An STI during pregnancy can pose serious health risks for you and your baby. As a result, screening for STIs , such as human immunodeficiency virus (HIV), hepatitis B, chlamydia and syphilis, generally takes place at the first prenatal visit for all pregnant women.

1. SEXUALLY TRANSMITTED DISEASE
IN PREGNANCY
Mukesh Sah
Post Graduate Medical INtern

2. SEXUALLY TRANSMITTED
DISEASE
 Infection transmitted by sexual contact are called as
sexually transmitted disease ( STIs).
Sex isn't the only way some of these infections are
transmitted. For example, you can also become infected
with the hepatitis B virus – which can survive outside
the body for at least a week—from contact with
contaminated needles or other sharp instruments,
contact with the blood or open sores of an infected
person, or even by sharing household items like a
toothbrush or razor.

3.  A sexually transmitted infection (STI)- sometimes
referred to as a sexually transmitted disease (STD) is a
bacterial or viral illness.
 STIs can have serious health consequences for mother
and baby.
 STDs are serious illnesses that require treatment,
regardless of whether or not pregnant.

4. STDs include
 Syphilis
 Herpes
 HIV/AIDs
 Genital Warts (causes by human papilloma virus, or
HPV)
 Hepatitis B
 Chlamydia
 Gonorrhea
 Trichomonas vaginalis

5. Syphilis in pregnancy
 It is STDs caused by the spirochete bacterium
Treponema pallidum.
 There are four stages to the progression of the infection.

6. Primary stage
occurring on average 21
days after exposure, where
a single painless, firm non-
itchy ulcer or chancre
appears.

7. Secondary stage
 Occurs between
4-10weeks after
exposure, with
the appearance of
a non-itchy,
diffuse rash with
fever and sore
throat evident.

8. Latent phase
 The individual is generally asymptotic, but still
contagious to others.

9. Tertiary phase
 Can occur between 3 to
15 years after the initial
exposure. If the person
doesn’t seek the
treatment, they will
exhibit neurological
symptoms such as
general sepsis and
seizures, as well as
cardiac symptoms
including aneurysms.

10.  Diagnosis is via a blood test and the treatment is
penicillin.
 It is highly likely that transmission of syphilis will occur
in pregnancy, causing preterm birth, stillbirth or
perinatal death, thus screening for syphilis should be
routinely offered to all pregnant women during the early
antenatal period.

11.  The baby may be born with congenital syphilis,
 Which is asymptomatic during infancy, but later in
childhood they may develop multi-organ conditions
such as deafness, seizures and cataracts

12.  Deafness: syphilis can cause the miningoneural abryrinthitis (inner ear disorder) with
round cell infiltration of labyrinth and VIIIth nerve(vestibulocochlear nerve transmits
sound and equilibrium) as the predomint lesion early cause. In secondary and tertiary
meningitides.

13. Herpes
 If a women with genital herpes has virus present in the
birth canal during delivery, herpes simplex virus (HSV)
can be spread to a baby, causing neonatal herpes, a
serious and sometimes fatal condition.
 Neonatal herpes can cause an overwhelming infection
resulting in lasting damage to the central nervous
system, mental retardation, or death.
 Medication, if given early prevent or reduce has serious
consequences for most infected infants.

14. Herpes

15. Genital warts
 Genital warts are a sexually transmitted infection (STI).
They typically appear as fleshy growths in the tissues of
the genitals.
 Genital warts are caused by certain strains of the human
papillomavirus (HPV).
 If women have the strain of HPV that results in genital
warts while pregnant, it is not likely to affect the health
of baby.

16. Genital warts

17.  Genital warts have been shown to grow faster during
pregnancy due to discharge, as well as changes to in
hormones and immune system.
 There are some rare causes where the mothers have
passed on the HPV that causes warts to their unborn
baby is usually able to overcome the symptoms on his or
her own or through early medical intervention by the
doctor.

18. Gonorrhea
 Gonorrhea is common STI affecting the genital tract
(especially the cervix) and rectum.
 It is transmitted by sexual activity with an infected
individual and is caused by the bacterium Neisseria
gonorrhea.
 Most infected individuals are symptomatic with signs
and symptoms occurring 2-10days after the initial
contact.

