may have constitutional symptoms such as
headache, fever, inguinal lymphadenopathy, anorexia, and malaise.
§ As the disease progresses, papules, vesicles on an erythematous base, and
erosions appear over hours to days.
§ Patterns of HSV-1 and HSV-2 infection appear identical: vesicles usually are
uniform in size, and the tense center umbilicates to form a depressed center.
These lesions usually crust and then re-epithelialize and heal without
scarring.
§ In women, ulcers can occur on the introitus, urethral meatus, labia, and
perineum. In men, ulcers often appear on the shaft or glans of the penis. In
both men and women, lesions may appear on the perianal area, thighs, or
buttocks.
§ Recurrent HSV outbreaks usually are milder than the initial episode: there
typically are fewer grouped lesions and viral shedding occurs at a lower
concentration and for a shorter duration (i.e. about 3 days).
§ Recurrences are spontaneous, but various factors such as fever; nerve or
tissue damage; physical or emotional stress; exposure to heat, cold, and
ultraviolet light; immunosuppression; menses; concurrent infection; fatigue;
and sexual intercourse have been associated with recurrences
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Diagnosis
§ Clinical exam/ high risk history
§ Swab test : swab from HSV lesions taken for culture or PCR
1. Viral Culture : very helpful in differentiating HSV-1 from HSV-2
2.POLYMERASE CHAIN REACTION TESTING for HSV DNA : greater sensitivity
3. SEROLOGIC TESTING
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Management
§Hospitalizahon is indicated for pahents with genital Herpes if
they also have
§ Symptoms of meningi_s: Severe headache, S_ff neck, Photophobia
§ Symptoms of autonomic nervous system dysfunc_on: Urinary reten_on,
Cons_pa_on , Dysesthesias of the perineal, sacral, or lower back regions
§ Symptoms of transverse myeli_s: Leg weakness , Decreased deep tendon reflexes
, Autonomic nervous system dysfunc_on
§If meningihs is suspected, send CSF for PCR to detect HSV DNA.
§Next step: Begin therapy with intravenous acyclovir, 5 to 10
mg/kg every 8 hours. ( do not wait for PCR results to come
back if pt has genital lesions suspicious of HSV and has above
indicaGons for aggressive therapy)
§When symptoms improve, switch to oral therapy for a total of
10 to 14 days of treatment
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Treatment
§ FIRST CLINICAL EPISODE à must be treated with anti HSV agents (
Acyclovir/ Famciclovir/ valacyclovir) as soon as possible.
§ Studies have shown prompt Rx for initial episode reduced constitutional
symptoms by three days, local pain by two days, viral shedding by seven
days, time until all lesions were crusted by three days, and time until all
lesions were healed by six days. à Counsel patients about the high
frequency of recurrences, the inevitability of asymptomatic shedding, and
the risk of transmission even after initial therapy.
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Rx – Recurrent herpes
§ Recurrences :
§ For mild, infrequent recurrences à Episodic therapy is the best. To be efective, it is very important
that treatment is started early during prodromal phase or within 1 day of lesion onset. So, counsel
pts to recognize the recurrences early and self-initiate the treatment ASAP. Provide prescriptions in
advance.
§ The goal of episodic therapy is to reduce symptoms and to reduce infectivity during the episodes.
This therapy does not prevent future recurrences or asymptomatic shedding between the
episodes.
§ Topical Acyclovir is not effective.
§ For Frequent recurrences à six or more episodes per year à START LONG TERM SUPPRESSIVE
THERAPY ( ACYCLOVIR/ FAMACYCLOVIR/ VALACYCLOVIR)
§ Inform patients that continuous suppressive therapy decreases, but does not eliminate,
transmission
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Treatment
§ Immunocompromised pts : Genital herpes Rx in HIV pts is similar to that
without HIV
§ But recognize that immunosuppressed pa3ents o4en develop extensive genital lesions that
may not respond to rou3ne courses of an3viral therapy
§ So, be sure to treat aggressively and early.
§ Treat early lesions that are not extensive with usual doses of oral medica3ons à If no
improvement occurs, or if ini3al involvement is extensive, try higher doses of oral
medica3ons.
§ If s%ll not responding à Treat with high-dose intravenous acyclovir ; note that prolonged
treatment may be required.
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Herpetic ulcers
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Neonatal herpes is classified into
1.Localised disease: to skin, eye
and/mouth (good prognosis)
2.Central nervous system (CNS)
disease (encephalitis alone)
3.Disseminated infection with
multiple organ involvement.
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Risks
• Where primary episode genital herpes lesions are present at the time
of delivery and the baby is delivered vaginally, the risk of neonatal
herpes is estimated to be 41%
• Women presenting with recurrent genital herpes lesions at the onset
of labour should be advised that the risk to the baby of neonatal
herpes is low (0–3% for vaginal delivery)
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Neonatal Herpes
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• For women presenting with first episode genital herpes in the third trimester,
particularly within 6 weeks of expected delivery, type- specific HSV antibody
testing (immunoglobulin G [IgG] antibodies to HSV-1 and HSV-2) is advisable.
• For these women, characterising the infection will influence the advice given
regarding mode of delivery and risk of neonatal herpes infection.
• The presence of antibodies of the same type as the HSV isolated from genital
swabs would confirm this episode to be a recurrence rather than a primary
infection and elective caesarean section would not be indicated to prevent
neonatal transmission.
• However, it should be noted that it may take 2–3 weeks for the results of this test
to become available.
• It is therefore recommended that an initial plan of delivery should be based on
the assumption that all first episode lesions are primary genital herpes.
• This plan can then be modified if HSV antibody test results subsequently confirm
a recurrent, rather than primary, infection.
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Breastfeeding
• It is recommended unless the mother has herpetic lesions around the
nipples.
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Prevention of postnatal transmission
• In 25% of cases a possible source of postnatal infection is responsible, usually a
close relative of the mother.
• The mother and all those with herpetic lesions who may be in contact with the
neonate, including staff, should practice careful hand hygiene.
• Those with oral herpetic lesions (cold sores) should not kiss the neonate
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Women who are HIV antibody positive and
have a history of genital herpes
• They should be offered daily suppressive aciclovir 400 mg three times daily from
32 weeks of gestation to reduce the risk of transmission of HIV infection,
especially in women where a vaginal delivery is planned.
• Starting therapy at this earlier gestation than usual should be considered in view
of the increased possibility of preterm labour in HIV-positive women.
• Delivery ?
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PPROM
• If there is initial conservative management, the mother should be
recommended to receive intravenous aciclovir 5 mg/kg every 8
hours.
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Varicella
• DNA virus
• Primary infection is characterised by fever, malaise and a distinctive pruritic
maculopapular rash that becomes vesicular and then crusts before it heals over.
• The incubation period is 10–21 days
• Patients are Infectious from 48 hours prior to the onset of the rash until the
vesicles crust over (7 days).
• During pregnancy it can cause serious maternal morbidity and death in a
minority.
• Fetal varicella syndrome does not occur at the time of initial fetal infection but is
the result of herpes zoster reactivation in utero and appears to happen only
when infection occurs before 28 weeks of gestation.
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Fetal varicella syndrome
• Limb defects, dermatomal skin scarring and damage to the eyes and central
nervous system.
• Skin lesions (scars and skin loss)
• Neurological defects (cortical atrophy, spinal cord atrophy, limb paresis, seizures,
microcephaly, Horner syndrome, encephalitis and dysphagia)
• Eye diseases (microphthalmia, chorioretinitis, cataracts and optic atrophy) in 51%
and limb hypoplasia in 49%.
• Fetal growth restriction, muscle hypoplasia, gastrointestinal and genitourinary
defects, developmental delay and, more rarely, cardiac defects
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RUBELLA
• RNA virus, only one serotype
• Spread by droplet infection
• Incubation period 14-21 days
• Period of infectivity: 7 days before rash to 5 days after rash
• Infection in pregnancy can cause congenital rubella syndrome
• Immunisation using life attenuated virus vaccine - Part of MMR vaccine; given to
both sexes causing long-term immunity but not life-long.
• Infection results in life-long immunity.