20.  Such symptoms include painful micturition,
yellow/bloodstained vaginal discharge and post-coital
bleeding.
 If untreated, in women it can cause PID, giving rise to
abdominal cramps, fever and inter-menstruation
bleeding, with an increased risk of ectopic pregnancy.
 Individuals are also at the risk of acquiring HIV.

21.  Testing for gonorrhea is via urine and cervical swabs.
 Treatment is with antibiotics, but drug resistance can be
problematic.
 Gonorrhea can be transmitted to the neonate during
vaginal birth and result in eye infection.

22.  Treatment- ceftriaxone and spectinomycion.

23. Chlamydia
 It is most commonly diagnosed STI, especially in under
25-year –olds, and is caused by the bacterium
Chlamydia trachomatis
 Between 70- 80% of women affected by chlamydia are
asymptomatic.
 Signs and symptoms usually occur from 1-3 weeks
following infection and include dysuria, vaginal
discharge, lower abdominal pain, post-coital and inter-
menstrual bleeding, anal discharge, conjunctivitis, eye
infections and sore throats following anal or oral sexual
practices.

24.  If left untreated, chlamydial infection can cause pelvic
inflammation disease (PID), which increases infertility
and the risk of miscarriage and ectopic pregnancy.
 Methods of testing include urine test, low vaginal swab
and cervical swab.
 Chlamydia can be transmitted to the neonate during
vaginal birth and can result in neonatal eye infections
and pneumonia.
 Treatment entails antibiotics such as azithromycin.

25. Trichomonas vaginalis
 It is sexually transmitted disease spread through skin-to-
skin contact during sexual activities.
 It is caused by parasite Trichomonas vaginalis.
 if left untreated, a trichomoniasis infection can last for
several months.
 Trichomoniasis can cause a fishy genital odor, large
amounts of white, gray, or green vaginal discharge,
genital itching.

26.  It can affect a women’s chances for a pre-term delivery
or the baby having a low birth weigh. Although rare,
there is chance that the infection could passes to baby
during birth.
 Treatment : antibiotics such as metronidazole, tinidazole

27. HIV/AIDs
 Human immunodeficiency virus (HIV) causes an
incurable infection that leads ultimately to a terminal
disease call acquired immunodeficiency syndrome
(AIDs).

28. The main modes of transmission of HIV
are
 Sexual contact (homosexual or heterosexual)
 Transplacental
 Exposure to infected blood or tissue fluids
 Through breast milk.

29.  Viral load-number of HIV viruses in the blood stream.

30. Effects of HIV in pregnancy
 Spontaneous abortion.
 Preterm labor and preterm babies
 IUGR
 Perinatal mortality

31. MANAGEMENT OF HIV/AIDs

32. Prenatal care
 Voluntary serological testing for HIV infection to all
pregnant women in the perinatal clinic should offered.
 Counselling about the risk of HIV transmission to the
fetus and neonates should be made and termination
offered.

33.  Progressive of the disease is assessed by- CD4+ T
lymphocyte counts and HIV RNA (Viral load).
Assessment is done at every 3-4 months interval. A
patient with low viral load (<3000copies/ml) and high
CD4+ count (>750 cells/mm3) has nearly a zero
probability of progressing to AIDs within 3years

34.  The patient should have T lymphocyte count in each
trimester. If the count falls to less than 200 cells/ mm3,
the patient should receive prophylaxis against
pneumocystis carinii and other opportunistic infections.
 Highly active antiretroviral therapy (HAART) to HIV 1
positive women is effective in reducing the viral (HIV
RNA) load.

35.  Women taking HAART should be screened for
gestational diabetes.
 Prophylactic antibiotics should be started when there is
opportunistic infection.

36. Intrapartum care
 Zidovudine is given IV infusion starting at the onset of
labor (vaginal delivery) or 4 hours before cesarean
section. Loading dose 2mg/kg, maintenance dose
1mg/kg/hr until cord clamping done.
 A single dose of Nevirapine at the onset of labor and a
single dose of it to the newborn at age 48hours is an
effective alternative requirement for women who had no
prior therapy.

37.  Elective cesarean delivery reduces the risk of vertical
transmission by about 50%. Avoidance of breastfeeding,
HAART therapy and appropriate mode of delivery has
reduces MTCT rates from 25-30% to <1%. Baby should
be bathed immediately.

38.  Invasive procedures that might result in break in the
skin or mucus membrane of the infants (procedures like
attachment of scalp electrode and determination of scalp
blood PH) are contraindicated. Instrument (Ventouse) is
avoided.
 Mechanical suctioning devices should be used to
remove secretions from the neonates airways.
 Elective cesarean delivery is recommended at 38 weeks
for women taking HAART who have plasma viral load
>50copies/ml.

39. Postpartum care
 Breastfeeding-Doubles the risk of MTCT (14%-28%)
but where alternative forms of infant nutrition are not
safe, the risks associated with breastfeeding may be
accepted. Mother is helped to make an informed choice.
 Zidovudine syrup-2mg/kg is given to the neonate 4
times daily for first 6 weeks of life. High risk neonate
should be treated with HAART. The infant is tested at
D1, weeks 6, 12 and at 18months of age.

40. Contraception
 Barrier methods of contraction (condom or female
condom) is effective in preventing transmission of the
virus. The disease could be prevented predominantly by
health education and by practice of safer sex.

41. THANK YOU

42. HISTORY OF HIV/AIDS AND PMTCT

43. Current situation of HIV/AIDs in Nepal
(2015 NCASC)
 The first HIV infection was detected in 1988 in Nepal.
• Since then HIV epidemic has evolve from low- to
concentrated among Key affected populations
– People with Injecting drugs (PWID)
– Female sex workers (FSW)
– Clients of female sex workers
– Men who have sex with men (MSM)
– Labor migrants
 HIV prevalence in general population is <1%

44. Nepal Estimate of HIV Infections 2015

45. Total HIV positive tested by 2015
Total Positive 28,865
Male 17,949
Female 10,824
TG 92

46. Nepal Estimate of HIV infections 2016
• PLHIV current on ART:12,446
• Reported:28,865
• Estimated:32,855
• Prevalance:0.17%

47. PMTCT SERVICES IN NEPAL
 In February 2005, the NCASC initiated a pilot PMTCT
program in three hospitals; this was been extended to
additional facilities. The National PMTCT Working
Group and its partners including WHO, United Nations
Population Fund (UNFPA), United Nations Children’s
Fund (UNICEF), Joint United Nations Program on
HIV/AIDS (UNAIDS) and United States Agency for
International Development (USAID) / Family Health
International (FHI) continue to provide active support to
the program.

48.  In early 2007, the NCASC, UNICEF and other members
of the Working Group undertook an operational Review
of the pilot PMTCT program.

49.  Government of Nepal launched the “Comprehensive
PMTCT Services”, for the first time in the year 2005
at Paropakar Maternity and Women’s Hospital. This
service package includes voluntary counseling and
testing (VCT), ARV prophylaxis of pregnant women
and for HIV - exposed babies, infant feeding
counseling and support, safe obstetric care, family
planning and referral care and support of HIV
infected women and children

50.  According to first national guideline of Nepal (2005),
single dose of Tab. Nevirapine (NVP) 400mg was given
to pregnant women at the onset of labor and neonates as
early as possible (within 72 hrs).
 In 2008, expanded prophylaxis (Zidovudine, Lamivudine
and Nevirapine) was started from 28 weeks of gestation
and after birth; baby was given Nevirapine and
Zidovudine.

51.  In 2010,ARV guideline has been reviewed again
and from 2011, triple drug therapy including
Zidovudine or Tofinavir if Hb is less than 8gm%),
Lamivudine and Efavirenz from 14wks till delivery,
and continuing in postpartum 1year till cessation of
breast feeding followed by Efavirenz one week
with subsequent 1 week Zidovudine and
Lamivudine was recommended.

52.  Nevirapine is given for six weeks for breast fed and
for seven days only, if replacement feeding is
chosen. Mother and baby are followed up monthly
from 45 days onward every month till 18 months. .
Cotrimoxazole prophylaxis to baby is started from
45 days of birth to 18 months. PCR test to baby is
offered at 6weeks followed by antibody test at 9
months and confirmatory antibody test is done at 18
months of birth. If infant death occurs, it is
recorded.

53. PMTCT
 All pregnant women of unknown HIV status should
be offered HIV testing at their first antenatal visit.
Pregnant women usually enter PMTCT services
either through an HIV program, or through antenatal
consultations.