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Congenital Rubella Syndrome
• Deafness
• Cataracts
• Heart defects
• Microcephaly
• Mental retardation
• Bone alterations
• Liver and spleen damage
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Testing
• Rubella IgM
• There is a false positive rate associated with IgM assays so it should be correlated
to history of rash, exposure, history of vaccination and previous rubella testing.
• Test must be repeated if negative and taken within 7 days of appearance of the
rash.
• Rubella IgG
• Those with a level <10 iu/ml are considered susceptible to rubella infection. IgG
is usually present 1 week after the onset of rash.
• Rubella IgG avidity
• high avidity antibodies indicates an infection 6 months ago, whereas low avidity
antibodies are found in recent infections up to 3 months previously.
Antenatal screening for rubella susceptibility stopped in England on 1 April 2016. The
evidence has shown that screening for rubella susceptibility during pregnancy does not
meet the UK National Screening Committee criteria for a screening
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Mangement
• At the first 12 weeks: it would be reasonable to consider termination of
pregnancy.
• Between 12–16 weeks: Prenatal diagnosis is done (PCR (RT-PCR) is used for the
detection of viral nucleic acid in amniotic fluid or Fetal blood for IgM) and
termination can be considered if +ve.
• After 16 weeks of gestation, the risks to the fetus are negligible and the value of
prenatal testing is questionable.
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Rubella Measls (Rubeola):
Rash a light red (almost pink) rash that is
spotted. This rash may last 1-3 days.
a red or reddish-brown rash that covers
the entire body
Accompaning symptoms a couple days of a low grade fever,
swollen lymph nodes, and there may
even be some joint swelling
The first symptom is normally a hacking
cough followed by a runny nose along
with a high fever.
Characterstics maculopapular appearance of red spots with blue white
centers found in the mouth, these are
also known as Koplik spots
Course children recover much faster than
adults. A child may recover within one
week, where adults may take longer to
recover.
. Rubeola is extremely contagious . It can
be severe in pregnancy and can cause
pnemonia
Contangiousity are contagious one week prior to the
breakout, during the breakout, and one
week following the breakout.
contagious four days prior to the
symptoms and four days after the onset
of the rash.
Human parvovirus B19
• DNA
• It has a predilection for rapidly dividing cells, mainly the erythroid cell
precursors.
• Approximately 60% of adults have serological evidence of prior infection so 40 to
50 % of pregnant women are susceptible to infection
• Epidemics typically occur on a three to five year cycle and outbreaks tend to
occur during the spring.
• The primary infection rate in pregnant women is about 1 %.
• Transplacental transmission occurs in 15% of cases before 15 weeks of gestation
and 25% between 15–20 weeks: this rises to 70% towards term
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Presentations
• Adult infections are frequently subclinical
• In children it is a mild illness characterised by fever and a typical facial rash
(‘slapped cheek’).
• Congenital B19 infection can cause profound fetal anaemia, leading to cardiac
failure, hydrops and intrauterine death.
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Testing
• Parvovirus B19 IgM
• Detected 10 days after infection but may be extremely short lived (4 weeks).
• If rash is present, IgM should be detectable because the rash is immune-
mediated.
• Failure to detect parvovirus IgM probably excludes infection in the previous 4
weeks
• Parvovirus B19 IgG
• Usually detectable 12–14 days after infection. It provides lifelong immunity.
Primary infection is confirmed by seroconversion from IgG negative to IgG
positive from paired samples.
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Management in fetal medicine unit
• Serial ultrasound examinations
• Measurement of fetal (MCA-PSV).
• >1.5 MOM indicates fetal anaemia
• Fetal blood sampling and transfusion can be carried out from 18 weeks.
• Possible transfusion sites include
• the placental insertion of the umbilical cord
• the intrahepatic umbilical vein.
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Pleural effusion & ascitis
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CMV
• DNA virus
• Congenital CMV infection is the commonest congenital infection
• Primary infection occurs in 1 % of pregnant women.
• It is the leading causes of childhood sensorineural hearing loss.
• Primary infection is usually asymptomatic or a mild illness characterised by fever,
lethargy and malaise.
• 50 % of women have evidence of previous CMV infection, as determined by the
presence of immunoglobulin G (IgG) serum antibodies.
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CMV
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