54. PMTCT strategies
 Primary prevention of HIV infection.
 Preventing unintended pregnancies in women with
HIV
 Preventing vertical transmission or HIV
transmission from women to their infants
 Providing care, treatment and support for mothers
with HIV and their children.

55. Primary prevention of HIV infection
 Preventing HIV infection in women, including those
who are pregnant or breastfeeding, is the most
efficient way to avoid HIV infections in infants and
it saves women’s lives as well.
 Programs and policy makers can give attention to
strengthening primary prevention services, such as
counseling and testing, and condom provision to
reduce the risk of sexual HIV transmission.

56. Preventing unintended pregnancies in
women with HIV
 Family planning provides couples with HIV an
opportunity to prevent unintended pregnancies and
to avoid having children who are infected with HIV.
 Strengthening family planning programs for all
women, especially in high prevalence settings, will
reach many infected women who still do not know
their status and need family planning

57. Preventing vertical transmission or HIV
transmission from women to their infants
 The risk that a woman with HIV will transmit the
virus to her infant can be reduced in a number of
ways—prophylaxis with ARVs during pregnancy
and breastfeeding, cesarean-section delivery, and
following safe infant feeding practices.

58. Providing care, treatment and support for
mothers with HIV and their children
 Offering ongoing care, treatment, and support for
mothers with HIV and their infants helps to ensure
the mother’s health and to protect the child’s health
and development.

59. PMTCT package
 HIV counselling and testing
 Antiretroviral prophylaxis for HIV-infants mother
and infant.
 Infant feeding counselling and support
 Safe obstetric care
 Family planning counselling.
 Referral care and support of HIV infected mother
and infant.

60. HIV counselling and testing
 All the pregnant women of unknown HIV status
should be offered HIV testing at their first antenatal
visit.
 Pregnant women usually enter PMTCT services
either through an HIV program, or through antenatal
consultations

61. Pretest information:
 Give information on HIV/AIDs, modes of
transmission and prevention.
 Explain the risk of HIV transmission to the child if
the pregnant women is HIV positive (30-40%
without PMTCT; less than 5% with PMTCT)
 Explain possible ways to prevent the mother to child
transmission of HIV

62.  Explain the testing procedure.
 Explain that the result of the test will remain
confidential
 Explain that the women may refuse to take the test
now but will be free to take it at a subsequent
consultation.

63. HIV testing:
 PMTCT programs should provide same day results
of HIV testing to reduce loss-to-follow-up and
ensure prompt action.
• Women should be tested for HIV during routine
prenatal testing, on an opt-out basis where possible.

64.  Women at high risk for HIV, including injection
drug users and women with multiple sex partners
during their pregnancy, should be tested again in
their third trimester.

65. • Women who have not been tested should be offered
rapid screening when in labor, and if the rapid test is
positive, they should start antiretroviral therapy
while waiting for results from a confirmatory test.
• All pregnant women should be screened for HIV
infection as early as possible during each pregnancy
using the opt-out approach where allowed.

66. • Repeat HIV testing in the third trimester is
recommended for women in areas with high HIV
incidence or prevalence and for women known to be
at risk of acquiring HIV infection.
• Women who were not tested earlier in pregnancy or
whose HIV status is otherwise undocumented
should be offered rapid screening on labor and
delivery using the opt-out approach where allowed.

67. • If a rapid HIV test result in labor is reactive,
antiretroviral prophylaxis should be immediately
initiated while waiting for supplemental test results.

68.  Diagnosis of HIV infection in infants is aided by
HIV culture or DNA/RNA polymerase chain
reaction (PCR); positive results are confirmed by
repeating the test.

69.  In suspected cases,
-HIV testing should occur in the newborn period (i.e.,
before the infant is 48 h old),
-at age 1-2 months, and again at age 3-6 months.
Testing
-at age 14 days may allow for earlier detection of HIV
in infants who had negative test results within the first
48 hours of life. By approximately age 1 month, PCR
testing has a 96% sensitivity and 99% specificity to
identify HIV.

70.  Because of the persistence of the maternal HIV
antibody, infants younger than 18 months require
virologic assays that directly detect HIV in order to
diagnose HIV infection

71. Post test information:
 The post-test session is crucial. It is meant to
encourage and support a woman with HIV infection
to accept her status and the PMTCT intervention
that will benefit both her health and that of her
future infant.

72. If the woman has tested negative:
• Explain the meaning of a negative HIV test and the
importance of remaining HIV negative
• Re-discuss methods of prevention (already explained
in the pre-test information)
• Discuss risky behaviors and the need for protection
particularly during pregnancy and post-partum

73. •Encourage the woman to return to take a test in 3
months or before delivery
• Encourage her to bring her partner for testing
•Give condoms now and at each antenatal visit

74. If the woman has tested positive:
•Explain the positive result and provide emotional
support
•Explain that she has a good chance to stay healthy and
well for a long time, and that her child has a good
chance to be HIV negative if she continues to come to
the clinic and to follow the advice given
•Explain the risk of transmission of HIV to the child if
there is no intervention

75. • Explain the PMTCT intervention, focusing on ARV
for her own health, prophylaxis for her child and
delivery in a medical environment (hospital or health
center)
• Explain the importance of regular follow-up, before
and after birth
•If she has other children, discuss issues around their
health and the possibility to test them
•Encourage her to bring her partner for testing

76. Antiretroviral prophylaxis for HIV-infants
mother and infant

79.  ABC- Abacavir
 FTC-Emtriva
 Lamivudin or 3TC (Epivir)
 Zudovudine or AZT or ZDV
 EFV- Efavirenz
 Nevirapine or NVP (viramane)
 ETR- Etavirine
 RPV- Rilpivrine
 LPV/r- Lopinavir +ritonavir
 NCASC- National Centre for AIDs and STD control.

80. Infant feeding counselling and support
 Decisions whether or not HIV-infected mothers
should breastfeed their infants is generally based on
comparing the risk of infants acquiring HIV through
breastfeeding with the increased risk of death from
malnutrition, diarrhea and pneumonia if the infants
are not exclusively breastfed.
 Antiretroviral medicines to the mother or the infant
can significantly reduce the risk of HIV
transmission through breastfeeding.

81.  Mothers know to be HIV-infected should
exclusively breastfeed their infants for the first 6
months of life, introducing appropriate
complementary foods thereafter and continue breast
feeding.
 Mothers living with HIV should breastfeed for at
least 12 months and may continue breastfeeding for
up to 24 months or longer

82. Safe delivery practices
 Normal vaginal delivery-
The greatest risk of MTCT occurs in intrapartum (i.e.
during delivery), when the fetus comes in contact with
maternal blood or cervical secretions and fetal and
maternal blood mix after the placenta separates from
the uterus.

83.  The risk is increased when prolonged rupture of the
membranes or STIs result in inflammation of the
lower genital tract, and when operative or
manipulative delivery increase the risk of mixing of
fetal and maternal blood.

84. Operative vaginal delivery
 Operative or manipulative vaginal delivery
(including forceps or vacuum extraction, breech
extraction and manipulations during vaginal
delivery of multiple pregnancy) increase the risk of
mixing of fetal and maternal blood. They should be
avoided

85. Caesarean section
 In the absence of any ARV prophylaxis, caesarean
section performed before the onset of labor or
rupture of the membranes may reduce the risk of
MTCT by up to 50%

86. Family planning
 Effectives options for women infected with HIV are
similar to those of women who are HIV negative
and include:
• Barrier methods (male and female condoms,
diaphragms, spermicides)
• The intra-uterine contraceptive device (IUD) .

87. • Female and male sterilization (Tubal ligation
• and vasectomy)
• The lactational amenorrhea method
• Natural methods.
• Male (or female) condoms are the only methods that
have the ability to prevent transmission of STIs and
HIV in addition to preventing pregnancy called dual
protection.

88. References
 http://www.ashasexualhealth.org/stdsstis/herpes/herpes-and-pregnancy/
 https://www.healthline.com/health/pregnancy/infections-prevention-
genital-warts#pregnancy-care
 http://americanpregnancy.org/pregnancy-complications/genital-warts-
during-pregnancy/
 https://www.healthline.com/health/pregnancy/infections-
trichomoniasis#treatment
 http://americanpregnancy.org/pregnancy-complications/trichomoniasis-
during-pregnancy/
 https://samumsf.org/sites/default/files/2018-
03/2017_PMTCT%20handout%20Final%20version%2003_01_2018.pdf